Every finding on record at Lakewood Rehabilitation & Healthcare Center

Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two of 22 residents reviewed (Residents 1 and 30) who required care and monitoring of a Peripherally Inserted Central Catheter (PICC) line. Findings include: Review of the facility policy entitled, Central Venous Catheter Care and Dressing Changes, last reviewed January 1, 2026, indicated the purpose of the procedure is to avoid complications associated with intravenous therapy (delivery of fluids or medications directly into a vein), including catheter-related infections (infections that occur when bacteria enter the bloodstream through a catheter, which is a tube placed into a vein) that are associated with contaminated, loosened, soiled, or wet dressings. The guidelines included information indicating staff are to check the State's Nurse Practice Act for Licensed Practical Nurses (LPN), regarding scope of practice (the tasks the nurse is legally allowed to perform) for care of central venous catheter dressings. The policy indicated intravenous site care and dressing changes are required at established intervals or immediately if the integrity of the dressing is damp, loosened, or visibly soiled. The guidelines revealed the length of the external central vascular access device (the portion of the catheter visible outside the body) should be measured with each dressing change, or if catheter dislodgement (movement of the catheter out of its proper position) is suspected. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnosis that included chronic obstructive pulmonary disease (COPD, a long term lung condition in which airflow is persistently blocked due to chronic inflammation and structural damage in the lungs, making it difficult to breathe). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 20, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognitive function, reflecting normal memory, orientation, and recall abilities). A review of the Admission/readmission documentation dated January 22, 2026, revealed Resident 1 was admitted with a Peripherally Inserted Central Catheter (PICC line, a long, thin tube inserted into a vein in the upper arm and advanced to a large vein near the heart to deliver medications, fluids, or nutrition over an extended period) for antibiotic (medication to help fight infection) administration. A physician's order dated January 22, 2026, required staff to measure, in centimeters (cm, a unit of length in the metric system), the length of the external PICC line from the insertion site (the portion closest to the resident's skin) to the port (the portion furthest from the resident) daily and as needed. A review of the electronic medication administration record (eMAR, the electronic system used to document medications and related treatments administered to residents) revealed no documentation of PICC line measurements for Resident 1 on February 5, February 11, February 24, February 25, and February 26, 2026, as ordered. A clinical record review revealed Resident 30 was admitted to the facility on [DATE], with diagnoses that included chronic multifocal osteomyelitis of the left ankle and foot (a persistent bone infection affecting multiple areas of the bone). A review of Resident 30's quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 30 was cognitively intact with a BIMS score of 13. A clinical record review revealed Resident 30 was admitted from the acute care facility on March 2, 2026, with a Peripherally Inserted Central Catheter (PICC) line inserted for antibiotic administration. A physician's order dated March 4, 2026, required daily measurement and as needed, in centimeters, of the external length of the PICC line from the insertion site to the port. A review of Resident 30's electronic treatment record revealed no documentation of PICC line measurements on March 14, March 15, and March 21, 2026. Review of physician orders dated March 5, 2026, required PICC line dressing and cap (protective sterile covering and connector at the end of the catheter) changes every seven days. A review of the electronic treatment administration record revealed no documentation that PICC line dressing and cap changes were completed at the required seven-day intervals for Resident 30. Failure to measure the PICC line as ordered limited the facility's ability to identify potential catheter displacement (movement out of proper position) in a timely manner, placing residents at risk for complications. Failure to complete and document PICC line dressing and cap changes as ordered increased the risk for infection and compromised the integrity of the catheter site. During an interview on April 22, 2026, at 9:45 AM, the Regional Administrator of Clinical Operations stated the facility did not consistently monitor and maintain PICC lines in accordance with physician orders, facility policy, and professional standards of practice for Residents 1 and 30. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records, employee personnel records, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for two of 22 residents reviewed (Residents 1 and 30).Findings include: Federal regulation requires a facility to develop, implement, and maintain an effective training program for all new and existing staff. The training program must be based on the facility assessment (an evaluation conducted by the facility to identify the resident population and determine the knowledge and skills staff need to meet resident care needs). Pennsylvania State Board of Nursing Regulations (Title 49, Chapter 21) requires licensed nurses performing intravenous therapy, including care involving PICC lines, complete appropriate education, receive supervised clinical instruction, and demonstrate ongoing competency. Licensed Practical Nurses may only perform those functions for which they have documented knowledge, skills, and abilities under appropriate supervision. A review of the facility policy entitled Administration of Medication or Flush Through Central Venous Line last reviewed January 1, 2026, reveals the procedure guideline assumes the licensed nurse has the nursing education and skills to perform the task. The policy statement indicated administration of medication or flush through a central venous line is a complex procedure that requires necessary education, training, and experience. A clinical record review revealed Resident 1 was admitted on [DATE], with a PICC line (a long, thin catheter inserted into a vein and advanced to a large vein near the heart to deliver medications, fluids, or nutrition over time) for antibiotic administration. Physician orders required routine flushing of the PICC line with 10 milliliters (ml) of normal saline (a sterile saltwater solution used to maintain catheter patency and prevent blockage). A review of the February 2026 electronic Medication Administration Record (eMAR, the legal record used to document medication administration) showed Employee 7 Licensed Practical Nurse (LPN) and Employee 8 (LPN) documented multiple instances of accessing the PICC line to administer normal saline flushes. Employee 7 Licensed Practical Nurse (LPN) documented administering a normal saline flush through the PICC line on the following dates and times: February 7, 2026, at 12:09 AMFebruary 12, 2026, at 7:07 PMFebruary 19, 2026, at 5:58 PMFebruary 19, 2026, at 11:26 PMFebruary 20, 2026, at 3:34 PMFebruary 20, 2026, at 11:52 PM Employee 8 LPN documented administering a normal saline flush through the PICC line on the following dates and times: February 6, 2026, at 12:04 AMFebruary 12, 2026, at 1:02 AM A clinical record review revealed Resident 30 was admitted on [DATE], with a PICC line for antibiotic therapy related to chronic multifocal osteomyelitis (a bone infection affecting multiple areas). A review of physician orders dated March 3, 2026, required the PICC line to be flushed with 10 milliliters (mL) of normal saline before and after medication administration and during the day and evening shift.Physician orders required routine flushing of the PICC line and administration of intravenous antibiotics. The March 2026 eMAR indicated Employee 7 (LPN) accessed the PICC line to administer flushes and intravenous antibiotics, including Ampicillin Sodium and Ceftriaxone Sodium (antibiotic medications used to treat bacterial infections). Employee 7 (LPN) documented administering a normal saline flush through the PICC line on the following dates and times: March 3, 2026, at 9:07 PMMarch 27, 2026, at 11:32 PM Further clinical review revealed Employee 7 (LPN) documented administering Ampicillin Sodium (medicine that helps fight bacteria) 2 grams (gm) through the PICC line on March 3, 2026, at 9:56 PM and Ceftriaxone Sodium 2gm (medicine that helps fight bacteria) on March 3, 2026, at 8:54 PM. A review of employee personnel records revealed: Employee 7, LPN, employed through a contracted agency beginning April 5, 2025, had no documented education, training, or competency validation (process used to confirm a staff member can safely and correctly perform a task) related to PICC line management.Employee 8, LPN, employed through a contracted agency beginning December 16, 2025, had no documented education, training, or competency validation related to PICC line management.There was no evidence that the facility or contracted agency provided a structured training program, competency validation or ongoing education specific to PICC line care for licensed nursing staff.During an interview on April 24, 2026, at 9:40 AM, the Regional Administrator of Clinical Operations confirmed the facility could not provide documentation of PICC line-specific training or competency validation and confirmed the facility had not developed or implemented a training program specific to PICC line management for agency licensed nurses. Pennsylvania State Board of Nursing regulations (Title 49, Chapter 21) require Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) performing intravenous therapy, which includes administration of medications and care involving PICC lines, to complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision. The facility failed to develop, implement, and maintain an effective training program based on its facility assessment to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely provide care to residents requiring PICC line management. 28 Pa. Code 201.20(a) Staff Development. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on a review of select facility policy, clinical records, and a staff interview, it was determined the facility failed to offer pneumococcal immunization in accordance with facility policy and current Centers for Disease Control and Prevention (CDC) recommendations, unless medically contraindicated or the resident had already been fully immunized, for one of five residents reviewed (Resident 81).Findings include: A review of facility policy titled Pneumococcal Vaccine, reviewed by the facility on January 1, 2026, revealed that it is the facility's policy to offer pneumococcal vaccines (vaccines that protect against infections caused by Streptococcus pneumoniae, including pneumonia, bloodstream infections, and meningitis) to aid in preventing pneumonia or pneumococcal infections. The policy indicated the administration of pneumococcal vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. A review of CDC Pneumococcal Vaccination Recommendations for individuals aged 50 years or older (2025) revealed that individuals who previously received PPSV23 (pneumococcal polysaccharide vaccine, a vaccine that protects against 23 types of pneumococcal bacteria) should receive one of the following at least one year after the PPSV23 dose:PCV15 (15-valent pneumococcal conjugate vaccine, protects against 15 types of pneumococcal bacteria), orPCV20 (20-valent pneumococcal conjugate vaccine), orPCV21 (21-valent pneumococcal conjugate vaccine). A clinical record review revealed that Resident 81 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A clinical record review revealed Resident 81 was [AGE] years old and received a PPSV23 vaccine on September 1, 2024.A clinical record review revealed no additional documentation of pneumococcal immunization for Resident 81. A clinical record review revealed no evidence that Resident 81 or the resident's legal representative was offered additional pneumococcal vaccination in accordance with current CDC recommendations. Specifically, there was no documented evidence that the resident or representative was provided education or information necessary to make an informed decision regarding receipt of PCV15, PCV20, or PCV21. During an interview on April 24, 2026, at 9:30 AM, the above information was reviewed with the nursing home administrator (NHA) and regional nurse consultant (RNC). The NHA and RNC were unable to provide evidence that Resident 81 or the resident's representative was offered pneumococcal vaccination or educated regarding pneumococcal immunization in accordance with current CDC recommendations. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa code 211.12 (d)(3)(5) Nursing Services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure the pharmacist conducted medication regimen reviews at least monthly for one resident out of five reviewed (Resident 42).Findings include: A review of a facility policy entitled Medication Regimen Reviews, last reviewed by the facility on January 1, 2026, indicated the facility's consultant pharmacist reviews the medication regimen review (MRR) for every resident in the facility at least monthly. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and re-solve medication-related problems, medication errors, and other irregularities, for example, medications ordered in excessive doses or without clinical indication; medication regimens that appear inconsistent with the resident's stated preferences; duplicative therapies or omissions of ordered medications; inadequate monitoring for adverse consequences; potentially significant drug-drug or drug-food interactions; potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; incorrect medications, administration times, or dosage forms; or other medication errors, including those related to documentation. A review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts) and post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events). A review of Resident 42's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 28, 2026, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 42's clinical record conducted at the time of the survey ending April 24, 2026, and of MRR conducted between June 2025 and March 2026, revealed that the pharmacist had not conducted MRR during the months of June 2025, August 2025, September 2025, and October 2025. During an interview with the Regional Nurse Consultant on April 24, 2026, at 11:00 A.M, confirmed there was no evidence the pharmacist conducted monthly medication regimen reviews as required for Resident 42. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.9(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, review of facility staffing schedules, and staff and resident interviews, the facility failed to provide sufficient nursing staff with the appropriate competencies to ensure timely and quality care and services for two of 22 residents reviewed (Residents 10 and 14). Findings include: A review of nurse scheduling assignments revealed the facility failed to meet the minimum nurse aide to resident ratio requirement on five of 21 shifts reviewed. The facility failed to meet the minimum state requirements for nurse aides on the following dates: January 25, March 29, and April 20, 2026. A review of nurse scheduling assignments revealed the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio requirement on nine of 21 shifts reviewed. The facility failed to meet the minimum state requirements for licensed practical nurses on the following dates: January 19, January 20, January 23, January 25, March 28, and April 23, 2026. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 10's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 9, 2026, revealed the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of the care plan initiated March 8, 2026, revealed Resident 10 required assistance with activities of daily life (ADLs, fundamental self-care tasks required for independent living such as bathing, dressing, toileting, and feeding oneself) including bed mobility with one staff member, transfers with two staff members, and assistance with toileting as needed.A review of the care plan initiated March 8, 2026, revealed Resident 10 required assistance with activities of daily life (ADLs, fundamental self-care tasks required for independent living such as bathing, dressing, toileting, and feeding oneself) self-care performance deficit related to generalized weakness and neuropathy (a nerve problem that can cause pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Interventions implemented to assist the resident with ADLs include bed mobility assistance of one staff member, transfers with two staff members, and assisting with activities of daily living as needed. During an observation on April 22, 2026, at 8:33 AM, Resident 10 was in bed and stated he had been waiting approximately ten minutes for assistance after activating his call bell for help off a bedpan. At that time, Employee 11, LPN, was observed standing outside the room near a medication cart. At 8:46 AM, Employee 12, nurse aide (NA), entered the room and at 8:47 AM assisted Resident 10 off the bedpan. Employee 11 remained outside the room during this time. When exiting the resident's room at 8:47 AM, Employee 11, LPN, remained outside of the resident's room, standing near the medication cart. It was also noted that Employee 13, LPN, was at the nurse's desk and stated that when a resident rings their call bell, it alerts them at the desk on a control panel. The resident whose call bell has rung will light up after it is pressed, which remains active until the call is answered. Review of the facility-provided staffing assignment for April 22, 2026, revealed three nurse aides and one LPN were assigned to provide care for Resident 10 in the East Long Hall on the day shift. A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses that include rheumatoid arthritis (a chronic, progressive autoimmune disorder where the immune system mistakenly attacks the joints, causing painful swelling, stiffness, and damage) and schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of the care plan revealed Resident 14 required assistance from two staff members for all transfers (from bed to chair or chair to bed) and ADLs related to rheumatoid arthritis and generalized weakness. A review of Resident 14's quarterly MDS dated [DATE], revealed that Resident 14 was cognitively intact with a BIMS score of 15 indication intact cognition. During an observation on April 21, 2026, at 9:50 AM, Resident 14 was in her bed. Resident 14 indicated that she has been waiting for staff to assist her out of bed since about 7:20 AM. At 10:01 AM, Employee 4, LPN, entered the room, administered medications, and acknowledged the resident's call light was active. The LPN stated the resident would need to wait until two nurse aides were available, as the assigned nurse aide was on break. During an interview on April 21, 2026, at 10:15 AM, Employee 5, nurse aide (NA), explained that another nurse aide had completed her break and now they would assist Resident 14 out of bed. Employee 5, NA, confirmed Resident 14 asked to get out of bed during breakfast (around 7:30 AM), but staff were busy assisting with passing out meals and were unable to get her out of bed at that time. Employee 5, NA, indicated that Resident 14 required two staff members for assistance to get out of bed, and now they have two nurse aides available to assist the resident. Employee 5, NA, explained that there are many residents that need care on the unit. During an interview on April 24, 2026, at 9:30 AM, the above information was reviewed with the Nursing Home Administrator (NHA), who was unable to provide an explanation for the delays in care. The facility did not provide sufficient nursing staff to meet resident needs, resulting in delays in toileting assistance for Resident 10 and a delay of approximately two hours and 15 minutes for Resident 14 to receive assistance out of bed. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(6) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(3)(4)(i)(2) Nursing services.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure a resident or the resident's representative was fully informed of and participated in treatment decisions related to intravenous micronutrient and hydration therapy, including the failure to provide information necessary to make an informed decision and the failure to obtain consent prior to administration of treatment for one of 22 residents reviewed (Resident 103).Findings include: A clinical record review revealed Resident 103 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood flow to the brain) and hemiplegia (paralysis on one side of the body). A review of Resident 103's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 3, 2025, revealed Section C Cognitive Patterns indicating Resident 103 has problems with short-term (recall after 5 minutes) and long-term (recall long past) memory. The assessment indicated Resident 103 was moderately cognitively impaired and required cues and supervision for making daily decisions. A clinical record review revealed a Pennsylvania Orders for Life Sustaining Treatment document dated July 20, 2024, indicating Resident 103 communicated advance care planning decisions to his physician. A Pennsylvania Orders for Life Sustaining Treatment document translates a resident's end-of-life treatment preferences into medical orders that follow the resident across healthcare settings. The primary purpose is to ensure residents receive desired treatments such as specific comfort measures, medication, or intubation and avoid unwanted interventions. The document indicated Resident 103 elected that no hydration and no artificial nutrition by tube be provided. A clinical record review revealed a physician's order dated October 28, 2025, for hydration infusion one time 500 milliliters (ml) of 0.9 percent normal saline (a sterile saltwater solution commonly used for hydration) at 250 ml per hour with directions to provide one-time micronutrient hydration therapy by an outside contracted nursing service. The order included an intravenous infusion (fluid delivered directly into a vein through a catheter) containing the following substances: B-Complex (a combination of B vitamins that support energy metabolism and nerve function).Thiamine (Vitamin B1, which helps the body use food for energy and supports nerve and muscle function). Ribo 4, identified as Riboflavin 4 milligrams (Vitamin B2, which helps the body produce energy and maintain healthy skin, eyes, and nerves). Nia 20 milligrams, identified as Niacin (Vitamin B3, which helps convert food into energy and supports the skin, nerves, and digestive system). Dex 4 milligrams, identified as Dexpanthenol (Vitamin B5, which supports healing and energy metabolism). Pyr 4 milligrams, identified as Pyridoxine (Vitamin B6, which supports blood production and energy metabolism). Methyl 2 milligrams, identified as Methylcobalamin (Vitamin B12, an active form of Vitamin B12 used by the body to support nerve function and red blood cell production). Magnesium chloride 600 milligrams (a mineral involved in muscle and nerve function). Calcium chloride 100 milligrams (a mineral important for bone strength and muscle function); and Zinc 10 milligrams (a mineral that supports immune function and wound healing). A medication administration record dated October 2025 revealed Resident 103 received intravenous micronutrient and hydration therapy with 500 ml of 0.9 percent normal saline at 250 ml per hour on October 28, 2025. A clinical record review revealed no documented evidence Resident 103 or Resident 103's representative was provided information regarding the risks, benefits, purpose, or alternatives related to intravenous micronutrient and hydration therapy to support an informed treatment decision. A clinical record review revealed no documented evidence Resident 103 or Resident 103's representative consented to the administration of intravenous micronutrient and hydration therapy. During an interview on April 24, 2026, at 9:30 AM, the above information was reviewed with the nursing home administrator (NHA) and regional nurse consultant (RNC). The NHA and RNC were unable to provide documented evidence Resident 103 or Resident 103's representative was informed of and provided an opportunity to participate in the decision-making process regarding intravenous micronutrient and hydration therapy. The NHA and RNC were further unable to provide documented evidence Resident 103 or Resident 103's representative consented to the treatment prior to administration. The facility failed to ensure Resident 103 was fully informed of and able to participate in treatment decisions regarding intravenous micronutrient and hydration therapy administered on October 28, 2025. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(7) Medical director. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on review of employee personnel files, select facility policies, external contract agreements, and staff interviews, it was determined the facility failed to fully implement abuse prohibition procedures to ensure the facility did not employ or otherwise engage individuals who may have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law for one of six employees reviewed (Employee 9). Findings include: A review of the facility policy titled Abuse Policy, last reviewed by the facility on January 1, 2026, revealed residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. The facility will conduct background investigations and reference checks to avoid hiring persons who have been found guilty by a court of law of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry. The policy indicated the facility will contact the last place of employment and obtain criminal background checks in accordance with state requirements. The policy indicated if an applicant had not been a resident of Pennsylvania for two continuous years prior to employment, the facility would obtain a Federal Bureau of Investigation (FBI) criminal background check within 90 days of hire and obtain a Pennsylvania State Police criminal history background check within 30 days of hire. In accordance with Pennsylvania Act 13 of 1997, known as the Older Adults Protective Services Act, and Pennsylvania Act 169 of 1996, relating to criminal history background checks, nursing facilities are required to obtain criminal history background information for prospective employees. These requirements include obtaining a Pennsylvania State Police criminal history record check within 30 days of hire. If an individual has not maintained continuous Pennsylvania residency for the two years immediately preceding employment, the facility is also required to obtain a Federal Bureau of Investigation (FBI) criminal history background check within 90 days. A review of an external contract agreement between the facility and an external intravenous therapy services company dated August 15, 2025, revealed the external company was responsible for conducting background checks and federal program exclusion screenings on all associates with direct resident contact or access to resident records at the facility. The agreement indicated background checks shall cover the previous seven years of employment, and would be conducted in accordance with applicable state law or, in the absence of state law, checks must be obtained within two months of the date of employment for all states that the individual has lived or worked in the past three years, be based on information provided by the appropriate state or local law enforcement agency, if so required by applicable state law; and would include verification through federal exclusion databases including the Office of Inspector General (OIG), System for Award Management (SAM), List of Excluded Individuals/Entities (LEIE), and applicable State Medicaid and Medicare exclusion databases. Based on a review of clinical records, Employee 9, External Registered Nurse, provided care to residents in the facility and accessed resident's medical records on October 27, 2025, and October 28, 2025. During an interview on April 24, 2026, at 9:30 AM, the Nursing Home Administrator (NHA) and Regional Nurse Consultant (RNC) stated the external intravenous therapy company maintained Employee 9's personnel records. The NHA and RNC provided personnel records for Employee 9 for review. Review of the records provided by the facility failed to show evidence Employee 9 had a Pennsylvania State Police criminal history clearance through the Pennsylvania Access to Criminal History (PATCH) system, the state-operated criminal background check system used for employment, licensing, and volunteer screening purposes. The facility failed to fully implement abuse prohibition procedures and failed to ensure required criminal background screening documentation was obtained and maintained for Employee 9 prior to permitting the employee to provide resident care and access resident medical records within the facility. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19(8) Personnel records.

Based on a review of clinical records, information submitted by the facility, the facility's abuse prohibition policy, and staff interviews, it was determined the facility failed to accurately and completely report, document, and investigate an allegation of abuse to identify the alleged perpetrator and ensure resident protection measures were implemented in accordance with federal and state reporting requirements for one of 22 residents reviewed (Resident 81).Findings include: A review of the facility policy titled Abuse Policy, last reviewed by the facility on January 1, 2026, revealed it is the facility policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act (ACA), 6703(b)(s). Specifically, it is the facility's policy to report immediately, but no later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the event that causes suspicion did not result in serious bodily injury. Report any occurrences of abuse, neglect, misappropriation of resident property, and suspicions of crime to the State Survey Agency, local Department of Aging, and local law enforcement entities for the political subdivisions in which the facility is located. Act 13 of 1997 requires an employee or administrator of a facility who has reasonable cause to suspect that a recipient is a victim of abuse to immediately report the abuse. The law requires oral reports to the Area Agency on Aging (AAA). In addition, reports must be made to the Pennsylvania Department of Aging (PDA) and local law enforcement for suspected abuse involving serious bodily injury, serious physical injury, sexual abuse, or suspicious death circumstances. The Pennsylvania state event notification overview dated March 16, 2021, directed facilities to complete mandatory state reporting forms for all allegations of staff-to-resident physical abuse. A clinical record review revealed that Resident 81 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of information provided by the facility dated March 30, 2026, revealed the facility investigated allegations that Resident 81 stated she had been hit in the right shoulder by a woman. The facility documented that based on resident and staff witness statements, resident assessment findings, and the facility investigation, the allegation of physical abuse could not be substantiated. However, a witness statement dated March 31, 2026, revealed Employee 6, nurse scheduler, documented that Resident 81 identified the assistant director of nursing's daughter, Employee 10, agency Licensed Practical Nurse (LPN), as the person who hurt the resident's arm. The witness statement documented Resident 81 complained of pain to her right upper arm. During an interview on April 22, 2026, at 1:47 PM, Employee 6 confirmed Resident 81 identified Employee 10, agency LPN, as the individual who hurt her arm. During an interview on April 24, 2026, at 9:30 AM, the above information was reviewed with the nursing home administrator (NHA) and regional nurse consultant (RNC). The NHA and RNC confirmed the facility's submitted reports and investigative documentation did not identify Employee 10 as the alleged perpetrator. The NHA and RNC further indicated the facility investigation concluded there was no alleged perpetrator identified. The facility failed to accurately and completely report and document the allegation of abuse after Resident 81 identified a specific staff member (Employee 10 LPN) as the alleged perpetrator. The facility failed to thoroughly investigate the allegation to determine whether Employee 10 was involved in the alleged incident and failed to ensure complete reporting information was provided to the State Survey Agency and the Area Agency on Aging to support appropriate oversight and resident protection. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies.

Based on a review of clinical records, the Resident Assessment Instrument (RAI) Manual, Minimum Data Set (MDS) assessments, and staff interview, it was determined the facility failed to ensure MDS assessments accurately reflected residents' clinical status for two of 22 residents reviewed (Residents 112 and 103).Findings include: The Resident Assessment Instrument (RAI) Manual is the federally issued instruction manual that provides specific coding guidance for each item on the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care). Facilities are required to complete and code MDS assessments in accordance with the RAI Manual to ensure assessments accurately reflect a resident's condition, care needs, and services provided. A review of Resident 112's closed clinical record revealed Resident 112 was admitted to the facility on [DATE], with diagnoses that included moderate protein-calorie malnutrition (a condition in which an individual does not receive enough protein and calories to maintain health). A physician order dated October 27, 2025, at 5:58 PM, written by the facility's Certified Registered Nurse Practitioner (CRNP), directed a one-time intravenous micronutrient hydration therapy to be administered by an outside contracted nursing service. The order included an intravenous infusion (fluid delivered directly into a vein through a catheter) containing the following substances:B-Complex (a combination of B vitamins that support energy metabolism and nerve function).Thiamine (Vitamin B1, which helps the body use food for energy and supports nerve and muscle function). Ribo 4, identified as Riboflavin 4 milligrams (Vitamin B2, which helps the body produce energy and maintain healthy skin, eyes, and nerves). Nia 20 milligrams, identified as Niacin (Vitamin B3, which helps convert food into energy and supports the skin, nerves, and digestive system). Dex 4 milligrams, identified as Dexpanthenol (Vitamin B5, which supports healing and energy metabolism). Pyr 4 milligrams, identified as Pyridoxine (Vitamin B6, which supports blood production and energy metabolism). Methyl 2 milligrams, identified as Methylcobalamin (Vitamin B12, an active form of Vitamin B12 used by the body to support nerve function and red blood cell production). Magnesium chloride 600 milligrams (a mineral involved in muscle and nerve function). Calcium chloride 100 milligrams (a mineral important for bone strength and muscle function); and Zinc 10 milligrams (a mineral that supports immune function and wound healing). These substances are classified as vitamins or micronutrients. Vitamins are organic compounds required in small amounts for normal body function and are typically obtained through diet or oral supplements. Vitamins are not considered parenteral nutrition (intravenous feeding that provides calories, protein, fats, carbohydrates, vitamins, and minerals as a primary nutritional source). The micronutrients were added to 500 milliliters (ml) of 0.9 percent normal saline (a sterile saltwater solution commonly used for hydration) and infused at 500 ml per hour on October 28, 2025. A review of the October 2025 Medication Administration Record (MAR) revealed the infusion was administered and completed on October 28, 2025, at 8:15 AM. The RAI Manual for Section K0520, Nutritional Approaches, Parenteral/IV Feeding instructs that parenteral feeding refers to nutrition provided intravenously when a resident cannot receive adequate nutrition through oral intake or the gastrointestinal tract. The manual further instructs that intravenous fluids administered solely for hydration purposes or fluids used to dilute medications are not to be coded as parenteral/IV feeding. A review of Resident 112's interim payment assessment (IPA) MDS (a type of evaluation to help decide how much Medicare will pay for a resident's care; an IPA is not routine and only done when the facility chooses to complete the interim MDS) dated [DATE], revealed: Section K0520 (Parenteral/IV Feeding) was coded yes, indicating the resident received IV feeding during the seven-day look-back period (the seven days preceding the assessment reference date). Section K0710A (Percent Intake by Artificial Route) was coded to indicate the resident received 25 percent or less of total calories through parenteral or tube feeding during the look-back period. Section K0710B (Average Fluid Intake by Artificial Route) was coded to indicate the resident received 500 ml or less per day by IV or tube feeding during the look-back period. However, review of the clinical record revealed documentation of a one-time intravenous hydration infusion containing vitamins and minerals added to normal saline. The clinical record did not contain documentation the infusion provided calories as a primary nutritional source, replaced oral intake, or constituted parenteral nutrition as defined by the RAI Manual. Therefore, the coding of Sections K0520 and K0710 on the October 31, 2025, MDS assessment was not supported by the clinical record or RAI Manual instructions. A review of Resident 103's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage caused by interrupted blood flow to the brain) and hemiplegia (paralysis affecting one side of the body). A physician order dated October 28, 2025, directed administration of a one-time intravenous micronutrient hydration therapy consisting of vitamins and minerals mixed in 500 ml of 0.9 percent normal saline administered at 250 ml per hour by an outside contracted nursing service. The order included an intravenous containing the following substances: B-Complex (a combination of B vitamins that support energy metabolism and nerve function).Thiamine (Vitamin B1, which helps the body use food for energy and supports nerve and muscle function). Ribo 4, identified as Riboflavin 4 milligrams (Vitamin B2, which helps the body produce energy and maintain healthy skin, eyes, and nerves). Nia 20 milligrams, identified as Niacin (Vitamin B3, which helps convert food into energy and supports the skin, nerves, and digestive system). Dex 4 milligrams, identified as Dexpanthenol (Vitamin B5, which supports healing and energy metabolism). Pyr 4 milligrams, identified as Pyridoxine (Vitamin B6, which supports blood production and energy metabolism). Methyl 2 milligrams, identified as Methylcobalamin (Vitamin B12, an active form of Vitamin B12 used by the body to support nerve function and red blood cell production). Magnesium chloride 600 milligrams (a mineral involved in muscle and nerve function). Calcium chloride 100 milligrams (a mineral important for bone strength and muscle function); and Zinc 10 milligrams (a mineral that supports immune function and wound healing). A review of the October 2025 MAR revealed Resident 103 received the intravenous micronutrient hydration infusion on October 28, 2025. A review of Resident 103's quarterly MDS assessment dated [DATE], revealed that: Section K0520 A (Parenteral/IV Feeding) was coded 1, indicating parenteral or IV feeding was performed at the facility during the seven-day look-back period. Section K0710A (Percent Intake by Artificial Route) was coded to indicate the resident received 25 percent or less of total calories through parenteral or tube feeding during the look-back period. Section K0710B (Average fluid intake per day by IV or tube feeding) was coded to indicate the resident received 500 ml or less per day by IV or tube feeding during the look-back period. However, review of Resident 103's clinical record revealed documentation of a one-time intravenous micronutrient hydration infusion consisting primarily of vitamins, minerals, and amino acids added to normal saline. The record did not contain documentation that the infusion provided calories as a primary nutritional source, replaced oral intake, or constituted artificial nutritional support as defined under parenteral feeding in the RAI Manual. Therefore, the coding of Sections K0520 and K0710 on the November 3, 2025, MDS assessment was not supported by the clinical record or RAI Manual instructions. During an interview on April 24, 2026, at 9:30 AM, the above information was reviewed with the Nursing Home Administrator (NHA) and Regional Nurse Consultant (RNC). The facility indicated it identified and corrected the inaccurate coding for Resident 103 in March 2026. The facility also acknowledged inaccuracies related to Resident 112's October 31, 2025, MDS assessment. The facility failed to ensure the MDS assessments accurately reflected the status of Residents 103 and 112. 28 Pa. Code 211.5(f)(ix) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered or evaluated the need for a prescribed medication according to physician-ordered parameters for two of 22 residents reviewed (Resident 4 & Resident 12).Findings include: A review of the facility policy titled Administering Medications last reviewed on January 1, 2026, revealed the purpose of the policy was to ensure safe and effective administration of medication and as prescribed. The policy required medications to be administered in accordance with the provider's written or verbal orders after verification of the right medication, right dose, right route, right time, and confirmation of the resident's identity, and only when no contraindications (a clinical reason a medication should not be given because it may cause harm) were present. The policy required the verification of vital signs (measurements that show how well the body is working) prior to administering medications, if necessary. Resident 4 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (an area of brain tissue that dies because its blood supply has been blocked). A review of Resident 4's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 9, 2026, revealed that Resident 4 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognitive function, reflecting normal memory, orientation, and recall abilities). A review of Resident 4's clinical record revealed a physician order dated February 4, 2026, for Midodrine HCl (medication that helps to raise low blood pressure, especially when the blood pressure is lowered when one stands up from a seated or lying position) 5 milligrams (mg) daily by mouth every eight hours as needed for hypotension (low blood pressure). The order indicated the medication was to be held if Resident 4's systolic blood pressure (top number in a blood pressure reading that measures how much pressure is in the arteries when the heart beats and pushes blood out to the rest of the body) was greater than 100 mmHg (millimeters of mercury, unit of measurement for blood pressure). Review of the electronic medication administration record (eMAR, the legal record used to document medications administered) revealed that during the time the medication was ordered (February 4, 2026, until March 11, 2026), Midodrine was not administered and the blood pressure was not obtained every eight hours to determine the need for the medication. Resident 12 was admitted to the facility on [DATE], with diagnosis which included primary generalized osteoarthritis (a condition that occurs when cartilage that cushions the ends of bones gradually breaks down, leading to pain, stiffness, swelling, and reduced joint mobility) and tachycardia (heart is beating faster than normal). A review of Resident 12's quarterly Minimum Data Set assessment (MDS), dated [DATE], revealed that Resident 12 was cognitively intact with a BIMS score of 13 which indicates intact cognitive function, reflecting normal memory, orientation, and recall abilities. A review of Resident 12's physician order dated November 5, 2025, revealed an order for Metoprolol Succinate 12.5 milligrams Extended-Release tablet (medication used to treat high blood pressure), orally, every day. The order revealed the medication was not to be administered if the systolic blood pressure was less than 90 mm/Hg or the heart rate was less than 60 heart beats per minute. Clinical record review of the electronic medication administration (eMAR revealed that from November 5, 2026, until November 12, 2026, Resident 12's heart rate was not assessed prior to administering Metoprolol Succinate 12.5 milligrams Extended-Release tablet to determine if the medication was safe to administer. An interview with the Regional Administrator of Clinical Operations on April 22, 2026, at 9:55 AM and again on April 23, 2026, at 9:20 AM confirmed the required, vital signs were not obtained and evaluated for medication administration according to physician orders and facility policy for both Resident 4 and Resident 12. 28 Pa. Code 211.5(f)(ii)(ix) Medical records. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of the facility's restorative nursing policy, staff interviews, and resident interview, it was determined the facility failed to implement and evaluate an individualized restorative nursing program with measurable resident-centered goals, resident participation in care planning, and ongoing reevaluation to modify the program as necessary for one of 22 sampled residents (Resident 13).Findings include: Clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a condition in which the body is unable to properly regulate blood sugar levels due to problems producing or using insulin) and obesity (excess body weight that may impair mobility and physical functioning). A review of Resident 13's quarterly Minimum Data Set assessment, (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 3, 2026, revealed that Resident 13 was cognitively intact with a BIMS score of 15, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to15 indicates intact cognition). A review of the facility's Restorative Nursing Services policy, reviewed January 1, 2026, revealed that restorative goals and objectives are individualized and resident-centered and are outlined in the resident care plan. The resident will be included in determining goals and the plan of care. In addition, restorative goals may include, but are not limited to, supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or strengthening physiological resources; maintaining dignity, independence, and self-esteem; and participating in the development and implementation of their plan of care and their restorative program. An interview with the resident on April 21, 2026, at 11:00 AM revealed that Resident 13 had a desire to get stronger so that a discharge to home would be possible. The resident indicated that he was receiving restorative nursing services on a daily basis, but this service was not being done or was not effective to meet his needs to get stronger. The resident indicated that restorative staff document that he is receiving restorative services, but he is not being offered these services to enhance his ability to strengthen on a consistent basis to become independent enough to go home. The resident indicated that he was not included in the decision-making process as to when these services could be completed or what exercises would be beneficial and did not receive periodic updates or suggested changes in the program or his comfort level with the program and modifications, which may allow him to make gradual improvement towards independence. A review of a physical therapy Discharge summary dated [DATE], revealed the resident was discharged from therapy services to a restorative nursing program to maintain current level of functioning. During an interview on April 22, 2026, at 2:45 PM, Employee 1, an occupational therapist, indicated that at the time of discharge from physical therapy on August 29, 2025, Resident 13 ambulated (walked) 25 feet using a front-wheeled walker. During an interview on April 23, 2026, at 10:15 AM, Employee 2, an occupational therapist, indicated the restorative nursing program was intended to include bed positioning and mobility activities, including rolling side to side and sitting at the edge of the bed. Employee 2 indicated the resident's ability to roll in bed had declined since March 3, 2026. Review of Resident 13's care plan dated March 3, 2026, revealed there was no individualized restorative nursing care plan identifying the specific restorative program interventions, exercises to be completed, duration or frequency of the exercises, measurable goals, methods to evaluate progress, or interventions directed toward the resident's stated goal of improving strength and independence for possible discharge home. During an interview on April 22, 2026, at 2:30 PM, Employee 3, nurse aide, was unable to explain how the facility evaluated Resident 13's restorative nursing program to determine whether modifications were necessary to meet the resident's specific goals or changing physical abilities. Review of March 2026 restorative nursing documentation revealed staff documented Resident 13 refused restorative services 17 times on day shift and 10 times on evening shift. The documentation did not identify reasons for the refusals, resident concerns, or attempts to modify the program to improve participation. In addition, documentation for completed restorative services failed to include the amount of time services were provided, making it unable to determine whether the restorative program was effective in maintaining, improving, or declining the resident's physical functioning and whether modifications to the program were necessary. There was no evidence that the restorative nursing program incorporated resident choice regarding preferred times for participation, preferred exercises, gradual progression of activities, or other individualized approaches intended to support the resident's stated goal of improving independence with the main goal of achieving the resident's wishes to be independent at home. During an interview on April 24, 2026, at 11:00 AM, the Nursing Home Administrator was unable to provide documented evidence the facility maintained ongoing restorative nursing documentation demonstrating measurable results, resident-centered goals and expectations, evaluation of the effectiveness of the program, or modifications to the restorative program based on the resident's progress, refusals, declining functioning, or stated preferences. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure a resident who entered the facility with an indwelling urinary catheter was assessed for catheter removal at the earliest possible time unless the resident's clinical condition demonstrated that continued catheterization was necessary for one of 22 residents reviewed (Resident 11). Findings include: A clinical record review revealed Resident 11 was most recently admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of physician orders revealed an order dated February 19, 2026, for a Foley catheter (a flexible tube inserted through the urethra into the bladder to continuously drain urine into a collection bag) size 16 French (a catheter measurement indicating the diameter of the tube) with a 30 cubic centimeter (cc) balloon (an inflatable retention balloon used to keep the catheter in place inside the bladder) to straight bag gravity drainage (urine drainage into a collection bag using gravity rather than suction) for neurogenic bladder (a bladder dysfunction caused by nerve damage that affects the bladder's ability to properly store or empty urine). A care plan indicating Resident 11 has a need for an indwelling catheter related to neurogenic bladder initiated on March 6, 2026. Interventions to ensure Resident 11 is free from catheter-related complications include reviewing with the resident and resident representative the risks of catheterization and providing catheter care every shift and as needed. Further clinical record review revealed no documented evidence the facility assessed Resident 11 for catheter removal or evaluated whether continued catheterization remained clinically necessary following the resident's admission to the facility on December 10, 2025. During an interview conducted on April 24, 2026, at 9:30 AM, the above information was reviewed with the nursing home administrator (NHA) and regional nurse consultant (RNC). The NHA and RNC were unable to provide documented evidence the facility assessed Resident 11's ongoing need for catheterization or documented evidence the resident's clinical condition demonstrated that continued catheterization was necessary. Following surveyor inquiry during the survey, the facility obtained a physician order scheduling Resident 11 for an appointment with an external urology specialist (a physician specializing in the urinary tract and related conditions) on April 30, 2026, at 11:00 AM. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3) Nursing services.

Based on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident regarding significant weight loss for one of 22 residents reviewed (Resident 5). Findings included: A review of a facility policy entitled Weight Assessment and Intervention, last reviewed by the facility January 1, 2026, indicated resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Any weight change of 5 pounds (if the resident weight is greater than 100 pounds) or 3 pounds (if the resident weight is less than 100 pounds), or more, since the last weight assessment will constitute a re-weight for validation. If the weight is verified as requiring evaluation, nursing will notify the registered dietician. Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria 1 month- 5 percent weight loss is significant; greater than 5 percent is severe. 3 months- 7.5 percent weight loss is significant; greater than 7.5 percent is severe. And 6 months- 10 percent weight loss is significant; greater than 10 percent is severe. A review of a facility policy entitled Change in a Resident's Condition or Status, last reviewed by the facility January 1, 2026, indicated the facility will promptly notify the resident, their attending physician, and the resident representative of changes in the resident's changes in the resident's medical or mental condition or status. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself with intervention by staff or by implementing standard disease-related clinical intervention and required interdisciplinary review and or revision to the care plan. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical or mental condition or status. A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying life-threatening events) and major depressive disorder (a mental health condition characterized by persistent low mood and loss of interest in usual activities). A review of Resident 5's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 2, 2026, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 5's weight record revealed the following documented weights: February 1, 2026: 125.3 poundsMarch 1, 2026: 115.4 poundsMarch 23, 2026: 117.4 poundsMarch 30, 2026: 116.2 poundsApril 1, 2026: 116.2 poundsApril 13, 2026: 114.8 poundsApril 20, 2026: 114.2 pounds The March 1, 2026, weight reflected a loss of 9.9 pounds, representing 7.9 percent body weight loss in one month. The clinical record revealed a re-weight to verify the significant weight loss was not obtained until 22 days later. A review of a nutrition note completed by the facility's Registered Dietitian (RD) dated March 22, 2026, at 8:00 AM, in response to a weight warning for the March 1, 2026, value, recommended obtaining a reweight, which then confirmed a documented weight loss of 7.9 percent (9.9 pounds), and reflected underweight status for the resident. The RD noted the resident was receiving a vegetarian diet with regular textures and thin liquids, with ice cream provided with lunch and dinner meals, with good intakes of 51-100 percent. The RD recommended fortified foods with all meals to increase calorie and protein intake with a goal of weight stability and weight gain. A review of a nurse progress note dated March 22, 2026, at 9:47 PM, revealed new orders were obtained from the physician for weekly weights related to weight management and documented the resident was their own resident representative. A review of physician orders revealed an order dated March 22, 2026, for weekly weights. A review of physician orders revealed an order dated March 24, 2026, at 9:54 AM, for a regular texture, thin consistency, renal diet (a diet modified to reduce certain nutrients to support kidney function), ice cream with lunch and dinner trays, fortified foods with meals, and continuation of the resident's vegetarian diet preference. The interventions were implemented two days after the RD recommendation. A review of a weight warning note completed by the RD dated April 21, 2026, at 1:23 PM, in response to a weight alert for the April 20, 2026, value, documented continued weight loss of 8.9 percent (11.1 pounds) since February 1, 2026, and recommended providing a health shake with breakfast to provide an additional 200 calories and 6 grams of protein related to progressive weight loss. A review of physician orders revealed an order dated April 21, 2026, at 1:29 PM, to provide a daily health shake with breakfast due to risk for malnutrition (a condition resulting from inadequate or imbalanced nutritional intake needed to maintain normal body function and health). The clinical record failed to reveal documented evidence Resident 5's attending physician and the resident were notified of the significant weight loss identified on March 1, 2026. Additionally, the clinical record failed to reveal documented evidence recommended nutritional interventions, including fortified foods with meals, were implemented timely following identification of the resident's significant weight loss. During an interview with the regional nurse consultant on April 23, 2026, at 12:30 PM, the above findings were reviewed. The regional nurse consultant confirmed no additional documentation could be provided demonstrating timely physician or resident notification regarding the identified significant weight loss or timely implementation of recommended nutritional interventions. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed medication to one of four sampled residents (Resident CR1).Findings include: A review of the facility policy titled Unavailable Medication, last reviewed by the facility on December 8, 2025, revealed it is the facility policy that, in conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. Upon receipt of information from the pharmacy regarding a medication that is unavailable, nursing staff shall notify the physician, obtain a new order and discontinue the prior order, or obtain a hold order for the unavailable medication. A clinical record review revealed resident CR1 was admitted to the facility on [DATE], with diagnoses that included cellulitis of the right lower limb (a skin infection affecting the deep dermis and subcutaneous tissues, characterized by swelling, redness, pain, and warmth). A physician's order for Vancomycin Intravenous (IV) Solution 1000 mg/200 ml (an antibiotic medication) with directions to administer 1000 mg intravenously every 12 hours for Methicillin-resistant Staphylococcus aureus (MRSA, a bacterium that is resistant to many common antibiotics) was initiated on March 20, 2026. A review of an admission progress note dated March 20, 2026, at 4:16 PM revealed resident CR1 was admitted to the facility with an abscess (a swollen lump filled with pus that forms under the skin) on her right foot and MRSA. The note indicated the resident's physician orders were reviewed and no clinically significant order issues were identified. A review of Resident CR1's medication administration record dated March 2026 revealed Resident 1 was not administered Vancomycin Intravenous (IV) Solution 1000 mg/200 ml on March 20, 2026, at 9:00 PM or on March 21, 2026, at 9:00 AM as ordered by the physician. A clinical record review revealed no documented evidence facility staff notified the physician that Vancomycin Intravenous (IV) Solution 1000 mg/200 ml was not available to be administered to Resident CR1. During an interview on March 26, 2026, at 1:45 PM, the nursing home administrator (NHA) and director of nursing (DON) confirmed Resident CR1 did not receive Vancomycin Intravenous (IV) Solution 1000 mg/200 ml in accordance with the physician's orders. The DON and NHA indicated the medication was not available for administration on March 20, 2026, at 9:00 PM or on March 21, 2026, at 9:00 AM. The NHA and DON were unable to provide documented evidence the physician was notified that Resident CR1's antibiotic medication was not available for administration. The facility failed to ensure the timely acquisition and administration of a prescribed antibiotic medication for resident CR1, resulting in two missed administrations. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of select facility policies, clinical records, facility-provided investigative documentation, observations, and staff interviews, it was determined the facility failed to ensure that one resident (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure placed one of eight residents sampled in Immediate Jeopardy to the health and safety of residents.Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility December 8, 2025, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility policy entitled Identifying Sexual Abuse and Capacity to Consent last reviewed December 8, 2025, revealed sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate sexual touching of any kind especially to the breasts or perineal area. Further it is indicated that sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. The policy further revealed the facility will investigate and protect a resident from non-consensual sexual relations any time there is a reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. The policy revealed that during an investigation into sexual abuse, evidence will be preserved and not tampered with. The policy identified examples of tampering as washing linens or clothing, destroying documentation, bathing or cleaning the resident before the resident has been examined including a rape kit, or otherwise impeding a law enforcement investigation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). An Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process completed periodically to plan resident care) dated October 21, 2025, revealed that the resident had a BIMS score of 7 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that assesses the resident's attention, orientation, and ability to register and recall new information. A score of 0-7 indicates severe cognitive impairment, reflecting impaired judgment and decision-making capacity). Clinical record review revealed the facility admitted Resident 2 on November 18, 2025, with a diagnosis of cerebral infarction (occurs when a blood vessel to the brain is blocked, causing tissue death due to a lack of oxygen and nutrients). A review of an admission MDS dated [DATE], revealed that Resident 2 had a BIMS score of 14 (a score of 13-15 indicates cognition is intact). A review of facility-provided investigative documentation revealed that on January 1, 2026, at 7:50 PM Resident 1 was in the shared bathroom connecting her room and Resident 2's room. The documentation indicated that Employee 1 (Nurse Aide) observed Resident 1 unlock and slightly open the door to Resident 2's room, which was documented as a habitual action by Resident 1 to indicate she was finished using the bathroom. The documentation revealed that Resident 2 opened his door and leaned toward Resident 1, at which time he kissed Resident 1 on the lips. Employee 1 immediately removed Resident 1 from the bathroom and notified the RN Supervisor on duty. An interview with Employee 1 (Nurse Aide) on January 15, 2026, at 9:35 AM confirmed the events as documented. Employee 1 stated she was waiting in the bathroom area to assist Resident 1 back to her bed when Resident 1 unlocked and cracked open the door to Resident 2's room, which Employee 1 stated Resident 1 routinely did out of habit to signal that the bathroom was available. Employee 1 stated Resident 2 was standing just inside the doorway, opened the door further, and leaned in to kiss Resident 1 on the lips.Employee 1 stated she immediately removed Resident 1 from the bathroom and reported the incident to the RN (registered nurse) Supervisor. Employee 1 stated that following the incident on January 1, 2026, she and another Nurse Aide (Employee 2) frequently remained in Resident 1's room to ensure her safety due to Resident 2's continued behaviors toward Resident 1. Employee 1 stated that on multiple occasions she observed Resident 2 sitting outside Resident 1's room or staring at Resident 1 while in common areas of the facility.Further review of the investigative documentation revealed the facility implemented an intervention to lock the inside of Resident 2's bathroom door to prevent Resident 2 from accessing the shared bathroom. The documentation indicated the facility provided Resident 2 with a bedside commode to limit his access to the shared bathroom with Resident 1. The investigative documentation indicated the facility attempted to relocate Resident 2 to another room following the incident; however, Resident 2 declined the room change. The documentation indicated Resident 2 was questioned regarding the incident and stated, She is my friend. Who cares if we kissed. A review of a written witness statement dated January 1, 2026, written by Employee 1, corroborated the investigative documentation and interview findings, documenting that Resident 1 opened the door to Resident 2's room and Resident 2 leaned through the doorway and kissed Resident 1 on the lips. An interview with the Nursing Home Administrator (NHA) on January 15, 2026, at 10:00 AM revealed the facility did not relocate Resident 1 following the incident on January 1, 2026. The NHA stated the decision was made due to concern that moving Resident 1 would increase confusion. Despite Resident 1's documented cognitive impairment, the resident was not offered a room change. A review of Resident 2's progress notes revealed that on January 3, 2026, Resident 2 was documented as exiting Resident 1's room following a visit with Resident 1 and her family. Further review of Resident 2's progress notes revealed that on January 7, 2026, at 8:37 PM Resident 2 was documented as having argued with the Nurse Aide on duty (Employee 1) at 4:00 PM and again at 8:00 PM. The progress note documented that Resident 2 stated he felt he was being watched and followed by staff. The note documented that Resident 2 made comments toward the aide, brought up past events, and caused agitation in another female resident toward the aide. The progress note indicated Resident 2 was unable to be redirected at that time. Further review of Resident 2's progress notes revealed that Social Services met with Resident 2 on January 8, 2026, due to ongoing agitation with staff. The progress note documented that Resident 2 reflected on past interactions with Resident 1. The note further documented that Social Services educated Resident 2 that he may speak with and be friends with the female resident in common areas, but that he should not enter Resident 1's room or allow Resident 1 to enter his room. Review of facility investigative documentation revealed that on January 11, 2026, at 1:15 AM Employee 3 (Nurse Aide) observed Resident 1 located in Resident 2's bed, naked, with Resident 2 seated in his wheelchair next to the bed. Employee 3's witness statement dated January 11, 2026, documented that during routine rounding, Employee 3 observed Resident 1 was not in her bed and noted that Resident 1's wheelchair, which she frequently used, was located next to her bed and empty. The statement further documented Employee 3 checked the shared bathroom between Resident 1's and Resident 2's rooms and found the door locked from the inside. Due to prior resident-to-resident history, Employee 3 proceeded to Resident 2's room.The witness statement documented that upon entering Resident 2's room, Employee 3 observed Resident 1 lying naked in Resident 2's bed. The statement documented that Resident 2 was touching Resident 1's private area, with Resident 1's legs observed to be open. Employee 3 shouted for the supervisor, at which time Resident 1 walked to the bathroom and put her gown back on. Employee 3 escorted Resident 1 back to her room, where Resident 1 complained of vaginal pain and was observed checking herself in the bathroom. Further review of facility investigative documentation revealed that both residents were questioned regarding why they were together and both stated they were talking. The documentation indicated the facility determined there was no evidence of penetration and no further assessment was completed at that time. An interview with Employee 3 on January 15, 2026, at 10:07 AM confirmed the accuracy of the information documented in her January 11, 2026, written witness statement. During the interview, Employee 3 stated that when she entered Resident 1's room to conduct rounding, Resident 1 was not in her bed. Employee 3 stated she checked the shared bathroom and found the door locked from the inside. Employee 3 stated she then proceeded to Resident 2's room based on known prior interactions between the residents. During the interview, Employee 3 stated facility staff had been aware of multiple prior incidents involving Resident 2 exhibiting inappropriate behaviors toward Resident 1. Employee 3 stated Resident 2 previously had bathroom privileges removed after being found in the bathroom with Resident 1 on multiple occasions. Employee 3 stated that between January 1, 2026, and January 11, 2026, there was an additional incident in which Resident 2 was found caressing Resident 1's breast; however, Employee 3 was unable to recall the specific date of that incident. Employee 3 stated during the interview that she observed Resident 2's fingers inside Resident 1's vagina and that she yelled for the supervisor, causing Resident 2 to stop the contact. A second interview with Employee 3 on January 15, 2026, at 12:34 PM revealed Employee 3 did not document in her initial written witness statement that she observed Resident 2's fingers inside Resident 1's vagina because she believed documenting that Resident 2's hand was on Resident 1's private area sufficiently conveyed what occurred. Employee 3 stated she was emotionally distressed by the incident and remained upset at the time of the interview. A review of a separate written witness statement authored by Employee 4 (Nurse Aide) revealed Employee 4 and Employee 3 were conducting rounds together when Resident 1 was not located in her room. The statement documented that the shared bathroom door was locked, prompting both employees to check Resident 2's room. The witness statement written by Employee 4 documented that upon entering Resident 2's room, Resident 1 was observed lying naked in Resident 2's bed and that Resident 2 was observed touching Resident 1's vaginal area. The statement documented that both Nurse Aides yelled for the supervisor and that Resident 1 went to the bathroom to dress and wipe herself. The statement further documented Resident 1 complained of vaginal pain. Multiple attempts to contact Employee 4 for interview on January 15, 2026, were unsuccessful. An interview with Employee 1 (Nurse Aide) on January 15, 2026, at 10:39 AM revealed that after the January 11, 2026, incident, Resident 1 and Resident 2 were found unattended together on multiple occasions, despite the facility's awareness of prior sexual abuse concerns. Employee 1 stated that at the time of the interview, Resident 1 and Resident 2 were alone together in the facility chapel. Following this statement, the surveyor proceeded to the chapel and observed Resident 2 being wheeled back toward his room, while Resident 1 was observed returning from the chapel hallway, confirming the residents had been alone together without staff supervision. An interview with Resident 2 on January 15, 2026, at 11:00 AM confirmed that Resident 1 and Resident 2 had been alone together in the chapel prior to the interview. During the interview, Resident 2 denied touching Resident 1's vaginal area. Resident 2 stated that Resident 1 frequently sought him out, described her as infatuated, and stated they spent time together, often alone, despite acknowledging Resident 1's diagnosis of dementia. A review of Resident 1's care plan revealed that 15-minute safety checks were not initiated until January 13, 2026, two days after the sexual abuse incident involving Resident 2. A review of Resident 1's physician orders revealed that every 15-minute safety checks were ordered for every shift beginning January 12, 2026, at 4:00 PM, which was over 36 hours after the January 11, 2026, incident. A review of Resident 1's 15-minute safety check documentation provided by the facility on January 15, 2026, at 3:00 PM revealed an incomplete form, indicating the safety checks were not completed at the ordered frequency. After multiple additional requests by the surveyor the facility provided additional 15-minute safety check documentation on January 16, 2026. Review of this documentation revealed new entries and signatures added after the originally submitted form, despite the documented dates and times having already passed. The updated documentation conflicted with the originally provided record, which reflected incomplete monitoring. A review of Resident 2's 15-minute safety checks revealed that no safety checks were documented immediately following the January 11, 2026, incident. The first documented safety check for Resident 2 was completed on January 11, 2026, at 3:00 PM, 13 hours after the incident. Further review revealed that on January 15, 2026, Resident 2's ordered 15-minute safety checks were not completed from 12:00 AM through 3:00 AM, and no other documentation accounted for Resident 2's whereabouts during that time. An interview with the Director of Nursing (DON) on January 16, 2026, at 10:00 AM revealed that when questioned regarding the newly added documentation and signatures on Resident 1's safety check records, the DON was unable to explain why the original incomplete documentation was later supplemented, despite the original record indicating the checks were not completed as ordered. As of the survey date of January 15, 2026, the facility had not implemented effective interventions to prevent Resident 1 from engaging in sexual contact with Resident 2, despite Resident 1's documented inability to consent due to cognitive impairment. The facility failed to rule out sexual abuse, despite facility policy requiring investigation of any allegation or suspicion of sexual abuse. An interview with the Nursing Home Administrator (NHA) on January 15, 2026, at 12:00 PM revealed the facility did not send Resident 1 to the emergency department for evaluation, despite facility policy indicating the need for evaluation following suspected sexual abuse. The interview revealed that the facility did not fully investigate or report the sexual abuse incident and did not develop or implement timely interventions for a resident with a known history of inappropriate sexual behaviors, either prior to or after the sexual abuse occurred. Applying the reasonable person concept, for Resident 1, who is unable to advocate for herself due to cognitive impairment, the circumstances surrounding the sexual abuse would be expected to result in psychosocial harm, fear, humiliation, and emotional distress. An interview with Employee 1 on January 15, 2026, at 11:00 AM revealed observable changes in Resident 1's behavior following the January 11, 2026, incident. Employee 1 stated Resident 1 typically went to bed between 8:00 PM and 9:00 PM; however, since the incident, Resident 1 stayed awake later and was not sleeping as usual. Employee 1 further stated Resident 1 appeared fearful when using the bathroom, frequently looking toward the doorway where Resident 2 had previously accessed the shared bathroom. An interview with the Nursing Home Administrator and Director of Nursing on January 15, 2026, at 3:15 PM included a review of survey findings related to the facility's failure to ensure that Resident 1 was free from sexual abuse perpetrated by Resident 2. These failures placed residents who are cognitively impaired at risk for sexual abuse resulting in Immediate Jeopardy (IJ). The facility was notified of the Immediate Jeopardy on January 15, 2026, at 12:40 PM and the IJ template was provided to the facility at 12:56 PM. An immediate IJ removal plan was requested and received on January 15, 2026, at 2:13PM and accepted on January 15, 2026, at 2:27PM. The IJ removal plan included: Resident 2 was discharged from the facility on January 15, 2026. All staff education was initiated immediately on the facility abuse policies including allegations of sexual abuse. Starting with the 7:00 PM to 7:00 AM shift, Nurse Aides and Licensed Nurses, education will be completed on documenting resident behaviors and will continue to be monitored by the Social Services Director and resident care plans will be updated as needed. Education will continue prior to each licensed staff members next shift. In the event of sexual abuse, the perpetrator and victim will immediately be placed on 1:1 supervision. The Immediate Jeopardy was lifted on January 16, 2026, at 11:45AM upon receipt of the facility's immediate action plan and verification that the actions had been implemented. Refer to F609 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10 (a)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on a review of clinical records, select facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in accordance with federal requirements. Specifically, the facility's administration failed to ensure that one of eight residents sampled (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure resulted in Immediate Jeopardy to resident health and safety.Findings included: A review of the job description for the Nursing Home Administrator (NHA) signed and dated August 19, 2024, revealed the administrator will be knowledgeable of and demonstrate the ability to provide quality care by fostering a safe environment for residents and staff, providing emotional and psychological support for the residents within the facility, directing, and overseeing the day-to-day operation of the facility to ensure that the highest degree of quality care is maintained at all times in accordance with current state and federal standards, and implementing and enforcing company policies and procedures. The Job Description for Director of Nursing (DON) Services signed and dated October 1, 2025, revealed the DON will assure resident safety through nursing staff, evaluate effects of care delivered and assign special treatments when indicated, and review and revise care plans and assessments as necessary. Review of facility documentation and interviews with staff revealed that administrative oversight failed to ensure effective coordination, monitoring, and implementation of facility systems designed to protect residents from abuse. Specifically, the facility failed to identify, mitigate, and manage known and foreseeable risks associated with resident interactions, particularly for residents with cognitive impairment (a condition that limits a person's ability to understand, process, or make safe decisions), thereby failing to protect Resident 1 from sexual abuse by Resident 2. The failure of the Administrator and Director of Nursing to carry out their respective administrative responsibilities demonstrated ineffective use of facility resources, including failure to ensure appropriate supervision, failure to ensure consistent implementation of facility policies related to resident safety and abuse prevention, and failure to ensure timely administrative intervention when resident safety risks were present. As a result of these administrative failures, the facility did not maintain an effective system of oversight to ensure residents were protected from abuse, and one resident experienced sexual abuse, placing residents, particularly those who were cognitively impaired, at continued risk for serious harm. This deficient practice is directly related to and supported by the Immediate Jeopardy citation under F600 (Freedom from Abuse, 42 CFR S483.12), which identified that the lack of effective administrative oversight, monitoring, and enforcement of policies by facility leadership contributed to the Immediate Jeopardy situation. Refer F600 28 Pa. Code: 201.14 (a) Responsibility of licensee28 Pa. Code: 201.18 (e)(1) Management28 Pa. Code 211.12 (d)(3) Nursing services

Based on a review of clinical records, information submitted by the facility, the facility's abuse prohibition policy and staff interviews, it was determined the facility failed to accurately and completely report and document an alleged incident of sexual abuse for 1 of 8 residents reviewed (Resident 1) to the State Survey Agency and the Area Agency on Aging. Findings include: A review of facility policy entitled Abuse Protection last reviewed by the facility on December 8, 2025, revealed under the category Reporting Serious crimes, it is the facility's responsibility to report any occurrences of abuse, neglect, misappropriation of resident property, and suspicions of a crime to the State Survey Agency, Department of Aging and local law enforcement. The policy further revealed if the reportable event resulted in serious bodily injury (sexual abuse), the facility is to report the event within 2 hours of forming the suspicion. A review of a facility policy entitled Identifying Sexual Abuse and Capacity to Consent last reviewed by the facility on December 8, 2025, revealed for any alleged violation of sexual abuse, protective measure and an investigation will begin immediately. The policy further details the protective measures, and investigation will include immediately implementing safeguards to prevent further potential abuse, immediately reporting the allegation to the appropriate authorities, conducting a thorough investigation of the allegation, including the resident's capacity to consent, and thoroughly documenting and reporting the result of the investigation of the allegation. A review of clinical record revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). An Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process completed periodically to plan resident care) dated October 21, 2025, revealed that the resident had a BIMS score of 7 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that assesses the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked, resulting in damage to brain tissue). An admission Minimum Data Set assessment dated [DATE], indicated Resident 2 had a BIMS score of 14, which reflects intact cognition (a score of 13-15 indicates cognition is intact). Review of a facility-provided abuse investigation report revealed that on January 11, 2026, at approximately 1:15 AM, a nurse aide (Employee 3) observed Resident 1 on Resident 2's bed. The report documented that Resident 2 was seated in his wheelchair at the bedside and Resident 1 was unclothed. The report further stated both residents indicated they were talking and concluded there was no evidence of penetration. However, review of a written witness statement completed by Employee 3 revealed additional information not accurately reflected in the facility's report. Employee 3 documented that at approximately 12:50 AM, Resident 1 was last observed seated in her chair. During routine rounds, Employee 3 noted Resident 1 was no longer in her bed and her wheelchair was empty and positioned beside the bed. Employee 3 checked the shared bathroom, which was locked, and then entered Resident 2's room where Resident 1 was found unclothed in Resident 2's bed. The witness statement documented that Resident 2 was observed touching Resident 1's vaginal area while Resident 1's legs were open. Employee 3 documented she immediately called for supervisory assistance. The statement further documented that Resident 1 walked to the bathroom, put her gown back on, and was escorted back to her room, where she complained of vaginal pain and was observed checking herself in the bathroom. Review of an additional witness statement from Employee 4 corroborated that Resident 2 was observed touching Resident 1's vaginal area and that Resident 1 complained of vaginal discomfort following the incident.Review of information submitted by the facility to the State Survey Agency and the local Area Agency on Aging on January 11, 2026, at 8:24 PM revealed the facility failed to accurately and completely report the incident. The report did not identify that staff directly observed Resident 2 touching Resident 1's vaginal area and failed to report that Resident 1 complained of vaginal pain immediately following the incident. The facility reported that Resident 1 exhibited no signs or symptoms of distress, which was inconsistent with the eyewitness documentation provided by Employees 3 and 4. The same inaccurate and incomplete information was reported to the Area Agency on Aging. During an interview conducted on January 15, 2026, at 10:00 AM, the Nursing Home Administrator stated the facility did not report all observed findings to the State Survey Agency and Area Agency on Aging because both residents stated they were just talking, despite staff eyewitness accounts documenting physical sexual contact. The facility's clinical consultant further stated that the nurse who submitted the report to the Area Agency on Aging was not present at the time of the incident and was later suspended for reporting false information, despite the reported information being inconsistent with the written witness statements. An interview with the NHA and DON (Director of Nursing) on January 15, 2026, at 2:15PM reviewed the findings that the facility did not follow their established abuse policy and procedures for reporting abuse and that the facility failed to factually report all relevant information obtained during an investigation 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10 (a)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on review of select facility policies, clinical record review, review of facility-provided documentation, and staff interviews, it was determined that the facility failed to protect and maintain personal privacy and dignity when staff recorded a resident receiving incontinence care without consent. This failure resulted in a violation of personal privacy protection for 1 of 5 sampled residents (Resident 1). This concern represents past non-compliance, as the facility identified, addressed, and corrected the issue before the survey.Findings include: A review of a select facility policy for Use of Employee Telephones, last reviewed December 8, 2025, revealed it is the policy of the facility that cellular phones may be used for personal calls and text messaging only when the employee is on authorized meal and break periods, and employees' cell phones will remain off or on silent during all other work hours. A review of a select facility policy for Dignity, last reviewed December 8, 2025, revealed it is the policy of the facility that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Further review revealed that staff should promote, maintain, and protect resident privacy, including bodily privacy, during assistance with personal care and during treatment procedures. A review of a select facility policy for Videotaping, Photographing, and Other Imaging of Residents, last reviewed December 8, 2025, revealed it is the policy of the facility that residents will be protected from invasion of privacy and abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. Further review revealed that staff may not take or release images or recordings of any resident without explicit written consent. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and cerebral infarction (brain damage that results from a lack of blood). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 1 dated November 06, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 01 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A clinical record review for Resident 1 of a care plan initiated on October 26, 2021, revealed the resident had urinary and bowel incontinence (involuntary loss of urine or stool) related to disease processes, impaired mobility, and physical limitations, and interventions included providing assistance with toileting and providing incontinent care as needed.A review of facility-provided documentation showed that on December 16, 2025, at 2:00 AM, Employee 1, NA (nurse aide), used her personal cell phone to record video footage of Resident 1 in Resident 1's room while incontinence care was being provided by Employee 3, NA. Employee 1 NA and Employee 2, NA, were positioned in another location across the facility courtyard (73 yards across the courtyard) and recorded through a window where the blinds had not been lowered. The recording was made without consent, and neither Resident 1 nor Employee 3 were aware that they were being recorded. During an interview with Employee 3, CNA, on December 22, 2025, at 11:15 AM, it was stated the window shade had not been lowered during incontinence care at the time of the incident.During an interview with the Nursing Home Administrator (NHA) on December 22, 2025, at 2:00 PM, it was acknowledged that Employee 1 and Employee 2 admitted to making the video recording. The NHA confirmed it is the facility's responsibility to ensure residents at the facility have a right to personal privacy. The NHA revealed that both Employee 1 and Employee 2 have been terminated from employment at the facility as of December 17, 2025. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, and there were no other facility staff or residents reporting any unauthorized videos. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to facility staff regarding HIPAA (Health Insurance Portability and Accountability Act) regulations and policy and usage of cell phones and electronic devices. To monitor and maintain ongoing compliance, the NHA/designee will perform audits twice a week for 4 weeks to ensure that staff are following HIPAA regulations and policy. Any negative findings will be immediately corrected. Results of audits will be forwarded to facility QAPI for review and recommendation as indicated. The facility's immediate corrective action plan was completed on December 18, 2025. 28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (c) Nursing services.

Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three of 20 sampled residents (Residents 49, 78, and 82). Findings include: A review of facility policy labeled Medication Process- Medications Unavailable last reviewed May 1, 2025, revealed the Licensed nurse is to check the Med Cubex (a pharmacy inventory management system) Inventory on Hand first. If a medication is identified as not being available in the Cubex, the Licensed nurse is to call the pharmacy to determine the medication deliver status. Following the information received from the pharmacy, the licensed nurse is to call the physician with the information on the medication delivery status and request a new order for medication administration if the medication will not be available to be administered. An interview with the Director of Nursing (DON) and the clinical nurse consultant on June 12, 2025, at approximately 11:32 AM revealed that to obtain a controlled medication (a medication with potential for abuse), a licensed nurse must contact the pharmacy to receive a code to retrieve the medication from the Med Cubex. A review of Resident 49's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities). A review of physician's orders dated May 16, 2025, revealed the physician prescribed Xanax 0.25 mg (medication used to treat anxiety) one tablet by mouth every eight hours for anxiety beginning on May 16,2025. A review of the May 2025 medication administration record (MAR) showed that the Xanax was not administered on May 27 at 10:00 PM, May 28 at 6:00 AM and 2:00 PM. The MAR was coded 9 to indicate see nurses' notes. A nursing progress note dated May 27, 2025, at 9:36 PM documented the dose was not given because the nurse was waiting on pharmacy, med unavailable. Additional record review indicated the medication had not been received because a new prescription was required. A nursing progress note dated May 28,2025 at 5:05 AM indicated the morning dose of Xanax was not given because the medication was unavailable. Further record review revealed the facility had not received the Xanax from the pharmacy because Resident 49 needed a new prescription. Continued review of the record revealed a nursing progress note dated for May 28, 2025, at 1:01 PM revealed the medication was unable to be pulled from the Cubex and was awaiting a return call from the physician. Further review of the MAR revealed no signature on May 29,2025, at 6:00 AM to indicate the medication was administered at the ordered time. A clinical record review of Resident 78 revealed they were admitted to the facility on [DATE], with diagnoses to include atrial fibrillation (a condition that causes the heart to beat irregularly, sometimes faster than normal) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A physician's order dated May 16, 2025, directed Macrobid 100 mg, one tablet by mouth twice daily for three days for infection. The May 2025 MAR for Resident 78 showed that the May 17, 2025, 9:00 AM dose was not administered, with the record again coded 9. An electronic MAR note dated May 17, 2025, at 11:14 AM documented that the Macrobid was unavailable from the pharmacy and that the facility was unable to provide a reason for the unavailability. A review of Resident 82's clinical record revealed the resident was admitted to the facility February 29,2024, with diagnoses which included Unspecified Dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities). A physician's order dated May 6, 2024, prescribed Oxycodone HCL 5 mg (an opioid analgesic used to treat pain), by mouth every eight hours for shoulder pain. A review of Resident 82's MAR (medication administration record) showed that the 6:00 AM dose on May 9, 2025, was not administered and was marked with a 9. A nursing note dated May 9, 2025, at 6:07 AM documented that the medication was unavailable. Further documentation revealed the facility had not received the medication due to a need for a new prescription. The record showed that multiple attempts were made to contact the pharmacy to obtain a release code, but no return call was received. An interview with the Director of Nursing (DON) on June 13, 2025, at approximately 8:55 AM acknowledged the facility did not have adequate procedures in place to ensure medications were obtained and administered in a timely manner for Residents 49, 78 and 82. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.9 (f)(2) Pharmacy services.

Based on clinical record review, facility policy, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences and failed to ensure that residents were invited to participate in the care planning process for three of 20 residents reviewed (Residents 16, 51, and 85). Findings include: Review of the facility Care Planning- Interdisciplinary Team Policy last reviewed May 1, 2025, indicated the interdisciplinary team (IDT) is responsible for resident care plans. The IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition staff, to the extent practicable the resident and/or the resident's representative, and other staff as necessary to meet the needs of the resident, or as requested by the resident. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If it is determined that participation of the resident or representative is not practicable for the development of the care plan, an explanation is documented in the medical record. Social services director, therapy (if on case load), nursing, and activities are to attend meetings. During an interview conducted on June 10, 2025, at 10:30 AM, Resident 16 stated that he had not been invited to participate in the care planning process and had not attended any care plan meetings with facility staff. He expressed interest in meeting with staff to discuss his care. A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE], transferred to the hospital on December 27, 2024, and readmitted on [DATE]. He was hospitalized again on January 31, 2025, and subsequently readmitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). Review of Resident 16's admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 13, 2025, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). Review of the clinical record revealed no documented evidence that a care plan meeting had been conducted for Resident 16 following the February 13, 2025, admission MDS or that the resident had been invited to participate in the development or review of his comprehensive care plan. Review of Resident 16's quarterly MDS dated [DATE], revealed the resident remained cognitively intact with a BIMS score of 15. Review of a Care Plan Report dated April 29, 2025, indicated that a care plan meeting was held between the resident and the facility's social worker. A corresponding social services progress note, also dated April 29, 2025, documented that the resident's code status, Resident Representative/POA (power of attorney), weight, oxygen use, blood pressure, discharge from therapy, and wounds were reviewed during this meeting. The note indicated that the resident would remain in the facility for long-term care and that assistance would be provided as needed. However, there was no documented evidence that required members of the interdisciplinary team (IDT), including representatives from nursing and activities, participated in the April 29, 2025, care plan meeting, as outlined in the facility's Care Planning policy. During an interview conducted with the Nursing Home Administrator (NHA) on June 12, 2025, at approximately 12:40 PM, the NHA was unable to provide documentation confirming that a care plan conference with IDT members was held following Resident 16's February 13, 2025, admission MDS or the April 21, 2025, quarterly MDS. There was no evidence that the resident's comprehensive care plan was reviewed by the full IDT to ensure development and discussion of the resident's goals, needs, and preferences in all areas of care. A clinical record review revealed Resident 85's was admitted to the facility on [DATE], with diagnoses to include spinal cord compression (pressure on the spinal cord causing numbness, pain, weakness and loss of bowel and bladder control), muscle weakness, and need for assistance with personal care. A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 14, 2025, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates the resident is cognitively intact). During an interview on June 10, 2025, at 2:00 PM, Resident 85 stated that she had not been invited to participate in the care planning process or any care plan meeting since admission. A review of the clinical record revealed no documentation of a care plan conference or invitation to participate in the development or review of her comprehensive person-centered care plan. A clinical record review revealed Resident 51 was admitted to the facility on [DATE], with diagnosis to include a hereditary ataxia (a group of genetic disorders characterized by progressive problems with coordination and balance (ataxia) that are inherited from one generation to the next. These conditions affect the nervous system, particularly the parts of the brain responsible for motor control, such as the cerebellum, spinal cord, and peripheral nerves) and muscle weakness. A review of the quarterly MDS dated [DATE], revealed that Resident 51 was moderately cognitively impaired with a BIMS score of 12 (a score of 8-12 indicates moderate cognitive impairment). Review of the clinical record revealed no documented evidence that a care plan conference had been conducted for Resident 51 or that the resident and resident's Responsible Party had been invited to participate in the development or review of his comprehensive care plan. During an interview with the Nursing Home Administrator (NHA) on June 12, 2025, at 11:30 AM, the NHA confirmed there was no documentation to show that a care plan conference had been held for Resident 85 or 51 or that the resident and/or Responsible Party had been invited to participate in the care planning process. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on observations, review of clinical records, facility policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure adequate staff supervision and effective safety measures for a resident who expressed exit seeking behaviors and was identified as a wandering risk. The failure resulted in the elopement for one resident (Resident 1) out of 6 residents reviewed that were at risk for elopment. Following this elopement the facility further failed to promptly identify the resident's absence as well as identify supervisory and safety needs to prevent unsupervised exits from the facility, which placed residents in immediate jeopardy of unsupervised exits from the facility and the potential for serious bodily injury or death. Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnosis to include Parkinsons disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems.) and Schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania). Review of an admission MDS assessment (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2, 2024 revealed the resident to have a BIMS (tool used to get a quick snapshot of how well you are functioning cognitively at the moment) score of 6. A score of 0 to 7 indicates severe cognitive impairment. Review of hospital documentaion including History and Physical dated September 28, 2024 (prior to the resident's admission to the facility), indicated that resident was admitted to the hospital after emergency services (paramedics) found (him/her) wandering in the street and confused. Review of Resident 1's care plan revealed, resident has behaviors such as wandering and/or exit seeking, often states (he/she) is going home. Interventions to include, Administer medications per physician order. Monitor for effectiveness and ineffective Give non-judgmental support. Keep resident safe during episodes of behaviors; attempt to redirect. Monitor and document episodes of behaviors; notify physician/NP/PA when behaviors persist or won't deescalate. Observe and report any changes in mental status caused by situational stressors. Offer psychologist/psychiatrist services as needed Offer/provide activities of interest to keep resident engaged in positive interactions. Provide a calm safe environment when the patient's frustrations escalate and allow time to voice feelings. Provide a structured schedule for daily care when possible. Review of a quarterly nursing assessment dated [DATE] indicated that Resident 1 had an elopement risk evaluation completed. The results noted as follows, the resident was physically capable of leaving the facility, (he/she) wandered in the facility and had a history of wandering, (he/she) verbalized exit seeking behavior. The form indicated that resident had not attempted or had an actual elopement. Review of a facility investigation document dated January 10, 2025 at 1:45 A.M. revealed, on January 10, 2025 at 1:45 A.M., it was reported by nurse aide staff that Resident 1 was missing from (his/her) room. The resident was last seen prior to 11 P.M. near the west side of the facility. Prior to that, resident was seen sitting in a chair outside (his/her) room at 9 P.M. The nursing supervisor was contacted between 1:55 A.M. and 2 A.M. by the unit LPN (Licensed Practical Nurse). A code [NAME] (missing resident) was immediately called. A thorough search of the facility as well as the facility grounds were conducted by staff. The Nursing Home Administrator (NHA) was contacted. A second thorough search of the facility was conducted as per the NHA. The Nurse supervisor was instructed by the NHA to call the local hospital emergency departments in an attempt to locate the resident. The resident's responsible party called the facility to inform them of the location of the resident. The facility called the hospital to inquire about the resident. The resident had been found 0.5 miles away, wandering at a car wash. Resident was admitted to the emergency room for altered mental status at 2:55 A.M. Review of a witness statement dated January 10, 2025, (no time indicated) Employee 5 (3 P.M. to 11 P.M. RN supervisor) stated This nurse observed Resident 1 walking up the hallway, returning to the west hall nursing station. This nurse asked (Resident 1) the gentleman if he needed any help. Resident 1 stated, I am trying to go home and I cannot get out. I escorted the resident to the main entrance of the facility, entered the door code and the resident exited the building. (Resident) exited the building with other visitors. I did not know that this individual was a resident until I was notified by the facility. Review of witness statements dated January 10, 2025, (no time noted) Employee 1( LPN) stated that she last saw Resident 1 around 9 P.M. January 9, 2025 while she was passing medications to residents. Resident 1 stated to her at that time I'm going home. The resident was verbally redirected by the nurse and nurse aide. The resident was sitting outside (his/her) room in the hall. I took a break January 10, 2025 at 1:15 A.M. I was alerted by Employee 2 (na) at 1:45 A.M. that Resident 1 was not in (his/her) room. A code [NAME] (missing resident) was called. The RN supervisor was made aware. All staff searched the facility and the grounds. At 2:27 A.M., the local police were called by this nurse. Another licensed nurse called the resident's family. Review of a witness statement dated January 10, 2025, (no time identified), Employee 2 (nurse aide) At the start of my shift (11 P.M. to 7 A.M.). received my assignment as the building float (the nurse aide that will work all nursing units, as needed on the shift). As part of the float assignment, water/ice pass to all residents. I prepared the water cups/ice and water and started the pass. I started the water pass on the East long hallway (Resident 1 resides in room East 103 B). Once I reached room [ROOM NUMBER] B at 1:45 A.M, I noticed that Resident 1 was not in (his/her) room. I immediately alerted the licensed nurse. Review of a witness statement dated January 10, 2025, (no time indicated), Employee 3 (na) stated, I entered the facility at 11 P.M. and walked to the nurses station to see where I was working. The nurse supervisor told me I was the float: nurse aide on the east long hallway. When I got to the east long hallway, an aide was sitting in the hallway. I told her she could give me report for the hallway. She never gave me report because of staffing assignment confusion. There were no additional nurse aide staff on the unit at that time to give me report. After some time, additional nurse aides showed up on the unit. So I sat in the middle of the 2 hallways until staffing was figured out. I never saw Resident 1 on my shift. Review of a witness statement dated January 10, 2025, (no time noted) Employee 4 (LPN worked January 9 into 10, 2025 11 P.M. to 7 A.M. shift) stated, due to a switch up with the schedule, I was not on the east nursing unit until 11:20-11:30 P.M. I never saw the resident on my shift. Telephone interview conducted January 17, 2025 at 2 P.M. Employee 5 (RN supervisor) stated that she works per diem (as needed) at the facility. She stated that she has been an employee at the facility since mid December 2024 and has only worked 2 or 3 times in the building. She stated that on January 9, 2024 she was the RN supervisor on the 3 P.M. to 11 P.M. shift and did not know the residents. She stated that she did not review the residents with the off going RN Supervisor at 3 P.M. that day when she started her shift. She stated that she was not aware of the wandering residents in the building. She stated that Resident 1 looked like a visitor and asked her to let him out to go home. She confirmed that she did not confirm (his/her) identity prior to unlocking the front door for (him/her). She stated that she was unaware of any wandering/elopement identification process in place at the time of the elopement. Employee 5 (RN super) was unaware of how nursing staff received assignments as well as the passing of shift to shift nursing information. She could not impart any information concerning the visitors that she stated that she let out of the building at the time of Resident 1's elopement from the building. Interview conducted on January 17, 2025 at 4 P.M., with the Nursing Home Administrator (NHA) revealed on January 10, 2025 at 2:15 A.M. Employee 6 (R.N. agency, Supervisor on duty January 10, 2025 11 P.M. to 7 A.M. shift) called her to make aware that Resident 1 was missing from the facility. The NHA told Employee 6 (RN supervisor) to call the local hospitals to locate the resident. Resident 1 did not have any identification on him/her when he/she exited the facility. The NHA stated that the resident was found 0.5 miles away at a local car wash. She stated that she was told that a community member found the resident and called the local police and 911 emergency services. Review of EMS (Emergency Medical Services) documentation dated January 9, 2025 at 11:05 P.M. revealed Resident 1 was found at a local car wash, wandering. (Resident 1's) temperature was noted to be 93.5 fahrenheit, tympanic (taken in the ear), and (Resident 1's) oxygen level was 94% on room air. Initial contact with the resident noted facial wounds with dried blood, confusion, noted hypothermia (low body temperature). Facial injuries and left hand and bilateral knee abrasions were noted. Staff initiated external warming procedures. Multiple blankets were applied. The EMS staff were unsuccessful with starting intravenous fluids. Review of hospital documentation dated January 10, 2025 at 12:12 P.M. revealed, Per EMS (emergency medical services), resident was found at a car wash, wandering around, appeared confused. The resident was trying to get into other peoples vehicles. The resident is covered in wounds, appeared to have fallen. Per EMS, unknown situation, unknown if taking blood thinner medication, unknown loss of conscience, abrasions/hematoma (a collection of blood due to trauma) to right side of his face. The resident states (he/she) fell , but unable to provide further details. Initial temperatures taken in the emergency department were noted as; January 10, 2025 at 12:14 A.M.-94.8 degrees Farenheit. Pt's (patient's) clinical exam demonstrate right facial abrasion/swelling, a 2cm laceration above right eyebrow with hematoma, bilateral knee abrasion, right lower leg abrasion. The resident received intravenous fluids and warmer treatment (used to increase the body temperature). Resident diagnoses in the hospital included, a Fall with abrasions, confusion, facial injury/contusion/laceration and hypothermia. The resident was transferred to a different facility with a noted locked dementia unit upon discharge from the hospital. Immediate Jeopardy was called on January 17, 2025, at 2:45 P.M. due to the facility's failure to timely identify a resident's absence from the facility and prevent an elopement and failed to provide a safe environment with resident identification by staff and provision of supervision. The facility was notified of the Immediate Jeopardy on January 17, 2025, at 2:45 P.M. and the IJ template was provided to the facility. The facility's corrective action plan included: 1. The resident was discharged from the facility from the hospital emergency room and admitted to a facility with a locked dementia unit. 2. All residents were assessed for elopement/wandering 3. Staff education was completed regarding elopement/wandering/resident safety 4. The facility visitation policy reviewed and revised 5. Audits were completed to ensure that no other residents in the facility are effected 6. Implemented a process of the RN supervisor will verify that all residents are accounted for at the beginning at each shift by physically performing walking rounds in the facility each shift. 7. Rn Supervisor will validate that nurse aides understand assignments/assigned residents. Education to Nursing staff regarding staff assignments was completed. 8. On January 10, 2025, facility completed staff education regarding elopement/wandering and visitation. Education regarding staffing, staff assignments and staffing responsibility was initiated for the 7 A.M. to 3 P.M. and 3 P.M. to 11 P.M. shifts were initiated January 17, 2025 at 3 P.M. The 11pm-7am shift will be educated when they arrive before their scheduled shift. This education will be completed by January 18, 2024. All nonscheduled staff will be educated prior to their next scheduled shift, and no staff will be permitted to work until they have received the education. 9. Facility QAPI committee convened on January 11, 2025, (after initial identification of the elopement) to review the initial interventions and start this plan. The QAPI committee to meet February 2025 to complete the plan. Following verification of the implementation of the corrective action plan, a tour of the facility and review of education, the Immediate Jeopardy was lifted on January 18, 2024, at 10:30 AM. 28 Pa. Code 201.18 (e)(1) Management

Based on a review of clinical records, select facility incident/accident reports, and staff interview it was determined the facility failed to timely implement effective safety interventions, including necessary staff supervision, at the level and frequency required, for a resident with known unsafe behaviors to prevent falls, including a fall with hip fracture for one resident out of the 24 sampled (Resident 91) and multiple falls for one out of the 24 sampled reviewed (Resident 33). Findings include: A review of the clinical record for Resident 91 revealed admission to the facility on [DATE], with a diagnosis to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and abnormalities of gait and mobility (difficulty walking). A review of an admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 29, 2024, revealed Resident 91 was severely cognitively impaired with a BIMS score of 0 (BIMS- Brief Interview for Mental Status is a tool to screen and identify the cognitive condition of long-term care residents). A score of 0-7 represents severe cognitive impairment), and she required substantial/maximal assistance of staff for activities of daily living. A review of a care plan dated July 25, 2024, revealed Resident 91 was at risk for falls related to impaired cognition with decreased safety awareness. Planned interventions included: alarm to bed and wheelchair, fall mats when in bed, implement preventative fall interventions/devices, maintain call light within reach, educate resident to use call light, maintain needed items within reach, and monitor for changes in mobility. A review of nursing documentation dated July 24, 2024, at 5:54 PM revealed Resident 91 was not cooperative with staff on the day of admission, not allowing staff to complete a body audit and clinging to the transport person, refusing to let him go. She was noted to be walking up the hallway without assistance, grabbing onto the side rails. Safety alarms were added to her wheelchair that sounded to alert staff of any unsafe movements. Nursing documentation dated July 26, 2024, at 7:29 AM revealed the resident pulled out her Foley catheter (a thin flexible tube inserted into the bladder that then drains the urine into a collection bag) and that she was trying to exit the building via doors and windows. The resident was placed on 1:1 (one-to-one supervision - one staff member is assigned to provide observation and assistance to one resident who is not to be left unattended at any time). Nursing documentation dated July 26, 2024, at 6:05 PM indicated Resident 91 continued to exhibit exit seeking behaviors with agitation and attempts at physical aggression. The physician was contacted, and the resident remained on 1:1 supervision while she remained awake. A physician's order dated July 26, 2024, revealed an order for 1:1 supervision while awake, every shift due to her exit seeking behaviors. Nursing documentation dated July 31, 2024, at 5:53 AM revealed Resident 91's bed alarm was sounding, and Resident 91 was observed sitting on the floor in her room across from the bathroom door. She was noted to be incontinent of urine at that time. The planned intervention was to continue watching the resident on 1:1 while she was awake. The resident was brought to the nurses station for close supervision. The resident made multiple attempts to stand up from her wheelchair and it was noted she was difficult to redirect. The resident assisted to bed at 5:30 AM after she utilized the bathroom. Nursing documentation dated August 2, 2024, at 5:39 AM revealed Resident 91 was on the floor of her bathroom, lying on her right side. Her bed alarm was sounding at the time of the fall. The resident stated, I got up to go to the bathroom. The resident was noted to have a 6 cm x 5 cm bruise to the right upper arm and a 2 cm x 3 cm bruise to her right inner wrist. The nurse assessed the resident, and the physician was notified. The resident was placed near the nurses station for close observation. Nursing documentation dated August 4, 2024, at 5:00 AM revealed Resident 91 was awake most of the night and remained at the nurse's station for close supervision. As noted she continues to attempt to stand and self-transfer and staff were unable to redirect her to ensure her safety. Nursing documentation dated August 7, 2024, at 3:00 AM indicated Resident 91 was found on the floor on the right side of her bed. A planned intervention to place fall mats next to her bed was put into place to prevent injury from future falls from her bed. Nursing documentation dated August 7, 2024, at 4:45 PM noted the resident stood up from her wheelchair and fell to the ground. She did not sustain any injuries at that time. A physician's order dated August 7, 2024, revealed the 1:1 supervision order had been discontinued. Nursing documentation August 8, 2024, at 8:25 AM revealed that Resident 91 was continually roaming the building (in her wheelchair), exit seeking, self-transferring, and unable to be redirected. She was found lying on the bench outside of the facility chapel (located in the front of the facility away from resident areas). She was returned to the nurses station. Nursing documentation dated August 13, 2024, at 11:00 AM revealed Resident 91 was observed lying on her back on the floor in room [ROOM NUMBER] (Resident 91 resides in room [ROOM NUMBER]-A). A full body assessment was completed. The resident was complaining of right hip pain. The physician was contacted, and an X-ray of the pelvis was ordered. A review of the X-ray report dated on August 13, 2024, revealed an acute right intertrochanteric hip fracture (fracture of the right hip). The resident was admitted to the hospital on August 14, 2024, and had surgical repair of her right hip on August 15, 2024. At the time of the survey ending August 30, 2024, the facility was unable to provide documented evidence that physician ordered 1:1 supervision was provided to Resident 91 as planned. The timeframe for 1:1 supervision was July 26, 2024 to August 7, 2024. The facility failed to repeatedly provide effective safety interventions and sufficient and timely staff supervision, at the level and frequency required, to prevent multiple falls for a resident at risk for falls, with known unsafe behaviors and a history of falls, resulting in a fall with major injury. An interview with the Nursing Home Administrator on August 30, 2024, at 8:00 AM confirmed the facility failed to provide effective safety interventions and sufficient and timely staff supervision to Resident 91 to prevent repeated falls with a major injury. A clinical record review revealed Resident 33 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of an admission MDS assessment dated [DATE], revealed that Resident 33 is severely cognitively impaired with a BIMS score of 03 (a score of 01-07 indicates severe impairment). A review of Resident 33's care plan, initiated on June 25, 2024, revealed she was at risk for falls due to a history of falls and impaired cognition with decreased safety awareness. Interventions to reduce this risk included a bed alarm, bed in the lowest position, wheelchair alarm, and non-skid footwear. A review of facility incident reports from June 25, 2024, to August 26, 2024 revealed Resident 33 sustained 9 unwitnessed falls. The incidents were as follows; June 25, 2024, at 6:30 PM: Resident 33 was found on the floor; no injuries were noted. Planned interventions indicated bed and chair alarms were added for resident safety. July 2, 2024, at 12:25 PM: The resident was found crawling out of her bedroom; no injuries were noted. New interventions: neurological checks, therapy screening, psychiatric care consult, care plan review. July 8, 2024, at 8:26 AM: Resident found on the floor, on hands and knees; no injuries were noted. New interventions: neurological checks, therapy screen, resident education, nursing interventions, care plan review. July 8, 2024, at 10:03 PM: Resident found on the floor with a skin tear on her knees. Pain level two out of 10 (minimal pain). Physician notified, and treatment ordered. New interventions: psychiatric care consult, monitoring for infection, care plan review. July 15, 2024, at 11:14 AM: Resident found sitting on the floor next to her wheelchair with the alarm sounding; no injuries were noted. The resident reported she had left cheek and shoulder pain. July 17, 2024, at 1:30 PM: Resident found lying on the floor in the east long hall; no injuries were noted. New interventions: neurological checks, therapy screen, social service support, care plan review. August 5, 2024, at 2:23 PM: Resident found on the floor; no injuries noted. New interventions: neurological checks, therapy screen, social service support, psychiatric care consult, care plan review. August 14, 2024, at 3:46 PM: Resident found sitting on buttocks with alarm sounding; no injuries noted. New interventions: neurological checks, therapy screen, social service support, psychiatric care consult, care plan review. August 26, 2024, at 3:31 PM: Resident found sitting on the floor with open purpura (small blood vessels leak blood under the skin) noted. Physician and resident representative notified. New interventions: treatment as ordered, neurological checks, therapy screen, social service support, psychiatric care consult, care plan review. The resident's care planned interventions proved ineffective in preventing multiple falls. The interventions were not changed to prevent falls, the facility's planned interventions implemented were in response to the falls such as neurological checks, therapy screens a review of care plans. The facility did not develop and implement measures to increase staff supervision and staff monitoring of the resident and the resident's activities to determine the cause of the falls and plans to prevent falls. During an interview on August 30, 2024, at approximately 11:30 AM, the Director of Nursing (DON) confirmed that Resident 33 had multiple unwitnessed falls and the facility's interventions and supervision have not been effective. The DON acknowledged the facility is responsible for providing adequate supervision to prevent resident falls. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, observations, select facility policy, and staff, resident, and resident family interviews, it was determined the facility failed to implement pain management interventions and failed to recognize when the resident suffered pain without relief for one resident out of 24 sampled (Resident 260). Findings include: A review of the facility policy entitled Pain Assessment and Management, last reviewed by the facility on July 21, 2024, revealed the facility's pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The policy indicates that pain management is a multidisciplinary care process that includes assessing the potential for pain, recognizing the presence of pain, developing and implementing approaches to pain management, and monitoring for the effectiveness of interventions. Also, the policy indicates that acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. A clinical record review revealed Resident 260 was admitted to the facility on [DATE], with diagnoses that included aftercare following digestive tract surgery and pressure injuries (skin and underlying soft tissue damage occurring from prolonged pressure). A progress note dated August 21, 2024, at 3:34 PM revealed that Resident 260 was admitted with an unstageable pressure ulcer to sacrum, 6.0 cm by 3.5 cm by 0.0 cm with wound base covered with 100% black eschar (dead tissue that forms over healthy skin and then, over time, falls off). The resident was admitted with a stage 3 pressure ulcer (pressure ulcers that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below) to the left ischial tuberosity, which is the bony part of the buttocks on the left side, just under the hip. The wound base was 80% covered with a thin beige drainage, leaving 20% of pink tissue exposed. According to The Merck Manual Professional Version, 2024, Pressure injuries can cause significant pain. Pain should be monitored regularly using a pain scale. Primary treatment of pain is treatment of the injury itself, but a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is useful for mild-to-moderate pain. Opioids should be avoided, if possible, because sedation promotes immobility. However, opioids or topical non-opioid preparations such as mixtures of local anesthetics may be necessary during dressing changes and debridement. In cognitively impaired patients, changes in vital signs can be used as indicators of pain. A care plan dated August 21, 2024, indicated that Resident 260 has the potential for pain related to her stage IV sacrum pressure ulcer (a stage IV pressure ulcer may extend through the skin into the muscle, tendons, and joints). Interventions in place to assist Resident 260 with her pain included: Administering medication per physician's orders. Monitor for changes in behavior that may be indicators of pain (e.g., screaming, babbling, cursing, repetitive questions, pacing, kicking, scratching, or refusals for treatments). Monitor for changes in mood that may be indicators of pain (e.g., increased agitation). A physician's order for Resident 260 to receive Ultram oral tablet 50 mg (Tramadol HCI) by mouth every 8 hours as needed for moderate to severe pain 7-10 initiated on August 22, 2024. A progress note dated August 22, 2024, at 4:58 AM revealed that Resident 260 was very agitated, yelling out and unable to be redirected. Care was provided, and the resident was repositioned for comfort without success. There was no documented evidence to determine if the resident's behavior was related to pain. A physical therapy evaluation and treatment plan dated August 22, 2024, revealed the resident verbally reported her pain level. The assessment revealed the resident experiences a pain intensity of 5/10 (moderate pain) during movement, occurring intermittently. The pain is localized in her spine and is described as aching, chronic, and shooting. According to the physical therapy note, this pain significantly impairs the resident's ability to sit and change positions. The note further states the resident experiences pain relief when remaining still or changing body positions. There was no documented evidence that Resident 260 received any pharmacological or non-pharmacological interventions to manage her pain following the physical therapy evaluation on August 22, 2024. A clinical record review revealed that on August 25, 2024, at 2:42 AM, Resident 260 experienced pain of 2 out of 10 (mild pain). There was no documented evidence that Resident 260 received any pharmacological or non-pharmacological interventions to manage her pain at this time. A nursing progress note dated August 26, 2024, at 9:25 PM revealed the resident's family member requested the nurse to call the physician regarding pain medication. The physician ordered Ultram 100 mg via G-tube every 6 hours, for pain level 7-10 (moderate to severe pain) complete a pain assessment every shift for 24 hours. May provide non pharmacological interventions for pain such as repositioning, back rub, music, warm/cool compress or diversional activities. There was no documented evidence that Resident 260 received any pharmacological or non-pharmacological interventions to manage her pain on August 26, 2024 at 9:25 PM. A clinical record review revealed that on August 26, 2024, at 1:11 AM, Resident 260 experienced pain of 5 out of 10 (moderate pain). There was no documented evidence that Resident 260 received any pharmacological or non-pharmacological interventions to manage her pain at this time even though there was an order to administer Ultram. A physician's order for Resident 260 to receive Norco oral tablet 5-325 mg (Hydrocodone-acetaminophen) every 4 hours as needed for moderate to severe pain 4-10 was initiated on August 27, 2024. A physician's order for Resident 260 to receive acetaminophen tablet 325 mg every 6 hours as needed for pain was initiated on August 27, 2024. An occupational therapy treatment note dated August 27, 2024, recorded that the resident was able to tolerate sitting for approximately 30 minutes but reported pain associated with a sacral wound. The nurse was promptly informed. During an interview on August 29, 2024, at approximately 11:30 AM, Employee 2, Certified Occupational Therapy Aide, confirmed she worked with the resident between 10:00 AM and 11:30 AM on August 27, 2024. She indicated that Resident 260 was experiencing pain that interfered with the resident's ability to participate in her therapy session. During an interview on August 27, 2024, at 11:45 AM, Resident 260's husband indicated his wife has been in pain since the previous night and has not received anything to help her with her pain. He explained she has a pressure injury on her sacrum that is hurting her. Resident 260's husband indicated he is frustrated because his family has been trying to get the facility to do something for his wife's pain since last night (August 26, 2024) at 6:30 PM, but nothing has been done. He explained his wife was acting out last night because of her pain. He indicated the facility reported they were not able to provide his wife pain medication because the physician did not send a prescription to the pharmacy. Resident 260's husband indicated he arrived at the facility this morning at 8:00 AM and still nothing has been done. A progress note dated August 27, 2024, at 12:05 PM revealed that Resident 260 has pain level 3 out of 10 when at rest related to an unstageable pressure wound on her right buttock. There was no assessment regarding Resident 260's pain when moving or shifting positions. During an interview on August 27, 2024, at 12:20 PM, Resident 260 was lying in her bed and described her pain as lousy. The resident did not respond when asked what her pain level was, on a scale of 1 to 10. During an interview on August 27, 2024, at 12:25 PM, Employee 1, Licensed Practical Nurse, indicated she is aware that Resident 260's family is indicating that Resident 260 has been in pain, but explained that she was unable to obtain the resident's pain medication from the facility's medication system. During an interview on August 27, 2024, at 12:30 PM, Employee 3, Corporate Nurse Consultant, explained that Resident 260 was not provided pain medication because the pharmacy indicated they never received a prescription from the physician. An order was implemented, but the pharmacy did not release the medication because they never received the prescription. Employee 3, Corporate Nurse Consultant, was not able to provide documented evidence that Resident 260 received non-pharmacological interventions or other medication interventions for pain from 6:30 PM on August 26, 2024, until August 27, 2024, at 12:35 PM. Employee 3, Corporate Nurse Consultant, was unable to provide documented evidence that Resident 260 had any pharmacological interventions available for use until August 27, 2024, at 12:35 PM. A review of the medication administration record revealed that Resident 260 was administered Norco Oral Tablet 5-325 (hydrocodone-acetaminophen) for severe pain level 8 out of 10 (severe pain) on August 27, 2024, at 12:40 PM. A follow-up evaluation of the resident's pain revealed that her pain was 5 out of 10. During an interview on August 30, 2024, at approximately 9:30 AM, the Corporate Administrator was not able to explain why Resident 260's did not receive any interventions for her severe pain from August 26, 2024, at 6:30 PM until August 27, 2024, at 12:40 PM. The Corporate Administrator was not able to explain why the facility failed to ensure pain medications were available to relieve Resident 260's pain. The Corporate Administrator confirmed it is the facility's responsibility to ensure that pain management is provided timely to residents who are experiencing pain. Refer F710 28 Pa. Code 211.2 (d)(9)(10) Medical director. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observation, a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that one resident (Resident A2) was free from verbal and mental abuse, which resulted emotional upset and mental anguish and failed to implement sufficient measures necessary to protect other residents from verbal and mental abuse perpetrated by one resident (Resident A1) out of 10 sampled residents. Findings include: Review of Resident A1's clinical record revealed admission to the facility on [DATE], with diagnoses, which included Alzheimer's disease, adjustment disorder with anxiety, and major depression. The resident was significantly cognitively impaired with a BIMS (Brief Interview for Mental Status a tool to assess cognitive function) score of 2. Resident A1's care plan, initiated May 27, 2024, identified that the resident had impaired cognitive function related to Alzheimer disease as evidenced by, confusion, long and short term memory problem and poor safety awareness. Planned interventions were to administer medication as per physician orders, allow time for the resident to respond, approach in a calm manner, and to provide activities. The resident's care plan did not identify that Resident A1 displayed any physically or verbally abusive behaviors towards other residents and staff. A review of clinical record documention dated June 8, 2024 at 10:38 AM, revealed that Resident A1 displayed behaviors during this shift of nursing duty. The resident was making sexually inappropriate comments to staff. A nurses note dated June 18, 2024 at 2:23 PM, revealed that the resident continue to make sexually inappropriate comments towards staff. A nursing note dated June 19, 2024 at 11:37 AM revealed that a nurse aide informed the nurse that the resident made inappropriate sexual comments, as well as derogatory comments regarding a nurse aide's ethnicity, while these nurse aides were showering the resident on June 18, 2024. In response to these inappropriate behaviors, a psychiatric nurse practitioner ordered June 18, 2024, to start Buspirone 5 mg PO (anti-anxiety medication) as needed every 8 hours for anxiety x 14 days Nursing documentation dated June 20, 2024 at 6:29 PM and June 21, 2024 at 2:58 PM revealed that the resident continued to make inappropriate sexual comments towards staff and had inappropriately touched a therapist and a nurse. Redirection was noted to be unsuccessful and the resident became agitated with redirecting. The resident's inappropriate sexual comments as well as derogatory comments, such as calling nursing staff a b*tch, continued to occur according to nursing documentation dated June 24, 20240 at 8:13 AM and June 24, 2024 at 2:26 PM. Staff reminded the resident that this inappropriate conversation cannot happen as other residents appear to be agitated by Resident A1's comments. Resident A1 was also interjecting himself into the conversation another resident was having, agitating that resident. Resident A1 asked another resident what the hell is wrong with your hands? (referencing the physical appearance of the resident's hands) Staff asked Resident A1 not bother this other resident, but he continued to do so. The nurse then removed the other resident from area due to Resident A1 continuing to ridicule the resident's physical condition. A nursing note June 24, 2024 at 2:47 PM noted that Resident A1 was continuing to agitate another male resident, pulling the resident's chair alarm from his wheelchair causing it to sound the alarm. Upon staff arrival, Resident A1 accused the nurse of stealing my toy. Resident A1 refused to given alarm back to the nurse or any other staff stating I had two of them. The nurse also advised the resident to stop reaching for another female resident's arm, which agitated Resident A1. Resident A1 then pursued another female resident and reached out stroking her arm, and the female resident became agitated. A nursing note June 28, 2024 at 1:37 PM, indicated that the psychiatric nurse practitioner wrote an order, in response to the resident's recent behavior, for depakote ( A seizure medication sometimes used for behavior control) 125 mg daily BID for dementia with behaviors. Nursing noted on July 3, 2024 11:00 A.M that Resident A1 continued to make lewd sexual comments to a female resident and attempts to redirect Resident A1 were unsuccessful. Nursing noted on July 3, 2024, at 1:40 PM that psych services saw the resident and increased the resident's buspirone to 10 mg TID (three times a day). A nursing note July 3,2024 11:24 P.M. revealed that Resident A1 threatened Resident A2, stating Wait till I get you alone later. The things I'm going to do to you. Resident A2 became fearful and started crying at which point the police were called to intervene due to Resident A1's physical aggression, assault and verbal/sexual remarks, comments and threats toward multiple staff at this time. A nurse' note dated July 3, 2024, at 11:43 PM Resident A1 smiled, winked and then waved at Resident A2 who was seated in her wheelchair in front of nurses station. He then yelled out to her stating, I'm looking forward to seeing you later when no-one is around. Winking again. Resident A2 began to cry, shake and tremble. She was immediately taken behind nurses station and other staff attempted to intervene while Resident A1 continued to advance down hallway in Resident A2's direction after stopping to curse, yell out loud and threaten the supervisor and the nurse once again for asking him to please do not come down this hallway. You are making this resident (Resident A2) scared and very uncomfortable. Several staff members attempted to redirect him without success and began to yell, and threaten staff and the police and emergency services/transport were called. A review of the clinical record revealed that Resident A2 was admitted to the facility on [DATE], with diagnoses to include orthostatic hypotension. A quarterly MDS assessment dated [DATE], indicated that she was moderately cognitively impaired with a BIMs score of 11 (a score of 8 to 12 indicated moderate, cognitive impairment). A review of Resident A2's clinical record conducted during the survey ending July 21, 2024, revealed no reference to the above incident of verbal and mental abuse and the resident's emotional distress. There was no documented evidence that the facility had provided therapeutic psychosocial interventions to Resident A2 to address the psychosocial harm suffered by the resident as the result of being verbally and mentally abused by Resident A1. During an interview conducted on July 21, 2024, at approximately 12 PM, Resident A2 stated that she did not want to discuss Resident A1 with this surveyor, only stating that she did not want him near her. A nursing note dated July 3, 2024, at 11:48 PM revealed that local police and EMS (emergency medical services) arrived at the facility and removed Resident A1 from the facility. The resident returned to the facility July 4, 2024, at 4:31 AM A nursing note dated July 7, 2024 at 10:18 AM revealed that Resident A1 continued to display inappropriate sexual behaviors, despite re-direction attempts. Resident A1 became agitated with re-direction. He sat across the hall from a female resident stating the things I would do to you. Staff again attempted to redirect Resident A1 with with no effect noted. Resident A1 then went and sat in the doorway of another resident's room, taunting the other resident by shouting at her causing her to become distressed and needing to be consoled. Resident A1 then began reaching towards a female resident's arm, and told staff You can't tell me not to touch her. At the time of the survey ending July 21, 2024, the facility was unable to identify these female residents. A nursing note dated July 7, 2024 at 6:42 PM revealed that due to the resident's behaviors, and the risk to the safety of staff and other residents, he was sent to emergency room for evaluation and behaviors and will be placed on one on one upon return. The resident was transferred to the hospital at 7:52 PM and returned to the facility on [DATE], at 6:47 P.M. A nursing note dated July 13, 2024 at 2:07 PM revealed that staff removed Resident A1 from the activity room because he initiated an argument with another resident, which was witnessed by several witnesses within the activity room. A nursing note dated July 13,2024 3:00 PM revealed that Resident A1 was overheard asking another resident, the age of the female resident's daughter, stating well if she needs a man I can be your son-in-law. Staff asked Resident A 1 to please keep conversation appropriate as the female resident did not seem to welcome this conversation A nursing note dated July 13, 2024, at 3:21 PM revealed that nursing responded to the sound of a female resident shouting. Nursing noted that the female resident shouted at Resident A1 You're a pain in the a*s you know that. You just won't shut up. Another female resident shouted to Resident A1 oh no buddy you, have the wrong one. Both (unidentified) female residents reported to nursing staff that Resident A1 will not leave them alone nor do they like his conversation. Resident A1 stated to one female resident I'm keeping my eye on you so you know. The female resident stated I really don't give a sh*t what you do. The RN and another nurse attempted to return Resident A1 to his room however he has refused. Nursing noted resident remains under close supervision by this nurse due to complaints of female residents near by and {Resident A1} refusing to leave area. A nursing note dated July 13, 2024, at 3:43 P.M. revealed that Resident A1 was at the nurse's station and began to self-transfer. Another female resident in the area, who was ambulatory told Resident A1 to sit before you fall. Resident A1 told the female resident well come fix my pants, baby, that's what you're supposed to do. A nursing note dated July 15, 2024 at 1:59 PM revealed that Resident A1 was insulting other female residents this morning regarding their appearances, such as hairstyle. Resident A1 was attempting to enter other residents' rooms and when redirected jumps up defensively and becomes aggressive with staff. A nursing note dated July 17, 2024, at 2:19 P.M. revealed that Resident A1 with was asking female resident to remove her panties and making derogatory racial comments to another resident. A nursing note dated July 17, 2024, at 3:51 P.M. revealed that Resident A1 was placed on 1:1 supervision due to safety issues. Interview with the Nursing Home Administrator and Director of Nursing on July 21, 2024, at 1 PM failed to protect residents from verbal and mental abuse perpetrated by Resident A1, a resident with known verbally abusive behaviors, which resulted in psychosocial harm to Resident A2. Refer F609 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on a review of clinical records, the facility's abuse prohibition policy, and select incident reports and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse perpetrated by another resident, (Resident 13), which resulted in physical distress to the resident victim, (Resident 14) out of 18 residents sampled. Findings include: The facility's policy entitled Abuse Policy dated as reviewed by the facility on May 3, 2023, revealed that Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses, which included bipolar disorder. A quarterly MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed that the resident was cognitively intact, and required staff assistance with activities of daily living. A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses, which included muscle wasting. An annual MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired, the resident's primary language was Spanish and required staff assistance with activities of daily living. A review of a nurse's note dated January 1, 2024, clinical record revealed that Resident 13's room was changed due to issues Resident 13 had with her roommate. Resident 13 was moved into room with Resident 14. On that same date January 1, 2024, nursing noted that Resident 13 was yelling at her new roommate, Resident 14, telling her to speak English. There was no documented evidence of the measures planned at that time to resolve the potential conflict between Resident 13 and her new roommate Resident 14. A nurses note in Resident 13's clinical record dated January 9, 2024, at 6:45 PM revealed that {Resident 13} initiated physical aggression towards roommate. {Resident 14} moved to another room for roommate's safety. Head to toe assessment completed. MD made aware and psych to consult tomorrow (1/10/24) and resident placed on q15 minute checks. Resident spoke with police. IR (incident report) completed. Resident's {Resident 13}sister, was made aware of incident and verbalized understanding and appreciation for psych consult. A review of a facility investigation report dated January 9, 2024, at 6:45 P.M. revealed that Resident 14 had asked Resident 13 to turn her TV off at night because she {Resident 14}couldn't sleep. Resident 14 turned away from Resident 13. Resident 13 was then seen standing behind Resident 14 with her hands on her neck shaking her. The residents were separated and Resident 13 was moved to a new room and placed on 15-minute checks. Resident 14 was then observed vomiting and had increased blood pressure. Resident 14 was prescribed Zofran and Clonidine to address those symptoms. A review of an undated employee witness statement from Employee 1 (LPN) revealed that the employee stated I was giving {Resident 14} her meds and she was telling me her roommate keeps her TV on all night and loud. I asked {Resident 13} if she could shut the TV off when she goes to sleep. {Resident 13} said 'I stay up all night watching it.' I asked if she could at least turn it down for her roommate {Resident 14}. I gave {Resident 13} her meds and both residents snacks. As I was walking out of room across the hall I could see into their room . {Resident 13} had her arms around {Resident 14} from the back and was shaking her so hard I could see {Resident 14's} body going back and forth. I ran into the room trying to get {Resident 13's} hands off {Resident 14}. {Resident 13} stopped and jumped into the bed. I took {Resident 14} to the entrance of the room and called for help. {Resident 14} started vomiting from the force Resident 13 gave her. Employee 1 further states that she never saw anything like it, was in shock, and it was like a movie. Stating that {Resident 13} seemed out of her mind. Resident 14 was seen by the physician who was in the building at time of incident on January 9, 2024. Resident 14's blood pressure was high, and the resident was vomiting. The physician prescribed Zofran for vomiting and Clonidine for high blood pressure. Resident 14's witness statement dated January 10, 2024, revealed that Resident 14 stated she asked Resident 13 to shut her fan off, and after, she asked her to shut off her fan Resident 13 yelled at her, jumped at her and hit her. An interview was attempted with Resident 14 on February 29, 2024, but the resident could not recall the incident at the time of the survey. Interview with the administrator on February 29, 2024, at 3:00 PM failed to provide evidence that the Resident 14 was free from physical abuse perpetrated by Resident 13. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights.

Based on observations, a review of clinical records and facility investigative reports and staff interviews, it was determined that the facility failed to provide necessary supervision to meet the individual safety needs of residents with known unsafe behaviors to prevent a choking episode for one resident and elopement by one resident out of 2 sampled residents (Residents CR1 and CR2). Findings include: A review of the clinical record revealed that Resident CR1 had diagnoses, which included [CONDITION(S)] (stroke), [CONDITION(S)] and pneumonia. Review of a significant change Minimum Data Set Assessment (MDS- federally mandated standardized assessment process completed at specific intervals to identify specific resident care needs) dated February 17, 2021, indicated that the resident had a BIMS (Brief Interview for Mental Status - a tool to assess cognitive function) score of five (5) indicative of severe cognitive impairment. According to the MDS the resident was independent in eating with set-up help for meals and required supervision for eating. Interview with the Rehabilitation Manager on April 9, 2021, at 10:10 a.m. revealed that Speech Therapy had been initiated for the resident March 31, 2021. The short term goals were that the resident will tolerate minced and moist diet without overt signs and symptoms of aspiration/dysphagia and patient will utilize alternation of liquids and solids, and small bites and sips to increase safety and reduce risk of aspiration/dysphagia deficits. Further review of the, Speech Therapy Evaluation and Plan of Treatment, revealed that Resident CR1 had a diagnosis of dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat). Review of Resident CR1's current plan of care-initiated February 10, 2021, indicated that Resident CR1 had chewing difficulties with the intervention of a modified diet, pureed consistency. A physician order dated February 15, 2021, was noted for a Regular diet, NDD2/Minced and Moist texture, Thin/ Regular consistency. A Speech Therapy evaluation dated March 31, 2021, indicated that the resident was on a minced and moist diet Review of Resident CR1's clinical record revealed a nursing entry dated April 5, 2021, by a Registered Nurse, noting that she was called to resident's room to assess the resident eating lunch. Nursing assessed the resident and found the resident to have shortness of breath and difficulty swallowing. Remnants of food and [MEDICATION(S)] were observed in the resident's mouth/throat. The resident was unable to expel/eject the remnants of food and mucous by coughing. The Registered Nurse noted that she was able to suction the remaining pureed food and mucous from the resident's throat and airway. A speech therapy consult was requested. Review of documentation provided by the facility of the Speech Therapist consult/evaluation conducted on April 6, 2021, revealed that Resident CR1 was provided a trial of nectar liquids and puree texture to decrease aspiration risk and reduce effort for intake. The documentation indicated that the resident tolerated with cough and congestion reduced during intake. The diet was downgraded to puree/nectar. Further review indicated that the Speech Therapist facilitated cough and reswallow strategies to increase the patient's ability to clear oral and pharyngeal cavity to decrease risk of aspiration. However, the Speech Therapist noted that the resident continued with increase rate of intake and poor carry over strategies. A physician order was noted April 6, 2021, at 9:09 a.m. to downgrade the resident's diet to Regular diet, Pureed texture, Nectar consistency. Interview with the Speech Therapist on April 9, 2021, revealed that she assessed the resident on April 6, 2021. The Speech Therapist explained her assessment of the resident to the surveyors, describing the resident's eating habits as a shoveler. The Speech Therapist stated that during the resident's evaluation on April 6, 2021, she worked with the resident to put the eating utensils down between bites to assist in decreasing his rate of intake. However, due to the resident's impaired cognition he had poor carryover and inability to apply these strategies without someone stopping him from shoveling the food into his mouth. A review of a facility report revealed that on April 7, 2021, at 8:50 a.m. Employee 5, Registered Nurse, was called to Resident CR1's room. The resident was found face down on the floor, unresponsive. The report indicated that the resident was turned onto his back and, yellow/brown, thick/sticky [MEDICATION(S)] was noted on floor, chest and in resident's mouth/throat. The resident was noted without respirations and no apical heart rate, pupils fixed and dilated, skin pale with bluish/grey tint noted around mouth. The facility report indicated that the last time Resident CR1 was observed by staff was at 8:15 a.m. when staff served his breakfast tray to the resident while the resident was in bed. A nursing noted dated April 7, 2021, at 8:50 a.m. noted that a call was placed to the physician and orders were provided for the RN to call time of death ([NAME]) and release the resident's body to the funeral home. Time of death called at 8:50 a.m. Interview with the Registered Dietitian on April 9, 2021, revealed that when resident's diets are changed as was Resident CR1's on April 6, 2021, she will receive a phone call. She stated that the meal tags (resident specific diet information included on the meal trays) are generally printed for several days in advance therefore she would have to manually write on the tag to ensure the resident received the newly prescribed diet. The Registered Dietitian stated that she called Employee 9, the cook, on April 7, 2021, and Employee 9 verbalized that Resident CR1 had received the downgraded diet, a puree diet/nectar diet the morning of April 7, 2021, comprised of pureed pancakes with syrup, cream of wheat, nectar thick juice, milk and coffee. Review of a witness statement provided by Employee 6, Nurse Aide, revealed that after passing breakfast trays at 8:45 a.m. on April 7, 2021, she looked in Resident CR1's room and found resident on the floor between the two beds. Employee 6 indicated that the resident was not acting any different before being found on the floor. Review of a witness statement provided by Employee 7, Licensed Practical Nurse, revealed that at 8:45 a.m. on April 7, 2021, while performing her medication pass a nurse aide called her to Resident CR1's room, Employee 7 noted that she entered room and found the resident face down between the beds with no movement noted. The Registered Nurse was called to assess the resident. Employee 7 noted that the resident was rolled over and his face was ashen, vital signs were inaudible. Review of a witness statement provided by Employee 8, Nurse Aide, dated April 7, 2021, which was not provided during the survey ending on April 9, 2021, but provided to the surveyor on April 13, 2021, 4 days after the survey, revealed information indicating, that Employee 8 reportedly saw the resident 5-10 minutes prior to the resident being found on the floor face down. Employee 8's statement noted that he was eating normally at that time. Additionally, Employee 8's statement noted that suctioning was performed to clear the resident's airway. However, this detail was not included in the information provided in any of the facility submitted reports received at the end of the survey on April 9, 2021, or in the resident's clinical record's account of the event. The facility failed to demonstrate the provision of necessary staff supervision during meals of a resident with known dysphagia, unsafe eating habits (shoveling food, rapid intake) and poor retention of instructions for eating to prevent the choking incident. A review of Resident CR2's clinical record revealed admission to the facility on [DATE], from inpatient Hospice, with diagnoses that included alcoholic [CONDITION(S)] of liver (advanced stage of alcoholic liver disease that causes the liver to become stiff, swollen, and barely able to do its job) with ascites (a condition in which fluid collects in spaces within the abdomen. As fluid collects in the abdomen, it can affect the lungs, kidneys, and other organs. Ascites causes abdominal pain, swelling, nausea, vomiting, and other difficulties) and liver cancer. The resident's care plan dated January 29, 2021, indicated that the resident required assistance of two persons for transfers, reinforce the need to utilize the call bell, room close to nurse station and observe for signs of detoxification. A physician's order was in effect for the use of a sensor pad to bed to alert staff of unassisted transfers as of February 1, 2021. An admission MDS assessment dated [DATE], indicated that the resident had a BIMS score of 11 (Brief Interview for Mental status, a tool to assess the residents attention, orientation and ability to register and recall new information), a score of 8-12 equates moderate cognitive impairment and was independent for locomotion on the unit with a wheelchair. The resident was receiving Hospice services at the facility as of February 1, 2021. The resident had a Pleurex catheter (flexible tube placed into the abdomen to drain ascites, fluid) in the right upper quadrant of his abdomen and will be drained three times a week for ascites. X-ray revealed a right sided Pleurex catheter extending into the mid lower pelvic region. Nursing documentation revealed that on February 15, 2021, the resident utilized his call bell for assistance. The resident questioned the nurse if there was a certain amount of times he needed to press the call bell for an emergency. The nurse educated the resident to press the red button once, which was sufficient to alert staff that he needs assistance. Nursing noted that on February 21, 2021, the resident was observed self-propelling in the wheelchair to his bathroom. The resident bumped the right side of head on the handrail causing small cut above right eye. He was educated once again on using call bell and not turning his alarms off. Nursing noted that on February 24, 2021, the resident approached the nurses' desk with two large bags and stated, This is for my sister she is coming at 5:30 p.m. to pick it up. The nurse asked the resident what was being sent home with his sister. The resident allowed the nurse to inventory the articles being sent to his sister and amended his inventory sheet in case of inconsistencies. Resident packed his slippers, shaving cream, razors, body wash, cologne, 10 pairs of white socks 4 pairs of boxer briefs, a moldy shower poof, a crumbled up bag of Lays potato chips, magazines that were given to him to read by activities, emergency kit for his Pleurex tube including clamp, and hair ties. Nursing noted that on February 25, 2021, the resident called the police from his personal cell phone. He was talking about a murder and a freezer bag full of goldfish crackers he had that he needed to get to Vietnam to do a eulogy. The resident insisted that he had the murder weapon and that he was the only one who touched it. The resident was non-compliant and very hard to redirect, consistently rang call bell even after being educated on call bell use. The resident rang the call bell requesting room service to find his candy. The resident was non-compliant on his face mask use and kept unhooking his bed alarm. On February 25, 2021, nursing noted that the facility received a call from the Hospice nurse, stating that the resident's responsible party had called the Hospice Nurse and was hysterical about the resident's erratic behavior. The resident's responsible party told the Hospice Nurse that the resident was agitated and hallucinating. On February 27, 2021, at approximately 1:30 a.m. nursing noted that the facility received a call from the local police asking if a facility resident was missing because they had a person at the convenient store wrapped in a blanket. In response to the call, the facility then did a full house sweep and noted that Resident CR2 was missing. The police returned the resident to the facility, but then transferred the resident to the hospital for an evaluation. The resident did not return to the facility. A review of the facility investigation revealed that staff last observed the resident in his room at 12:20 a.m. seated in his chair in his room wearing lounge pants and a T-shirt. A statement by Employee 3, the Registered Nurse, indicated at 1:34 a.m. the resident was missing. Employee 3 noted that the resident's bed was ruffled, the call bell was on the floor next to the bed, the window screen was underneath the bed by the window. A chair was in front of the window and the window was wide open and the latch that holds the window was broken off and the screws were unscrewed and left on the windowsill. A dinner knife and spoons were observed on the dresser next to the bed. Upon observation of the location of the resident's room during the survey ending April 9, 2021, the resident's room was located six rooms away from the nursing station and three rooms from the very end of the hall. The resident's care plan dated January 29, 2021, identified the planned approach for the resident's room to be close to the nurse station. The distance from the window to the ground outside was measured at 6 ft by the Maintenance Director on April 9, 2021, at 2:15 p.m. The Maintenance Director stated during interview on April 9, 2021, that at the time of the resident's elopement there was a snow pack making the distance from the window to the ground less than 6 feet. The distance from the facility to the convenient market was approximately a little over a half mile away. Although, the resident was not assessed as an elopement risk, the facility had identified that the resident was unsafe with transfers, unhooking alarms, agitated and acting erratically and hallucinating prior to his elopement. The resident had the potential for elevated ammonia blood levels due to his medical condition, which may cause confusion. The resident's room was not in close proximity to the nurse's station as care planned. The facility's investigation did not indicate if the resident was wearing shoes and other than the blanket did not indicate what he was wearing when he eloped in the wintry conditions of January 2021. The facility failed to adequately supervise a resident during periods of increased confusion and behaviors. The resident was experiencing hallucinations and had recently gave most of his possessions to his sister. Interview with the Maintenance Director at the time of the survey ending April 9, 2021, revealed that immediately following Resident CR2's elopement all windows in the facility were inspected and additional screws were added to deter a similar occurrence, which was confirmed during observation at the time of the survey ending April 9, 2021. Interview with the Nursing Home Administrator on April 9, 2021, at approximately 2:00 p.m. failed to provide evidence that Resident CR2 was adequately supervised to prevent the elopement to maintain the resident's safety. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services Previously cited 10/18/19, 2/11/21

Based on review of clinical records and select policy review and interview with facility staff members it was determined that the facility neglected to provide the residents with necessary care to avoid serious injury/physical harm for two of five residents reviewed (Resident CR1 and Resident 4) Findings include: The facility's Abuse Policy dated as reviewed on (MONTH) 24, (YEAR), stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility defines abuse as actions such as willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to avoid physical harm, mental anguish, emotional distress, or mental illness. A review of the clinical record revealed that Resident CR1 was admitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated (MONTH) 5, 2019, revealed that the resident was severely cognitively impaired, required maximum assistance of staff for activities of daily living including bed mobility, transfers and walking. The MDS Assessment further indicated that Resident CR1 was not steady while seated and only able to stabilize with staff assistance. A review of a facility investigation report dated (MONTH) 6, 2019, at 7:00 AM revealed that the licensed nurse (Employee 5) was called to Resident CR1's room. Resident CR1 was found lying on the floor on his right side on the fall mat. Employee 3 (nurse aide) had witnessed the resident sitting on the side of the bed. According to the facility report, the resident's routine was to put his left hand on the footboard of the bed and onto the bed for balance (while sitting on the bed). Employee 3 (nurse aide) reportedly just turned to get the fall mat (out of the way) and the wheelchair into place to transfer the resident. Resident CR1 just flopped out of bed and onto the floor. He did not hit his head according to Employee 3. Nursing noted some bruising to the resident's right anterior shoulder and an abraded area on his right posterior shoulder. Predisposing factors noted on the facility's incident investigation report included gait imbalance, a history of falls and impaired vision. Immediate interventions planned were to contact the physician and to monitor Resident CR1's shoulder and to apply first aid. A review of nursing documentation dated (MONTH) 6, 2019, at 7:15 AM revealed that Employee 5 (RN Supervisor) stated, called to see Resident CR1 by Employee 3 (NA - nurse aide). Resident CR1 was lying on his right side on the floor mat. Employee 3 witnessed the fall, since he was providing care to the resident. Employee 3 (NA) stated I had him sitting up on the side of the bed, he puts his left hand on the footboard of the bed for balance, just like everyday. Employee 3 turned to pull the floor mat out of the way and bring the wheelchair closer. Resident CR1 just flopped out of the bed onto the floor. Resident CR1 did not hit his head. Nursing noted that the resident was assessed for injuries, hips symmetrical, legs equal in length, no out turning of his feet, able to move all his extremities. He denied pain. There was bruising to his anterior right shoulder and a brush burn to his posterior right shoulder. He was then assisted to his wheelchair. Nursing documentation at the time of the fall indicated that Employee 5 (RN Supervisor) assessed Resident CR1 including the completion of a neuro check (Neuro checks are an assessment made by a medical professional on someone with a head injury, cervical injury, nerve function in injury/surgery, or stroke to assess level or change in consciousness). An employee witness statement dated (MONTH) 6, 2019, (no time indicated) from Employee 3 revealed that the incident occurred while the aide was providing AM care to Resident CR1. Employee 3 stated that just like every morning, Resident CR1 has a certain way of helping in his transfer to his wheelchair. Employee 3 described the process as that after being set up to the side of the bed, with both feet on the floor, he holds the footboard with his left hand to help push off and stabilize while someone (an aide) helps him to stand and turn; and sit in his wheelchair. The employee further stated that this morning, while following this method and during the step before the transfer, I assisted him to the side of the bed, with his left hand on the footboard and both feet firmly on the floor, I turned away from him approximately three steps to get his wheelchair to transfer him into it and about two seconds after I did, he ended up prone with bent knees to his left towards his bed on the fall mat, which I hadn't moved yet because I wasn't ready to transfer him. It was noted that the resident was wearing his personal shoes and socks at the time of the fall. The resident did not display new behaviors or new signs of pain. Employee 3 stated that the resident did not give me any impression that I could not turn away for a few minutes to get his wheelchair as per the usual get up process. A review of a facility incident investigation report dated (MONTH) 7, 2019, at 1:10 PM revealed that Employee 7 a (nurse aide) reported to Employee 5 (RN Supervisor) that Resident CR1 had bruising to his right posterior ear. The physician and the responsible party were notified at that time. In an employee witness statement dated (MONTH) 7, 2019, (no time indicated) Employee 7 (nurse aide) stated while providing resident care during the 3 PM to 11 PM shift on (MONTH) 6, 2019, I noticed a little bruise to the patient's (Resident CR1) right ear. I assumed the bruise was already reported because the resident had fallen earlier in the morning. During an interview on (MONTH) 4, 2019, at approximately 11:00 AM Employee 7 verified that on (MONTH) 6, 2019, during the 3:00 PM to 11:00 PM shift she noticed a small bruised area on Resident CR1's right ear. Employee 7 also stated that she did not report the bruise to licensed nursing staff on (MONTH) 6, 2019, because she assumed that the area had already been identified at the time of resident's fall that morning. Employee 7 stated that she had informed the licensed nurse of the bruise on (MONTH) 7, 2019, around lunch time. The facility obtained a second statement from Employee 3 (nurse aide) via telephone on (MONTH) 7, 2019, at 3:00 PM. Employee 3 stated that during care on (MONTH) 6, 2019, at 7:10 AM he turned momentarily to get the Broda chair (a type of wheel chair able to recline) closer to the resident's bed. He heard a noise, looked down and Resident CR1 was lying prone on the floor mat. Employee 3 now stated that he did not actual witness the resident's fall, but that Resident CR1 denied hitting his head. During an interview (MONTH) 4, 2019, at approximately 11:15 AM Employee 6 (LPN) stated that on (MONTH) 6, 2019, at approximately 7:15 AM she responded to Resident CR1's room and found the resident on the floor. She stated that Employee 3 stated that he witnessed the fall and Resident CR1 did not hit his head. During an interview (MONTH) 4, 2019, at approximately 11:30 AM Employee 5 (RN Supervisor) stated that she responded to the resident's fall on (MONTH) 6, 2019, at approximately 7:15 AM The resident was on the floor at that time. Employee 5 stated that Employee 3 said that he witnessed the resident's fall and the resident did not hit his head. She stated that she assessed the resident and his injuries included bruising on the right shoulder and an abrasion on the back side of his right shoulder. Employee 5 stated that she obtained vital signs and did a neuro check, which she noted to be within normal limits. Employee 5 confirmed that neither she, nor any other licensed nursing staff had conducted any further neuro checks because Employee 3 stated that he had witnessed the fall and that the resident did not hit his head. Employee 5 further stated that on (MONTH) 7, 2019, the day after the fall at approximately 12:00 PM the resident's son reported to nursing staff that there was a decline in his father's condition. The resident had slurred speech, more than usual, the son was not understanding him and a bruise was observed on his father's ear. Employee 5 stated that she assessed Resident CR1 at that time. She noted that he did have a small bruise on his right ear and what appeared to be a bluish hue to his skin from his right ear across the back of his neck to his left ear. Employee 5(RN) asked the resident's son what he wanted done at that time. The physician was contacted and the resident was sent to the hospital. A review of nursing documentation dated (MONTH) 7, 2019, at 2:30 PM revealed that Resident CR1 was admitted to the hospital. A review of the hospital history and physical also dated (MONTH) 7, 2019, indicated that Resident CR1 had a fall at the facility; came to the emergency room for CT scan (computed tomography scan, and formerly known as a computerized axial tomography scan or CAT scan, makes use of computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas of a scanned object, allowing the user to see inside the object without cutting) of the head, which showed bilateral subdural hematomas (a type of hematoma-usually associated with [MEDICAL CONDITION]-in which blood gathers between the inner layer of the dura mater and the arachnoid mater. It usually results from tears in bridging veins that cross the subdural space. Subdural hematomas may cause an increase in intracranial pressure, which in turn can cause compression of and damage to delicate brain tissue. Acute subdural hematomas are often life-threatening). The hospital assessment indicated that Resident CR 1 had some changes in his usual neurological functioning. It was noted that at the time of the evaluation he was not making any sensible communication. He was twisting and turning, whimpering on the stretcher. The impression from the hospital report was that Resident CR1 had bilateral mixed subdural hematomas overlying the cerebral convexities, predominately the frontoparietal regions. The left sided hematoma measured 13 mm (millimeters) in thickness and the right sided hematoma measures 5 mm. Both contained hyperdense hemorrhage (bleeding). There was associated mass effect, probably related to the left-sided subdural hematoma. There was approximately 3 mm of rightward midline shift (A midline shift occurs when the pressure exerted by the buildup of blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off center. This is considered a medical emergency). The resident expired at the hospital (MONTH) 11, 2019. A review of an employee education form dated (MONTH) 7, 2019, (no time indicated), revealed that Employee 7 did not report a change of condition to a resident's skin (bruise right ear). The education included any change of condition in a resident must be reported to the nurse immediately. There was no education or disciplinary action noted at the time of the survey ending (MONTH) 4, 2019, for Employee 3, although the employee failed to accurately report a factual account of the resident's fall at the time of occurrence. The resident presented a potential injury of unknown origin (bruise on the right ear on (MONTH) 6, 2019), but the facility failed to promptly investigate the accuracy of Employee's 3 account of the resident's fall at that time to determine the potential cause of the head injury. The facility did not obtain another statement from Employee 3 until (MONTH) 7, 2019, when Employee 7 reported the right ear bruising and Employee 5 further assessed the resident. Employee 7 failed to promptly report the evidence (right ear bruising) identified on (MONTH) 6, 2019, indicating that the resident had possibly struck his head during the unwitnessed fall that morning. After the resident's fall, licensed nursing staff failed to consistently monitor the resident for a potential head injury because Employee 3 stated that he had witnessed the fall and the resident did not hit his head. Employee 7 failed to immediately report the resident's right ear bruising to licensed nursing staff. Nursing staff only conducted one neurocheck and did not timely identify the resident's change in condition. The resident's neurological changes were identified by the resident's son the day after the fall. During an interview (MONTH) 4, 2019 at approximately 2:00 PM the Director of Nursing (DON) confirmed that Resident CR1's fall was unwitnessed. The DON further stated that Employee 3 did not accurately communicate the event to licensed nursing staff and Employee 7 did not timely report the bruise to nursing when initially observed to ensure that Resident CR1 received timely and necessary treatment and services for a head injury. A review of the clinical record revealed that Resident 4 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated (MONTH) 25, 2019, indicated that the resident's cognition was severely impaired and the resident required the assistance of two staff member for activities of daily living (ADLS are routine activities people do every day without assistance, including eating, bathing, getting dressed, toileting, transferring) in the areas of transfers, toileting, and personal hygiene. A review of a facility abuse investigation dated (MONTH) 11, 2019, revealed that on (MONTH) 11, 2019, at 10:41 AM Employees 2 (nurse aide) and 4 (LPN - Licensed Practical Nurse) were toileting Resident 4. As these employees began to stand the resident, the resident had difficulty standing and was yelling. According to the facility's investigative report, Employee 2 stated that the resident typically screams during care. Employees 2 and 4 assisted the resident back to her chair and the resident had no further complaints. At approximately 11:15 AM on (MONTH) 11, 2019, the resident's husband told the charge nurse that the resident had pain in her hip and was cursing. Upon nursing assessment, it was noted that the resident was yelling and her left knee was swollen. A review nursing progress notes dated (MONTH) 11, 2019, at 11:41 AM indicated that Resident 4 had swelling, pain, and decreased mobility. The physician was contacted. A new order for x-ray to the left hip and to place the resident back to bed were noted. A review of the x-ray report dated (MONTH) 11, 2019, at 5:46 PM revealed that Resident 4 had a comminuted (a break or splinter of the bone into more than two fragments), angulated (displacement where the normal axis of the bone has been altered), impacted (broken ends of the bone are jammed together by the force of the injury), displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) left [MEDICAL CONDITION]. A review of progress notes dated (MONTH) 11, 2019, at 7:10 PM indicated that the physician reviewed the x-ray and an order was noted to send the resident to hospital for evaluation and treatment. A review of an employee statement dated (MONTH) 11, 2019, no time, from Employee 2, a nurse aide, regarding the incident revealed that she did not transfer the resident out of bed that morning. The employee stated that she saw the resident in the hall that day going to breakfast; then saw the resident again at 10:40 AM to take the resident to the bathroom with Employee 4. Employee 2 stated that, at that time, the resident had trouble standing and was yelling, but didn't say one particular thing hurt. The nurse aide and another staff member toileted the resident and assisted her back to her chair. A review of an employee statement dated (MONTH) 11, 2019, no time, from Employee 1, a nurse aide, regarding the incident revealed that she got the resident out of bed that morning. The facility asked the nurse aide if she had someone helping her get the resident out of bed. Employee 1 stated that Employee 2 assisted her with the resident's transfer out of bed. When Employee 1 was told Employee 2 was interviewed and denied assisting her with the resident's transfer from bed that morning, Employee 1 stated she was there, she is scatterbrained at times. Employee 1 denied that she had transferred the resident out bed without assistance that morning and further stated that nothing unusual occurred during the resident's transfer. A review of a second employee statement dated (MONTH) 12, 2019, no time, from Employee 1, revealed that after she provided the resident's care she assisted the resident to the side of the bed and proceeded to assist her into her wheelchair. Employee 1 stated there was no unusual occurrences during the transfer from the bed to the wheelchair. She stated that the resident did not complain of any pain at the time. However, Employee 1 did now admit that she had transferred the resident out of bed by herself on the morning of (MONTH) 11, 2019, because it was busy in the morning and Employee 2 was in another room. Employee 1 further stated that she failed to verify the resident's transfer status. A review of a discipline report dated (MONTH) 12, 2019 revealed Employee 1 was suspended during the facility's investigation into an incident of neglect. The facility identified that the nurse aide failed to provide Resident 4 with necessary assistance the resident's plan of care. A review of the employee's personnel file revealed that the nurse aide also received disciplinary action on (MONTH) 8, (YEAR), and (MONTH) 27, (YEAR), regarding failure to provide assistance according to the residents' plans of care. An interview with the DON on (MONTH) 4, 2019, at approximately 2:30 PM confirmed the facility failed to ensure that Resident 4 received the services necessary to avoid physical harm. 28 Pa. Code 201.18(e)(1) Management Previously Cited [DATE], [DATE] 28 Pa. Code 201.18(e)(3) Management Previously Cited [DATE] 28 Pa. Code 201.29(a) Resident Rights Previously Cited [DATE], [DATE] 28 Pa. Code 201.29(c) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services Previously Cited [DATE], [DATE], [DATE]

Based on observations, a review of clinical records, select facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and to maintain a resident's environment free of potential accident hazards, that increased the risk for injury from a fall during which the resident sustained [REDACTED]. Findings include: A review of the clinical record of Resident 94 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 28, 2017, revealed that the resident was severely cognitively impaired, with a BIMS score of 3 (brief interview for mental status - a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment). The resident required staff assistance for transfers, bed mobility and ambulation in her room. The resident had a history of [REDACTED]. A review of a facility incident investigation dated January 22, 2017, at 5:45 a.m., revealed that Resident 94 was found on the floor next to her bed with no injuries. Interventions in place at the time of the fall included non skid socks, a personal safety alarm (to alert staff to unassisted transfers) and to keep the resident's call bell within reach. Bilateral (both sides) bed bolsters were placed on the resident's the bed (bolsters are raised devices attached to the sides of the bed to protect people from falling out of bed). Nursing documentation dated February 1, 2017, 1:38 p.m. revealed that the resident had a fall from the wheelchair in the hallway with no injuries. On February 6, 2017, Resident 94 was found on the floor in another resident room. On February 10, 2017, at 9:26 a. m. nursing noted that the resident made multiple attempts at standing unassisted. On February 20, 2017 at 6:41 a.m. Resident 94 climbed out of bed, over the bed bolsters, and fell out of bed. The intervention planned after this fall was for a therapy screen the resident and to evaluate the use of the bilateral bed bolsters. A review of the therapy screen form dated February 21, 2017, revealed that Resident 94 remained on occupational and physical therapy services. The screen noted that the resident was getting out of bed, over the bolsters, this weekend. She continues to require assistance for ambulation and transfers. She demonstrates decreased safety due to cognitive impairments. Risks vs benefits discussed with therapy and nursing. The screen noted the plan to continue bolsters to define the perimeter of the bed during bed mobility tasks. During an interview on December 8, 2017, at approximately 1 PM the Director of Therapy Services stated that at the time of the therapy screen February 21, 2017, the bed bolsters were evaluated for safety during bed mobility tasks, including turning and repositioning and during resident care while attended by staff. The Director of Therapy confirmed that the appropriateness of the bolsters while in the resident was in bed unattended by staff was not evaluated at that time. The Director of Therapy was unable to state that the bolsters were a safe intervention to prevent falls for this resident. Nursing documentation continued to note the resident's unassisted rising from bed and wheelchair, as well as, falls without injury. A review of a facility incident investigation dated June 1, 2017 at 7:45 a.m. revealed that Resident 94 was found on the floor in her room. The investigation stated that the resident had climbed over the bed bolsters and fell to the floor. She was complaining of right shoulder pain, grimacing upon movement and range of motion. The physician was contacted at that time and ice and an X-ray of the right shoulder were ordered. A review of an X-ray report dated June 1, 2017, revealed that Resident 94 had a comminuted fracture (is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) with mild displacement of the base of the right humeral head (a broken shoulder). Orthopedics (doctor specializing in bones) was consulted and a sling to the right arm, ice and [MEDICATION NAME] (pain medication) were ordered until the ortho appointment. The noted intervention put into place after the June 1 2017, fall was to discontinue the bilateral bed bolsters and place bilateral floor mats at the resident's bedside. Nursing documentation continued to document the resident's unsafe rising from the bed and the wheelchair. An observation made on December 7, 2017, at 10:10 A.M, upon entering Resident 94's room revealed that the resident was not in view, but the resident's bed pressure alarm was sounding. Continued observation revealed that at 10:20 a.m. the resident ambulated out of her bathroom into the hallway while the bed alarm was still sounding. At 10:25 a.m., Resident 94 ambulated back to her bed and got in bed. The pressure from her body against the bed pad silenced the alarm. At no time during this observation did any staff member respond to this resident's alarm sounding. The planned bilateral floor mats in place at this time were observed to be the box type in which the top of the mat is approximately 2 inches off the floor, which created an additional tripping, fall hazard. The facility failed to respond to the sounding safety alarms for this resident at high risk for falls and failed to demonstrate that the resident was consistently provided with necessary staff supervision to prevent unsafe acts and prevent falls. Refer F725 483.25(d)(2) accidents previously cited 1/13/17 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services. Previously cited: 1/13/17.

Based on review of clinical records and an Event Report submitted to the State Survey Agency, it was determined that the facility failed to provide adequate supervision and monitoring of a resident at risk for self-injury due to behavioral symptoms resulting in actual harm for one of two residents sampled (Resident CRA2). Findings include: A review of an event report submitted to State Survey Agency on [DATE] revealed that a resident, newly admitted to the facility on that same date, had self removed her tracheostomy tube (surgical opening into the neck and windpipe for breathing) on two occasions within 10 minutes of each and on the second self-removal of the tracheostomy tube, the resident was found by nursing staff to be nonresponsive, without respirations or pulse and the resident's pupils were fixed and dilated. Following unsuccessful efforts to resuscitate the resident at that time the resident expired. Resident CRA2 was admitted to the facility on [DATE] at approximately 2 PM. Transfer information sent with the resident from an acute care facility identified that the resident had a recent surgical insertion of a tracheostomy (surgical opening into the neck and windpipe for breathing) due to respiratory failure and had been evaluated by psychiatry due to behavioral symptoms of restlessness, combativeness with care and agitation exhibited by pulling at the oxygen and tracheostomy tubing. A review of the psychiatric consultation conducted while at the acute care facility and completed five days prior to being admitted to the long term care facility revealed that the consult was conducted due to a management problem that was occurring at the acute care facility with the resident's behavioral symptoms. The resident was attempting to pull out the tracheostomy tube and at the time of the consult was currently on one-to-one watch by a staff member. During the consult, documentation from the psychiatrist revealed that the resident was constantly rubbing, grabbing and touching the tracheostomy tube and appeared not to be able to comprehend current medical status. The resident was prescribed and started on a daily administration of an anti-psychotic medication and had been receiving anti-anxiety medication (Ativan) that was used as needed, when redirection was ineffective, to manage the resident's restlessness exhibited by pulling and grabbing at oxygen tubing, the tracheostomy tube and pushing staff away when providing care. Discharge evaluation from the acute care facility included in the resident's transfer information to the facility also revealed that the resident's short and long term memory and decision making abilities were impaired. The resident was admitted to the long term care facility on [DATE] and the anti-psychotic medication Seroquel was continued along with the anti-anxiety medication Ativan as needed every six hours for agitation and restlessness. An interdisciplinary screen form for rehabilitation services for speech and physical therapy conducted on the resident's admission to the long term care facility on [DATE] revealed that the screens for therapy could not be completed due to the resident's restlessness and agitation exhibited during the screening attempts. An initial plan of care dated [DATE] identified that the resident had "dementia with behaviors" and for the resident's safety, the resident was placed on 15 minute checks by staff. The initial plan of care also directed that the nurse was to be notified if the resident was observed to be restless or removing oxygen tubing and oxygen mask that was utilized on the tracheostomy tube. A review of the Resident Activity/Monitoring Form revealed that 15 minute checks were started at 2:30 PM and conducted every 15 minutes afterwards. Documentation revealed that from 2:30 PM through 6:15 PM, the resident was in bed and had a calm demeanor. The 15 minute checks from 6:30 PM through 7:15 PM revealed that the resident was restless, pulling at the tubing and that the nurse was made aware. Nursing documentation at 7:05 PM revealed that staff called the nurse to the resident's room because the resident had pulled out the tracheostomy tube and was holding the tracheostomy oxygen mask with mist over the stoma (surgical opening) in the trachea. The tracheostomy tube was successfully replaced by the nurse. Although the resident had self-removed the tracheostomy tube, which had the potential to compromise the resident's respiratory status, and had a known history of such behavioral symptoms, the facility failed to assure that the resident received adequate supervision and monitoring to prevent further self removals of the tracheostomy tube and oxygen. Despite this episode of self-removal of the tracheostomy, the facility continued 15 minute checks, even though that level of supervision had proven ineffective in preventing the resident from removing the tracheostomy that evening and the resident was displaying restless behavior beginning at 6:30 PM according to the 15 minute check monitoring form. Nursing documentation at 7:15 PM, 10 minutes later, revealed that the resident was found unresponsive with the oxygen and mist mask off and the tracheostomy tube again pulled out. The resident was described as unresponsive, without respirations or pulse. Cardiopulmonary resuscitation (CPR) was started by nursing staff and continued by emergency medical technicians that arrived at facility. CPR was not successful and the resident was pronounced expired approximately seven and ,[DATE] hours after the resident's initial admission to the facility. 483.25 (h) Free of Accidents/supervision/devices Previously cited [DATE] 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited [DATE]