Every finding on record at Lancaster Nursing and Rehabilitation Center

Based on review of policies and clinical records and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of three residents reviewed (Resident 4).Based on review of policies and clinical records and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of three residents reviewed (Resident 4).Findings Include:Review of facility policy Podiatry Service Policy states The facility shall provide access to Podiatry services for residents based on physician or authorized practitioner orders, resident needs and applicable federal and state regulations.Review of Resident 4 quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 14 2026, indicated that the resident was alert and oriented, dependent on staff for daily care needs, and had a diagnosis of diabetes (disease that interferes with blood sugar control).Progress note May 7, 2026 at 2:12 p.m. nursing note stated Resident has excessive dry, flaking skin on BLE. Toenails very thick. Spoke with resident and will email for podiatry consult.Review of email correspondence on May 8, 2026, revealed facility reached out to podiatry office to add Resident 4 on to podiatry list.Progress note of May 14, 2026 at 11:20 a.m. nursing note stated Resident has dry, flaking skin on BLE. Podiatry consult was sent and awaiting date for service in house. Provider has new order for ammonium lactate 12% apply to BLE BID.Progress note of May 21, 2026 at 3:57 p.m. nursing note stated Patient is requesting to be seen by the podiatrist. Patient placed on doctor board.Progress note of May 21, 2026 at 5:14 p.m. nursing note Dr. [NAME] gave podiatry referral. POA is aware.Review of email correspondence on June 26, 2026, revealed facility reached out to podiatry office to add Resident 4 on to podiatry list.Progress note of June 29, 2026 at 1:17 p.m. social service note stated Social Worker completed Bhims and PHQ9 with Resident 4. Resident 4 is cognitively intact, scoring a 15/15 and a 5 in PHQ9 assessment. During assessment, (Resident 4) complained that her toenails have not be clipped. Social Worker noticed overgrown toenails. (Resident 4) states that 4 orders have been placed. Social Worker reviewed orders, noting 1 order placed 5/22 for consult. Social Worker will follow-up.Review of Resident 4 clinical records revealed no evidence of follow up by facility between May 21,2026 to June 26, 2026.The facility failed to ensure Resident 4 was provided with foot care. Interview with Nursing Home Administrator on June 30, 2026, at 1:45pm confirmed the above findings.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services28 Pa Code 211.5(f) Clinical Records

Based upon review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure appropriate items were in place for a resident with a restraint for one of thirty-five residents reviewed (Resident 1).Findings include:Review of facility policy and procedure titled Use of Restraints revealed Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.Further review of the policy and procedure revealed The definition of a restraint is based on the functional status of the resident and not the device. I the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint.Further review of the policy and procedure revealed Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to : a) treat the medical symptom; b) protect the resident's safety and c) help the resident attain the highest level of his/her physical or psychological well-being. Restraint evaluation will be completed upon initiation of a restraint and quarterly. Restraints shall only be used upon the written order of a physician. The order shall include the following: a) the specific reason for the restraint and b) the type of restraint and period for the release of the restraint.Review of Resident 1's diagnosis list revealed diagnoses including the presence of a gastrostomy tube to facilitate tube feeding.Review of Resident 1's current care plan revealed an intervention initiated November 24, 2014, which stated abdominal binder in place loosely enough to allow air to get to area but still close enough to prevent [resident] from pulling PEG tube out. Check placement of binder every shift. If PEG tube comes out, insert foley tube to prevent stoma from closing and sent to ER if dislodged.Review of Resident 1's physician orders revealed an order dated May 27, 2026, which stated abdominal binder on at all times, may remove for care, release every two hours every shift.Observation of Resident 1 on May 28, 2026, at 10:00 a.m. revealed an abdominal binder in place covering Resident 1's PEG tube.Review of all clinical documentation failed to reveal evidence that a physician's order was in place for the use of an abdominal binder restraint which was initiated on November 24, 2014.Interview with the Director of Nursing on May 29, 2026, at 11:00 a.m. revealed that through an audit of physician's orders, it was discovered that no physician's order existed for Resident 1's use of the abdominal binder restraint until May 27, 2026. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on clinical record review and staff interview, the facility failed to update the Comprehensive Care Plan for one out of thirty-five resident's reviewed. Review of clinical orders for Resident #11 finds an order placed on June 28, 2025, for a status of Full Code (medical directive where a resident requests all possible life-saving measures be utilized in the event of a cardiac arrest). Review of Resident #11's Comprehensive Care Plan reveals that the care plan was updated on May 28, 2026, to reflect the resident's change in code status to Full Code. Review of Resident #11's clinical record failed to reveal evidence that Resident #11's care plan was updated to Full Code Status on June 28, 2025, when Resident #11's physician initiated the Full Code Status order. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based upon clinical record review, it was determined the facility failed to ensure that physician ordered fluid restrictions were monitored daily as ordered for two of thirty-five residents reviewed (Resident 2 and Resident 19).Findings include: Review of Resident 2's diagnosis list revealed diagnoses including congestive heart failure (CHF – excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 2's physician's orders revealed an order dated March 31, 2026, for 2000 milliliter (ml) fluid restriction every day – Dietary 1080 ml; nursing 920 ml (480 ml day shift, 360 ml evening shift and 80 ml night shift. Review of Resident 2's May 2026 Medication Administration Record revealed daily documentation of fluid consumption for nursing. Further review of Resident 2's clinical record failed to reveal any documented evidence of dietary fluid consumption and also failed to reveal any documented evidence of a total daily fluid consumption to ensure Resident 2 did not exceed the physician ordered 2000 ml daily fluid restriction. Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2026, at 11:30 a.m. confirmed that the facility was not ensuring that Resident 2 did not exceed the 2000 ml fluid restriction as ordered by Resident 2's physician. Review of Resident 19's clinical record revealed diagnoses including congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 19's physician's orders dated February 21, 2026, revealed an order for 2L Daily Fluid Restriction – dining 1040 mL/day; Nursing - 960mL/day (400 mL 7-3, 400 mL 3-11, 160mL 11-7) every shift Review of Resident 19's Fluid Task sheet and Medication Administration Record revealed Resident 19 exceeded the daily fluid allotment as follows on: May 4, 2026; May 11, 2026, and May 20, 2026. Interview with Nursing Home Administrator on May 20, 2026, at 10:15 a.m. confirmed the above findings. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of four residents reviewed. (Resident 1)Findings include: Review of Resident 1's clinical record Face Sheet revealed the resident admitted into the facility from the hospital on September 16, 2025, with medical diagnoses that include Anoxic Brain Damage(brain is completely deprived of oxygen for four minutes or longer, causing widespread cell death and potential permanent damage). , Osteomyelitis (infection of the bone), Acute and Chronic respiratory Failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide ), Mild Protein Calorie Malnutrition and Tracheostomy Status (surgical procedure creating an opening (stoma) in the neck into the trachea, often with a tube inserted to bypass upper airway obstructions, facilitate long-term mechanical ventilation, or clear secretions). Review of Resident 1's physician orders revealed an order dated January 19, 2026, for enteral feed (a method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) every shift, Glucerna 1.5 (a nutritional drink) via peg tube, continuous feeding, 60 ml (milliliters) per hour, tv (total volume) = 1320 ml. Further review of Resident 1's physician orders revealed an order dated January 19, 2026, for enteral feed order every shift hydration flush 40ml of H20 (water) every hour. Document ml in POC enteral flush task. Review of Resident 1's February 2026 Medication Administration Record (MAR), on February 12, 2026, at 11:00 a.m. revealed no documentation of the resident receiving enteral feeding or medications for the dayshift. Observations made of Resident 1's enteral feeding machine on Thursday February 12, 2026, at 11:20 a.m., revealed an empty bottle of Glucerna hanging with the feeding pump beeping. Observations were made of Registered Nurse Employee E3 entering Resident 1's room at 11:25 a.m., administering the resident's medications, and hanging a new bottle of Glucerna and Hydration fluids on the tube feeding machine. When questioned, Employee E3 verified that Resident 1's enteral feeding should have been continuous. Observations made of Resident 1's enteral feed settings following Employee E3's set up revealed settings of 60 ml with total feed volume of 1667 ml, as opposed to the total feed volume of 1320 ml as prescribed in the resident's orders. Review of Resident 1's Medication Administration Record (MAR) for the months of January and February 2026 failed to reveal documentation that the resident received a total volume of 1320 ml per day as ordered by the physician. Review of Resident 1's task forms revealed no enteral flush task documenting the resident's hydration amounts as prescribed by the physician. Interview with the Nursing Home Administrator and Director of Nursing on August 14, 2024, at 9:45 a.m. confirmed there was no documented evidence Resident 1 had received the amount of Glucerna or water that was ordered by the physician. 28 Pa Code: 211.5(f) Clinical records 28 Pa code: 211.12(d)(1)(3)(5) Nursing services

Based on observation, staff interview, and facility documentation review revealed the facility failed to maintain a sanitary environment for 3 of 7 units. (4th, 5th, and 6th floors)Findings include:Observation on January 9, 2026 at 10:45 a.m. of the 6th floor west side shower room revealed 1 live roach in a supply cabinet, 5 dead roaches in the same supply cabinet, and 1 dead roach in the sink. 1 dying roach (approximately 3 inches in length) was observed in the 6th floor lobby in front of the elevators.Observation on January 9, 2026 at 11:30 a.m. of the 5th floor east side shower room revealed multiple dead roaches in the toilet and shower rooms and 1 live roach on the shower curtain.Observation on January 9, 2026 at 12:15 p.m. of the 4th floor west shower room revealed multiple dead roaches in the shower room and 1 live roach on the shower curtain.Interview with Resident 1 on January 9, 2026 at 1:30 p.m. revealed that he reported live roaches in his bed to the Maintenance department several weeks ago.A review of Service Inspection Reports from the exterminating company reveals service calls for roach activity in spa rooms, resident rooms, and staff areas on the following dates: 11/6/25, 11/13/25, 11/20/25, 11/23/25, 12/4/25, 12/11/25, 12/18/25 (Resident 1's room was treated during this service call), and 12/21/25.Interview with the Nursing Home Administrator and Director of Nursing on January 9th at 2:00 p.m. revealed that they have a contract with an exterminating company that comes out weekly and as necessary. All staff has access to the ticketing system and when staff puts in a ticket, the Maintenance Department contacts the exterminating company to let them know where they should treat.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management

Based on clinical records review and staff interview, it was determined that the facility failed to follow physician's wound care order for one of two residents reviewed (Resident CL1).Findings include:A review of Resident CL1's clinical records revealed resident was admitted to the facility on [DATE], with an Unstageable Pressure Ulcer (Obscured full-thickness and tissue loss) to both heels.A review of the physician's order dated August 12, 2025, revealed a wound care order to cleanse bilateral heels with mild soap and water, rinse well and pat dry, apply Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of a healthy skin) at nickel thickness to wounds careful to minimize the amount of Santyl on surrounding skin. Cover with Alginate (material used in wound to absorb fluid) then cover with abdominal dressing and wrap with Kling (gauze wrap) every day shift.A review of September 2025, Treatment Administration Record (TAR) revealed Resident CL1's wound treatment to both heels were not done on September 21, 2025. A review of the nursing progress notes dated September 21, 2025, at 3:56 p.m., revealed Resident in stable condition, treatment not admin (administered) r/t (related to) workflow.An interview with the Nursing Home Administrator (NHA) conducted on October 10, 2025, at 2:00 p.m. confirmed Resident CL1's bilateral heels wound treatment was not done on September 21, 2025, due to workflow .The facility failed to ensure Resident CL1's wound care treatment to both heels were followed.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services28 Pa Code 211.5(f) Clinical Records

Based on observation, clinical record review and staff interviews, it was determined the facility failed to provide toenail care for one of three residents reviewed (Resident 1). Findings include: A review of Resident 1's Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents), dated August 2, 2025, revealed that the resident has severe cognitive impairment. The same MDS indicated that the resident required partial/moderate assistance with personal hygiene. An observation conducted on October 10, 2025, at 11 a.m. in the presence of an unlicensed Employee E3 revealed that the resident's big toenails of the right and left foot were thick, long and curled inward. Additional observation revealed the right and left second, and third toenails were also long. An interview with Licensed Nursing Employee E3 on October 10, 2025, at 11:03 am was conducted and Licensed Nursing Employee E3 was unable to determine the last time foot care was provided to Resident 1. A review of Resident 1's clinical record failed to reveal toenail care was provided. An interview conducted with the Nursing Home Administrator on October 10, 2025, at 12:15 pm revealed that the resident had not been seen by the podiatrist (a doctor who treats the foot, ankle, and related structures of the leg) for toenail care. A permission form for podiatrist care was sent to the resident's guardian by mail in the year 2023, but no follow up was made. The Nursing Home Administrator confirmed the resident was not provided with podiatry nail care since admission to the facility.The facility failed to ensure Resident 1 was provided with a foot care.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services28 Pa Code 211.5(f) Clinical Records

Based on resident and staff interviews, it was determined that the facility failed to protect and facilitate the resident's right to receive unopened mail for two of two residents interviewed (Resident 16 and Resident 17).Findings include:Review of Resident 16 comprehensive annual Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated February 8,2025, revealed a score of 15 out of 15 on the BIMS (Brief Interview of Mental Status) which places the resident as cognitively intact. During an interview with Resident 16 on July 11,2025 at approximately 12:15 p.m., resident stated that they received mail that was opened against their wishes. Review of Resident 17 comprehensive annual Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated June 28,2025, revealed a score of 15 out of 15 on the BIMS (Brief Interview of Mental Status) which places the resident as cognitively intact.During an interview with Resident 17 on July 11, 2025, at 12:30pm, resident stated that they received mail that was opened. Resident 17 revealed open mail was stamped with a date of 5/2/2025 and initial on the back of the envelope.An interview with the Nursing Home Administrator (NHA) on July 11, 2025, at 1:30 p.m. confirmed that Business Office had opened residents' mail. 28 Pa Code 201.29 (j) Resident rights

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding showers for 1 of 5 resident's reviewed (Resident 1). Findings include: Review of Resident 1's physician orders revealed the resident is scheduled for shower every Monday evening shift and PRN (as needed). Review of Resident 1's clinical records revealed a 30-day shower task form, dated from May 29, 2025, through June 16, 2025, documenting the resident received a shower on May 29, 2025, at 11:07 a.m., May 30, 2025, at 11:26 a.m., and June 3, 2025, at 8:55 p.m. Further review of the shower task form revealed documentation that the resident refused to shower on June 16, 2025, at 9:48 p.m. Interview with Licensed Practical Nurse Employee E14 and Registered Nurse Unit Manager Employee E15 on June 26, 2025, at 12:18 p.m., E14 stated the resident has received a shower since June 16, 2025. E15 confirmed no shower was documented on the resident's shower task form or clinical records since June 3, 2025. Interview conducted with Nursing Home Administrator (NHA) or Director of Nursing (DON) on June 26, 2025, at 2:15 p.m. when the above information was presented the DON confirmed there was no documentation to prove that the resident has had a shower since June 3, 2025. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure weights were monitored and a significant weight change was promptly addressed for five out of 15 residents reviewed (Residents 27, 74, 158, 202, and 338). Findings include: A review of the facility's policy titled Weight Assessment and Interventions, last revised in March 2022, states Resident weights are monitored for undesireable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment must be retaken the next day for confirmation. A. If the weight is verified, nursing will notify the dietitian. Review of Resident 27's physician's orders included an order to weigh monthly every day shift every four weeks. Review of the clinical record revealed a weight of 153.9 pounds on September 16, 2024, and a weight of 139.4 pounds on September 30, 2024, indicating a loss of 14.5 pounds (9.4%). Further review of the clinical record indicated that a weight was not obtained until October 9, 2024 (9 days after the identified weight loss). Further review of Resident 27's clinical record revealed no weight was obtained in November 2024 or January 2025. Review of Resident 74's clinical record revealed that on February 14, 2025, the resident weighed 152.0 lbs. On March 11, 2025, Resident 74's weight was recorded at 137.8 lbs., indicating a 9.34% decrease in weight. Further review of Resident 74's clinical record on April 11, 2025, revealed that nursing staff did not retake the resident's weight the following day, as required by the facility's policy. An interview conducted with the Nursing Home Administrator (NHA) on March 11, 2025, at 1:15 p.m. confirmed the above. Review of Resident 158's physician's orders included an order to weigh monthly every day shift every four weeks on Friday. Review of the resident's clinical record revealed the last recorded weight was on February 21, 2024. Review of Resident 202's clinical record revealed a weight was obtained on November 27, 2024. No weight was documented for December 2024 or January 2025. A weight was obtained on February 23, 2025, with no further documentation of weights for March 2025. Interview with Employee E12 on April 11, 2024, at 10:54 a.m. revealed that the standard is for residents to be weighed monthly and reweights should be obtained within 72 hours. Review of Resident 338's clinical record revealed an order that stated, 'weigh monthly every evening shift every 4 weeks on Sun for wt (weight)'. Further review of Resident 338's clinical record revealed of monthly weights of 114.6 pounds on October 15, 2024 ;112 pounds on October 27, 2024; and 107.5 pounds on December 4, 2024. Further review of the weights revealed facility failed to weigh and record resident weight for the month of November 2024. Interview with the Nursing Home Administrator on April 11, 2025, at 1:15p.m. confirmed the above 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of the facility policy, review of the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to properly store and label medication on four of four medication carts reviewed (7th Floor South Side Cart, 7th Floor North Side Cart, 8th Floor North/South Cart and 8th Floor Southeast/Northeast Cart) Findings include: A review of the facility's policy titled Medication Labeling and Storage, revision date of February 2023, revealed that medications and biologicals are stored in the packaging, containers, or other dispensing systems they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications may not be transferred between containers. Multi-dose vials opened and accessed are dated and discarded within 28 days unless the manufacturers specify a shorter or longer time for the open vial. A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Aspart (Novolog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of manufacturers' storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. An observation on the south side medication cart was conducted on April 8, 2025, at 10:00 a.m., in the presence of licensed nurse Employee E6. The observation revealed two Lantus Insulin pens used and undated and one Lispro Insulin pen used and undated. An interview conducted with Employee E6 on April 8, 2025, at 10:05 a.m., confirmed that the Insulin pens should have been dated when opened. An observation on north side medication cart was conducted on April 8, 2025, at 10:12 a.m., in the presence of licensed nurse Employee E8. The observation revealed one Lispro insulin vial used with an open date of February 9, 2025. The same observation revealed a two Lantus insulin pen used and undated, and a Lidocaine vial (A medication that prevents pain by blocking the signals at the nerve ending in the skin) used and undated. An interview conducted with Employee E8 on April 8, 2025, at 10:15 a.m., confirmed that the above medications should have been dated when opened. An observation on the north/south side medication cart was conducted on April 8, 2025, at 12:15 p.m., in the presence of licensed nurse Employee E9. The observation revealed the following insulins were all opened, used, and undated: three Novolog pens, one Lantus pen, one Insulin Aspart pen, and two Insulin Gargline pens. An interview conducted with Employee E9 on April 8, 2025, at 12:28 p.m., confirmed that the above insulin pens should have been dated when opened. An observation conducted on the southeast/northeast side medication cart was conducted on April 8, 2025, at 12:40 p.m., in the presence of licensed nurse Employee E10. The observation revealed the following: Two Insulin Aspart vials and one Insulin Gargline pen were all opened, used, and undated. Further observation revealed 16 white long tablets in a medication cup in the top drawer. An interview conducted with Employee E10 on April 8, 2025, at 12:45 p.m., confirmed that the insulin medications should have been dated when opened. Furthermore, Employee E10 was unable to verify the name of the white medications observed on the top drawer of the medication cart. The above findings were discussed with the Nursing Home Administrator on April 11, 2025, at 11:00 a.m. The facility failed to ensure correct storage and labeling were maintained on the 7th and 8th Floor medication carts. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/22/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/22/24

Based on observations, clinical records review, and staff interview, it was determined that the facility failed to ensure dignity was maintained during meals for one of the 35 residents reviewed (Resident 51). Findings include: A review of Resident 51's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated March 11, 2025, revealed that Resident 51 had a moderate cognitive impairment. The same MDS revealed that the resident had a diagnosis of Traumatic Brain Injury (A brain dysfunction caused by an outside force, usually a violent blow to the head). An observation conducted on April 9, 2025, at 9:16 a.m., revealed Resident 51 was sitting on a recliner in the hallway outside of his/her room. The resident was alert to themself with difficulty finishing words. When the resident was asked by the surveyor if they could talk inside his room, non-licensed Employee E5 who was passing another resident's breakfast meal tray suddenly interrupted and stated No, he's going to have breakfast. Instead of placing the meal tray and setting up the resident for breakfast, Employee E5 opened the top lid of the resident's breakfast plate that was still in the tray on the food cart, and with bare hands picked up half of a peice of French toast and handed it to the resident's right hand. The resident started eating the French toast placed by the staff in his/her hands. Employee E5 proceeded to pass the breakfast trays of the other residents. The above was conveyed to the NHA (Nursing Home Administrator) on April 11, 2025, at 10:00 a.m. The facility failed to ensure dignity was maintained during breakfast for Resident 51. 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on a review of the facility's policy, clinical records, and facility documentation, as well as staff interviews, it was determined that the facility failed to timely notify the physician of an unwitnessed fall with a facial bruise for one of 35 residents reviewed (Resident 305). Findings include: A review of the facility's policy titled Change in Resident's Condition or Status, with a revision date of February 2021, revealed that the facility promptly notifies the resident, attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been an: Accident or incident involving the resident; and need to alter the resident's medical treatment significantly. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Clinical records review revealed Resident 305's diagnosis list includes Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety, and Heart Failure. The clinical records also revealed Resident 305 was on Eliquis (An anticoagulant medication) for Afib (Atrial Fibrillation irregular, often rapid heart rate that commonly causes poor blood flow). A review of the nursing progress notes dated April 1, 2025, at 7:45 a.m., revealed Resident 305 had an unwitnessed fall in her/his room while attempting to toilet self. Injury details revealed right eye swollen, hematoma (A collection of blood outside of blood vessels, often within tissues, typically caused by injury). A review of the facility's documentation Incident Report, revealed that on April 1, 2025, at 7:20 a.m., the resident's roommate alerted the staff that Resident 305 had fallen. The resident was observed on the floor with their head at the end of the bed. The resident stated that she/he was attempting to go to the bathroom but fell and hit her/his right eye. The same report revealed that the Nurse Practitioner and the family were notified via VM (voicemail). A review of the Nurse Practitioner's progress notes dated April 2, 2025, at 6:40 p.m., revealed that the patient was seen due to reports from therapy that the resident had a change in breathing status. The same note revealed that nursing reported that the resident had a fall yesterday which resulted in bruising over the right eye. The resident was assessed, and the order was made and followed. An interview with the Nurse Practitioner was conducted on April 10, 2025, at 1:38 p.m. The NP reported not being notified of the fall that occurred on the morning of April 1, 2025. The NP reported that she/he was notified of the April 1, 2025, fall on April 2, 2025, at around lunchtime after she/he observed the bruise on the resident's right eye during the visit. The NP reported that she/he would have ordered to hold the resident's Eliquis for a day if notified timely. An interview conducted with licensed nurse Employee E7 on April 11, 2025, at 9:05 a.m., revealed that she/he completed the fall incident report on April 1, 2025, and the one who notified the family and the NP of the fall with injury to the face. Employee E7 reported that she/he notified the NP [stated the name of the NP] on the day of the fall by sending the NP a text message via personal mobile phone but Employee E7 was unable to provide any evidence that the notification had occurred. Employee E7 stated, I thought I did. The above occurrence was conveyed to the NHA on April 11, 2025, at 10:00 a.m. The facility failed to timely notify the physician of Resident 305's unwitnessed fall with facial injury. 28 Pa Code 483.25 Quality of Care Previously cited 5/22/24 28 Pa. Code 201.18(b)(1) Management Previously cited 5/22/24 28 Pa. Code 211.5(f) Clinical records Previously cited 5/22/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/22/24

Based on housekeeping routine schedule, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 40 sampled residents (Resident R197). Findings include: The facility's ISH Health Services, Job Routine H4 states that housekeeping is scheduled to clean Resident R197's room between 8:00 a.m. and 9:00 a.m. An interview with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that housekeeping had not cleaned his room for several days. Observations of Resident R197's room revealed a dried, light brown substance under the resident's urinary drainage bag. Resident R197 reported that the substance had been there for over four days. Further observations on April 9, 2025, at 9:16 a.m. and 12:43 p.m. confirmed that housekeeping had not cleaned the room, as the dried light brown substance remained under the urinary drainage bag. Additional observations on April 10, 2025, at 9:59 a.m. showed the same dried light brown substance under the urinary drainage bag. A review of Resident R197's clinical record found no documentation indicating that Resident R197 had refused housekeeping services. An interview with the Nursing Home Administrator (NHA) on April 11, 2025, at 1:15 p.m. confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based upon clinical record review, and staff interview it was determined the facility failed to ensure Minimum Data Set Assessments (MDS) were completed accurately for two of two residents reviewed (Resident 193 and Resident 244). Findings include: Review of Resident 193's diagnosis list revealed diagnoses including traumatic brain injury, diabetes mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), protein calorie malnutrition, gastrostomy (feeding tube) and tracheostomy (breathing tube). Review of Resident 193's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated January 25, 2025, revealed Resident 193 had a significant weight loss. Review of Resident 193's Weight Summary failed to reveal evidence of a significant weight loss. Interview with Licensed Employee E11 on April 10, 2025, at 12:15 p.m. revealed that Resident 193's Quarterly MDS was completed in error regarding the significant weight loss and Resident 193 did not have a significant weight loss. Review of Resident 244's MDS (Minimum Data Assessment - periodic assessment of resident needs) assessment dated [DATE], section O0110 - Special Treatments, Procedures, and Programs revealed Resident 244 was not receiving hospice care. Review of Resident 224's physician's orders revealed Resident 244 was receiving hospice care since December 11, 2024. Interview on April 11, 2025, at 9:40 a.m. with Licensed Employee E11 confirmed Resident 244's MDS assessment was marked incorrectly. 28 Pa. Code 211.5(f) Clinical Records Previously cited 5/22/2024

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of the 35 residents reviewed (Resident 23 and 111). Findings include: A review of Resident 23's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated February 16, 2025, revealed that the resident had severe cognitive impairment. The same MDS revealed that the resident utilizes a wheelchair for mobilization. A review of the nursing progress notes dated March 19, 2025, at 4:00 p.m., revealed Resident 23 was found on the ground floor of the building with clothes stating she/he was leaving. An Alpha Watch (device that triggers alarms if they approach restricted areas or attempt to leave) was applied to the resident's wheelchair. A review of Resident 23's Elopement Evaluation dated March 19, 2025, revealed a Yes check mark for the following questions: Resident with a history of elopement or attempted leaving the facility without informing the staff; Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; Resident wander; and Resident's wandering behavior a pattern, goal-directed. The evaluation revealed Resident 23 was at risk for elopement. A review of Resident 23's care plan failed to reveal a care plan for the resident's exit-seeking behavior was developed. An interview with the NHA (Nursing Home Administrator) on April 11, 2025, at 1:00 p.m., confirmed a care plan for Resident 23's exit-seeking behavior was not developed. An observation conducted on April 8, 2025, at 10:15 a.m., revealed Resident 111 was lying on the bed with a wound vac machine (A medical device that uses negative pressure to help heal wounds) on the bedside table. A review of Resident 111's physician order dated March 12, 2025, revealed an order for a wound vac to the sacrum continuously setting 125 mm/Hg every shift. Check placement and function every shift, and change canister as needed. A review of Resident 111's care plan failed to reveal that a comprehensive plan of care was developed for Resident 111's use of a continuous wound vac. An interview with the NHA on April 11, 2025, at 10:00 a.m., confirmed that a comprehensive care plan for Resident 111's continuous use of a wound vac was not developed. The facility failed to ensure a comprehensive care plan was developed for Resident 23's exit-seeking behaviors and Resident 111's continuous use of a wound vac. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observation, interview with residents and staff, it was determined that the facility failed to ensure resident call bells were answered and addressed in an appropriate amount of time for one of one resident (Resident R197). Finds include: Review of Resident R197's clinical record revealed the following diagnoses: unspecified injury at an unspecified level of the cervical spinal cord (spinal cord injury), quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down), and muscle wasting and atrophy (thinning of muscle tissue). Review of Resident R197's care plan revealed the following interventions: TRANSFER: Resident is dependent on the assistance of two staff members using a mechanical lift (Hoyer lift) for all transfers; non-ambulatory. This care plan had a start date of March 4, 2019. An interview conducted with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that when he activates his call bell (a system used to notify staff that assistance is required), staff will enter his room, turn off the call bell, and then leave without providing further assistance. Review of Resident R197's clinical record revealed a progress note dated April 1, 2025, at 3:01 p.m., which stated: Resident rang for assistance to get out of bed (OOB) four times, all within approximately 15-minute intervals. Resident was informed each time that the CNA assigned to provide care was also training a new CNA that day, so it would take her longer to complete her duties in order to ensure proper training. Resident was unhappy with this explanation. We will continue to communicate with the resident regarding their assignments and any changes to them. An interview conducted with the Nursing Home Administrator (NHA) on April 11, 2025, at 1:15 p.m. confirmed the above. 28 Pa. Code 211.12(d)(1(5) Nursing services

Based upon clinical record review and interview, it was determined the facility failed to follow physician orders for medication administration and fluid restrictions for 3 of 3 residents reviewed (Resident 1, Resident 27 and Resident 371). Findings include: Review of Resident 1's diagnosis list includes Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) and Acute Respiratory Failure. Review of Resident 1's physician order dated October 21, 2024, revealed an order for 2000 ml fluid restriction every 24 hours. 1020 ml- dietary, and 980 ml - nursing. Review of April 2025 Medication Administration Record (MAR) revealed no documentation that the fluid restriction was followed. Review of Resident 27's care plan revealed resident had a diagnosis of hyponatremia (low blood sodium level) with a need for fluid restriction. Review of physician's orders included an order for 1000 milliliter (mL) fluid restriction (Nursing total=280 ml in 24 hours; Dining total=720 ml in 24 hours). Review of the March 2025 and April 2025 Medication Administration Record (MAR) revealed no documentation that the fluid restriction was followed. Interview with the Nursing Home Administrator on April 11, 2025, at 10:57 a.m. confirmed that there was no documentation indicating that the fluid restriction was followed for Resident 27. Review of Resident 371's diagnosis list revealed diagnoses including coronary artery disease (narrowing of the blood vessels which supply the heart with blood and oxygen), hypertension (high blood pressure) and carotid artery stenosis (narrowing of the carotid artery). Review of Resident 371's physician orders revealed an order for Amlodipine (high blood pressure medication) 2.5 milligrams (mg) to be administered daily for hypertension and to give the medication if the systolic blood pressure (measure of blood pressure while heart is beating; amount of force that blood exerts on the walls of the blood vessels) is greater than 140 mm Hg (millimeters of mercury). Review of Resident 371's February 2025 Medication Administration Record (MAR) revealed Resident 371 received Amlodipine 2.5 mg 19 times from February 1, 2025, through February 28, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. Review of Resident 371's March 2025 MAR revealed Resident 371 received Amlodipine 2.5 mg 16 times from March 1, 2025, through March 31, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. Review of Resident 371's April 2025 MAR revealed Resident 371 received Amlodipine 2.5 mg four times from April 1, 2025, through April 11, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. The above information was conveyed to the Nursing Home Administrator on April 11, 2025, at 1:00 p.m. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/22/2024

ased on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a wound treatment order for one of the four residents reviewed (Resident 111). Findings include: Clinical records review revealed Resident 111 was admitted to the facility on [DATE], with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the sacrum (The triangular bone just below the lumbar vertebrae). Admission skin assessment revealed that the sacral wound measured 12 x 9.0 x 1.0 cm. with 10% slough (A non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Further review revealed that the resident has Osteomyelitis (bone infection) and was receiving Intravenous (Medication administered through a vein) Antibiotics (medication used to fight infections). A review of resident 111's physician's order dated March 12, 2025, revealed an order for a wound vac (A medical device that uses negative pressure to help heal wounds) to the sacrum continuously setting 125 mm/Hg every shift. Check placement and function every shift, and change canister as needed. An observation conducted on April 8, 2025, at 10:15 a.m., revealed Resident 111 was lying in bed, a wound vac machine was observed on the bedside table. Further observation revealed that the machine was off. The canister was observed filled with a light red gel-like substance. An observation conducted on April 8, 2025, at 12:41 p.m., and 2:15 p.m., revealed that the machine was off/not working. An interview with licensed nurse Employee E3 on April 8, 2025, at 2:20 p.m., revealed that she/he was Resident 111's nurse for the day. When asked when the last time she/he checked on the resident's wound vac, Employee E3 stated, I did not see it the whole day. Employee E3 checked the machine and found that the cord that was plugged into the wall socket was not connected to the machine's adaptor. After Employee E3 connected the cord, she/he turned the machine's power on button, but the machine did not start and started beeping. Employee E3 reported that the canister might be full which could be the reason why it was beeping. Employee E3 reported that the wound dressing/canister was changed on April 7, 2025. An interview with licensed nurse Employee E4 on April 8, 2025, at 2:25 p.m., revealed that she/he was one of the nurses on the unit and did observe Resident 111's wound vac working at around 9:44 a.m., and documented on the TAR (Treatment Administration Record) that the machine was working for the day shift. Clinical records review failed to reveal that Resident 111's wound vac machine was monitored from 10:15 a.m., until 2:10 p.m., to ensure the functioning of the machine. The above was conveyed to the Nursing Home Administrator on April 11, 2025, at 10:00 a.m. The facility failed to ensure Resident 111's order for a continuous wound vac to the sacral wound was followed. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were free from neglect when they failed to respond in an appropriate and timely manner to a missing resident for one of 44 residents approved for leave of absences (Resident 1). Additionally, the facility failed to develop and implement guidelines for staff, including time frames for responding to missing residents. This failure placed the residents at high risk of potential for accidents, injury, or serious harm and placed the facility in an Immediate Jeopardy situation. Findings include: Review of facility policy, Abuse and Neglect - Clinical Protocol, last revised [DATE], defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy, Therapeutic Leave of Absence/Plan of Care, issue date [DATE], revealed, It is the policy of the facility to allow residents self-determination for leave of absence from the facility. The facility will ensure the resident is adequately prepared for the therapeutic leave and that the resident is accompanied by a responsible party, or has been assessed as capable of leaving the facility under his or her own supervision .It is also the policy of this facility to develop a plan of care for resident taking therapeutic leave from the facility. The plan of care will be reviewed for understanding with the party accepting responsibility for the resident during the leave of absence, provided with a copy of the plan and the original will be maintained in the resident's medical record. Review of facility policy, Security/Elopement/Missing Persons, issue date of [DATE], revealed, If the resident has not been found after the initial search of the floor, then under direction of the Administrator or DON/ADON, the following notifications will be made: a.) Resident's responsible party b.) Attending physician c.) Local police to report missing resident (call 911) i.) Prior to arrival of police, complete Missing Resident Information sheet. ii.) Picture of resident may be obtained from the Resident Profile book, kept at the receptionist desk d.) Consider notifying the local fire department to assist with the search. Review of Resident 1's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's clinical record revealed the resident was own responsible party. Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) revealed the resident refused a BIMS (Brief Interview for Mental Status - assessment to determine resident's cognitive function); however, staff reported the resident had no memory problems and was independently cognitive. Further review of the MDS revealed the resident was totally dependent on two staff persons for transfers, toileting, did not ambulate, had impairment to bilateral upper and lower extremities, and utilized a wheelchair. Review of Resident 1's care plan revealed a goal dated [DATE] that the resident will remain safe when out on self sign out LOA (leave of absence) with interventions added the same date for staff to request an approximate time of return when he signs himself out and to review self sign out process when the resident signs out. Review of Resident 1's progress notes revealed a nurse's note dated [DATE] at 12:22 a.m. which stated that the resident returned from a leave of absence at 12:15 a.m., and his medications from the ,d+[DATE] shift were given at this time. Further review of Resident 1's progress notes revealed a nurse's note dated [DATE] at 10:15 p.m. which stated, Received call from a concerned neighbor . that resident was [on the street by a park] that resident's electric wheelchair battery died and he needed assistance to get back here. Administration called, Maintenance and front desk person in w/c [(wheelchair)] van to go pickup resident. Per administration No LOA until further notice, awaiting resident to come back to facility. Review of an occupational therapy (OT) evaluation and plan of treatment dated [DATE] revealed that the resident was referred to OT for an evaluation after the resident was out on LOA for 11 hours, w/c battery became drained and unable to get himself back to facility on [DATE], [requested] staff to retrieve him from an intersection. OT further stated that the resident was safely able to maneuver the electric wheelchair inside and outside the facility. The resident reports he left building when chair was not completely charged 2x [(times)] and needed [assistance] to return and he drove into mulch and needed [assistance] to get out of mulch. He reports he fell asleep and got [caught] in rain 1x. He can verbally communicate solutions to these situations compromising his safety. Review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's sign out pass from [DATE], revealed the resident went out on LOA and planned to return to the facility approximately 5 p.m.-5:30 p.m. Review of Resident 1's progress notes revealed a nurse's note dated [DATE], at 10:48 p.m. which stated, Resident out on LOA all shift. Writer contacted RN supervisor at [10:30 p.m.] to inform her of this. Per RN supervisor -administer [bedtime] medications upon resident's return. Will pass onto third shift [(night shift)]. Further review of Resident 1's progress notes revealed a nurse's note on [DATE] at 7:39 a.m. which stated, This nurse arrived at facility on [DATE] approximately [11:00 p.m.] Received report at approximately [11:30 p.m.] ,d+[DATE] supervisor reported that resident had not returned from LOA. At [11:38 p.m.], I sent an email to administration and DON, notifying them of the situation. In addition, text message sent to administration. Notified by administration that resident will often be at the flagpole on facility property. This nurse checked and walked to street to look for resident and updated administration. At [6:35 a.m.] received text from administration to call [local hospital] and police. This nurse called [local hospital], requesting if resident was in their facility. Per [local hospital], no record of resident at [local hospital.] 911 called with request to assist in finding resident. This nurse also called residents cellphone, which went directly to voicemail and message was left. Resident is his own responsible party. The other number in his profile is a person whom is out of state. [Police] arrived to facility at approximately [7:30 a.m.] and received residents information and photo, was told of areas resident frequents, officer left facility to look for resident and will be in contact. Interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 9:00 a.m. revealed that Resident 1 left the faciity on LOA at 1:00 p.m. on [DATE] and was expected to return to the facility by 5:30 p.m. the same day, and at the time of the interview, the whereabouts of Resident 1 were unknown. Further interview with the NHA on [DATE], at 9:45 a.m. revealed the facility was informed Resident 1 was in the local hospital's emergency room and claiming that resident was robbed. Further interview at 10:15 a.m. revealed Resident 1 drove himself into the emergency room via electric wheelchair because he could not find the police station and wanted to report a robbery and stated he was punched in the face. The emergency room did not find any injuries on the resident. Interview with licensed nurse, Employee E4 on [DATE], at 4:27 p.m. revealed that during shift transfer report she found out Resident 1 was out on LOA and was not sure when resident was supposed to return. Employee E4 tried to read the ticket and thought it said 5:30 p.m. Employee E4 stated that staff said that it was normal for him to be out later and also knew that he is allowed LOA and is responsible for himself. Employee E4 indicated that she sent an email and text message to administration at 11:30 p.m and stated that if they would not have answered she would have phoned them. The Nursing Home Administrator (NHA) told her to check the flagpole due to him falling asleep out there on a different occasion. She told NHA resident wasn't there and suggested resident was at a friend's house. Employee E4 reported the NHA stated that Resident 1 did not have friends in the area and was maybe at the park. Employee E4 stated that she could keep checking the flagpole area but didn't know what else to do except file an APB (all points bulletin) with the police. Employee E4 stated that the NHA did not text her back until 6:35 a.m. when he asked for an update and told her to call the local hospital and 911. Employee E4 believed if she was expected to call the police, the NHA should have directed her to contact police when she sent a follow up text at 12:52 a.m. Interview with licensed nurse, Employee E3 on [DATE] at 2:14 p.m. revealed that she was the ,d+[DATE] supervisor on [DATE]. Employee E3 stated she received a call between 9:,d+[DATE]:00 p.m. asking how to handle Resident 1's medications as resident did not return from LOA yet. Employee E3 recalled that there have been times in the past (at least 2 times that Employee E3 could recall) when Resident 1 did not return to the facility until after 11:00 p.m. Employee E3 informed Resident 1's medication nurse to give the medications when Resident 1 returns. Employee E3 indicated she did not call Resident 1's phone in an attempt to contact the resident. Employee E3 recalled a related conversation between self and licensed nurse Employee E4, regarding existence of a curfew for residents. Employee E3 recalled that coworker Employee E4 responded No, did not think so. Employee E3 stated she was not too concerned about Resident R1 failure to return at the anticipated time due to past events. Interview with licensed nurse Employee E5 on [DATE], at 4:02 p.m. revealed that she worked 11:00 a.m. to 11:00 p.m. on [DATE]. Employee E5 stated she knew that Resident 1 was out on LOA throughout the day, and nurse aides on the floor told her that Resident 1 stays out late and this was normal behavior. Interview with licensed nurse Employee E6 on [DATE], at 2:33 p.m. revealed that she was given report that Resident 1 was out on LOA. Employee E6 checked with other nurses and was told that this was not unusual. Employee E6 did call the RN supervisor, but was not aware of anyone calling administration, the resident, or the police. Employee E6 stated that staff really seemed to think that this was a normal occurrence for Resident 1. Interview with licensed nurse Employee E7 on [DATE] at 2:50 p.m. revealed that she occasionally cares for Resident 1 and that he goes out on LOA a lot and typically returns around 10:,d+[DATE]:00 p.m. Further interview with Nursing Home Administrator (NHA) on [DATE], at 1:40 p.m. revealed that he was made aware of Resident 1 not returning from the LOA at approximately midnight on [DATE]. The NHA stated he told licensed nurse Employee E4 to check out area around the flagpole outside the building, as the resident was known to fall asleep in the area. The NHA stated that Employee E4 sent him a text message at 12:52 a.m. stating the resident was not there and Employee E4 was not sure what else to do besides calling 911. The NHA admitted that he fell asleep and did not respond to Employee E4's text until approximately 6:30 a.m, which is five hours 30 minutes later. Adminsitrator indicated at that time (6:30 a.m.); he asked Employee E4 if the police had been called. Employee E4 responded, the police were not contacted. The NHA instructed Employee E4 to call the police at this time. The surveyors asked the NHA if he expected nursing to call the police and the local hospital when the Administrator did not respond to the text message of 12:52 a.m to which Administrator responded, yes. An Immediate Jeopardy situation was identified on [DATE], at 5:24 p.m. when the Immediate Jeopardy template was presented to the Nursing Home Administrator and the Director of Nursing regarding the facility's failure to respond in an appropriate and a timely manner to one missing resident for one of 44 residents approved for leave of absences. The facility failed to develop and implement guidelines for staff, including time frames for responding to missing residents. The facility submitted and completed an immediate action plan which included Resident 1 being assessed by facility registered nurse who determined resident had no injuries; suspended orders for leave of absence privileges until re-evaluated by physician. Resident 1's care plan was updated to reflect suspended leave of absence privileges until re- evaluation by physician. Facility will complete an audit of all current residents who have leave of absence privileges to determine safety and appropriateness. No residents will leave facility for LOA until current residents are re-evaluated and determined safe for Leave Of Absence privileges. Re-evaluation will be completed by end of day [DATE]. The facility updated the leave of absence policy to include, if a resident does not return at specified time as reported during sign out by resident or responsibility party, the licensed nursing staff will attempt to call the resident or responsible party within an hour of that specified time. If unable to contact resident or responsible party at that time and resident still has not returned within 30 additional minutes, nursing supervisor is instructed to notify the Director of Nursing and/or Administrator, Responsible Party/Accompanying Person and Attending Physician. If no response from facility leadership team members within 30 minutes of notification, nursing staff is to call and notify the local police of resident status. The facility developed and implemented a Leave of Absence Tracking tool that will track the estimated return time for any resident that goes on leave of absence. Education will be completed by Staff Development or designee with all licensed nursing staff on the updated leave of absence policy. Education to be completed with all currently working licensed nursing staff and any additional staff prior to the beginning of their work shift. Education will be completed by Staff Development or designee with all licensed nursing staff on the updated leave of absence sign out log. Education to be completed with all staff currently working or prior to the start of their shift. Education will be completed by end of day [DATE], and any licensed nursing staff with education not completed will have training at beginning of first shift after [DATE]. Licensed nursing staff who receive the education must complete and pass a posttest. The action plan was accepted on [DATE], at 9:30 p.m. The Immediate Jeopardy was lifted on [DATE], at 1:27 p.m., when it was confirmed that the facility provided licensed nursing staff the education regarding Leaves of Absence in accordance with the facility's new policy, and completed a posttest to ensure licensed nurses comprehend the new facility policy and the sign out logs. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 483.13 - Resident Behavior and Facility Practices, [DATE] edition 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE] 28 Pa. Code 201.18(b)(1)(3) Management.Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management.Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]

Based upon facility policy and procedures, clinical record, and facility reported incident review, it was determined the facility failed to ensure residents were free from significant medication errors for one of six residents reviewed, which resulted in actual harm to one resident (Resident R1). Findings include: Review of facility policy and procedure titled Administering Medications revealed If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Further review of facility policy revealed the individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: checking identification band; checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel. Review of Resident R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident dated August 3, 2021 revealed Resident R1 received medication ordered for Resident R2. Review of Resident R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R2's August Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's change in condition note dated August 4, 2021 revealed 97.8 116 20 113/51 sats 92% [vital signs] on room air lung sounds clear diminished resident observed with lethargy [tiredness] only responding once aroused, baseline resident is usually singing and conversing with staff MD in to assess ordered stat [immediate] labs. Stat labs obtained INR>11.4 [international normalization ratio - lab test which measures the pathway of coagulation/time it takes for blood to clot and compares it to an average], PT >109 [lab test that measures the ability of blood to clot] hgb [hemoglobin] 6.8 vitals reassess 98.5 115 19 98/64 conts [continues] with lethargy required asst [assistance] with all meals received n/o [new order] to sent to hosp [hospital] for eval. Resident was transferred to [acute care facility] for eval case manager was updated. [physician] placed call to #1 updated him on assessment and eval to hosp. Review of hospital emergency room records dated August 4, 2021 revealed The patient has acute [sudden] drop in H/H [hemoglobin and hematocrit] secondary to accidental [MEDICATION(S)] [[MEDICATION(S)]] administration; with INR of 11 on admission. Vitamin K [required to help body form blood clots and reverses the anticoagulation pathway] was given, check h/h; clear diet, trend INR; give additional Vitamin K if needed. 2 units of RBCs [red blood cells] was ordered. Review of hospital laboratory results dated [DATE], on admission to the emergency room , revealed Resident R1's hemoglobin was 6.9 and INR was >11.4. Interview with Nursing Home Administrator on August 16, 2021 at approximately 10:00 a.m. revealed that there was a transcription error with Resident R1 and Resident R2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident R1 was free of significant medication errors which resulted in a sudden drop in hemoglobin levels and a rise in anticoagulation levels which ultimately resulted in Resident R1 being admitted to the hospital for [CONDITION(S)] and requiring treatment to reverse the anticoagulation levels caused by the inadvertent [MEDICATION(S)] administration. 28 Pa Code 211.10(c) Resident care policies Previously cited on 06/07/21 28 Pa Code 211.12(d)(1) Nursing Services Previously cited on 06/07/21

Based upon clinical record review, review of documentation provided by the facility to the State Agency and observation, it was determined that the facility failed to ensure residents were free from accidents resulting in a fall from bed with a head injury resulting in actual harm to a resident requiring transfer to the hospital for one of thirty nine residents reviewed (Resident #187). Findings include: Review of Resident #187's [DIAGNOSES REDACTED]. The disorder results from deterioration of cells in areas of the brain that control body movement and thinking), dementia (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability), and a history of falls. Review of Resident #187's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 29, 2019 revealed Resident #187 had severe cognitive impairment and required the extensive assistance of two staff person for bed mobility including turning side to side. Review of Resident #187's active plan of care revised (MONTH) 11, 2019 revealed Resident #187 required 2 staff members for repositioning and turning in bed. Review of Resident #187's nursing progress note dated (MONTH) 2, 2019 at 12:45 a.m. revealed This nurse called to floor approximately 0045. Resident noted on floor of room laying on back between bed and outer wall. Head next to bedside chest, feet extended to foot of bed. Room well lit, copious amounts of blood noted from laceration above left eyebrow. Moves all extremities at baseline. Alert, non-verbal but followed this nurse with eyes. 4 cm (centimeter) x 4 cm L-shaped laceration noted to left eyebrow. Further review of this progress note revealed 911 called for transport to (acute care emergency room ) for eval and treatment. Review of emergency room provider notes dated (MONTH) 2, 2019 revealed presents with chief complaint of head injury via EMS (emergency management system). EMS reports nursing staff at (facility) was attempting to roll the patient in bed to change sheets when (resident) fell out of bed to the ground. Patient hit face on the ground causing a 6 cm laceration on her forehead. Review of emergency department supervisor note dated (MONTH) 2, 2019 revealed patient has a history of dementia with [DIAGNOSES REDACTED] and is completely dependent upon healthcare workers and (spouse) for (patient ' s) care. (resident) is a functional quadriplegic. They were turning her in bed tonight at the nursing home when (resident) fell and struck (resident's) left facial area. Review of Resident #187's nursing progress note dated (MONTH) 2, 2019 at 9:46 a.m. revealed assessment post fall. Resident is non verbal but responded with eye opening on entering room. L (left) eye swelling increased from beginning of shift @ 0700. Ice applied per order. L shaped laceration to left side of forehead measuring 3.5 cm down, and 2 cm across, 12 sutures counted, bleeding controlled. Bruising forming to upper lid and below eye. Swelling to face around laceration, eye and cheek. Review of Employee E4's witness statement dated (MONTH) 2, 2019 revealed while in (resident's) room I started with a different resident. Not til I heard the other aid struggling did I realize who (staff member) was working on. The (staff member) yelled out and I quick ran over to assist. By then it was too late (resident) was on the floor, face down and bleeding from (resident's) face. There was a puddle of blood. I quick ran out getting help from the licensed staff and assuring that the supervisor be called immediately. When I ran back to the room we moved the bed and turned (resident) over. With the supervisor there and other staff we got (resident) back into bed with the lift. With all the commotion, the (staff member) quick came over to me and asked me to tell everyone that we were together when the resident fell so (staff member) wouldn't get fired. I told both the nurse and supervisor what I was asked of by the (staff member). Review of documentation provided by the facility to the State Agency dated (MONTH) 2, 2019 revealed during course of personal care, resident slid out of bed when rolled over for care. Investigation initiated. Interview with the Nursing Home Administrator on (MONTH) 8, 2019 confirmed that Resident #187 was turned in bed utilizing only one staff member when resident required two staff members for bed mobility and subsequently rolled out of bed striking Resident #187's head on the floor and sustaining a laceration requiring transfer to the hospital and application of sutures to the area of the laceration resulting in actual harm to the resident. 28 PA Code 201.14(a) Responsibility of Licensee Previously cited 9/13/18 28 PA Code 201.18(a)(b)(1) Management Previously cited 8/10/17, 9/13/18, 4/25/19 28 PA Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 8/10/17, 9/13/18, 2/5/19, 4/25/19, 7/2/19

Based on clinical record review, facility policy and information submitted by the facility, it was determined that the facility failed to ensure that a resident was free of a significant medication error for one of three residents reviewed (Resident CL1) which resulted in a resident receiving additional doses of an anticoagulant medication, becoming unresponsive, requiring transfer to the hospital and expiring with a [DIAGNOSES REDACTED]. This was identified as a past non-compliance Immediate Jeopardy situation for one of three residents reviewed (Resident CL1). Findings include: Review of the facility policy title, [MEDICATION NAME] Policy, revised (MONTH) 20, 2014, stated that the purpose of the policy was to administer [MEDICATION NAME] (anticoagulant - blood thinning medication to prevent clotting) accurately, safely and efficiently and to monitor therapeutic levels, according to the physician's order. Document the PT/INR (international normalized ratio - laboratory test to show how long it takes for blood to clot), new orders (if any) and the next scheduled PT on the [MEDICATION NAME] Anticoagulant Record. Update the, [MEDICATION NAME] Lab Tracking form in the unit's laboratory book. Review of Resident CL1's clinical record revealed [DIAGNOSES REDACTED]. The mitral valve is the inflow valve for the left side of the heart), and history of cerebral infarction (stroke). Review of Resident CL1's (MONTH) (YEAR), physician's orders revealed an order dated (MONTH) 27, (YEAR), for [MEDICATION NAME] (anticoagulant - blood thinning medication to prevent clotting) 40 milligrams (mg) twice daily until INR above 2.5 and a second anticoagulant medication [MEDICATION NAME] 2 mg daily. Review of the resident's, [MEDICATION NAME] Anticoagulant Record noted the target INR range for the resident was 2XXX,[DATE].5. On (MONTH) 2, (YEAR), the resident's INR was documented at 1.7, a [MEDICATION NAME] order was obtained for 6 mg tonight and the next PT/INR on (MONTH) 3, (YEAR). Further review on the, [MEDICATION NAME] Anticoagulant Record noted on (MONTH) 3, (YEAR), the resident's INR was 2.9 and a [MEDICATION NAME] order was obtained for 4 mg daily with the next PT/INR on (MONTH) 7, (YEAR). The, [MEDICATION NAME] Anticoagulant Record also contained a Misc. (miscellaneous) information section. There was no documented evidence on the Misc. information section of the additional anticoagulant medication [MEDICATION NAME] 40 mg until INR above 2.5. Review of nursing notes from (MONTH) 30, (YEAR), to (MONTH) 7, (YEAR) revealed no documentation that the physician was notified of the current [MEDICATION NAME] 40 mg order and that nursing staff obtained further orders to lower or discontinue the resident's [MEDICATION NAME] when the resident's INR reached 2.5 on (MONTH) 3, (YEAR). Review of Resident CL1's (MONTH) (YEAR), Medication Administration Record [REDACTED]. Review of Resident CL1's progress notes revealed a nurse's note on (MONTH) 7, (YEAR), at 12:03 a.m. stated, resident pale and shaking . language barrier but resident is holding her chest and acting like she is SOB (short of breath). Pulse 97% on RA (room air) . PRN (as needed) Nitro ([MEDICATION NAME] table-is a type of [MEDICATION NAME]. It relaxes blood vessels, increasing the blood and oxygen supply to the heart) given which was effective. Nursing note on (MONTH) 7, (YEAR), at 1:40 a.m. noted, resident up to use bathroom. resident vomited a large amount of undigested food while on toilet. Resident is pale and shaky. Further review of nursing notes on (MONTH) 7, (YEAR), at 5:30 a.m. indicated, resident continues with increased weakness, vomited a small amount of undigested food, pale and shaky. RN (Registered Nurse) assessed resident. HR (heart rate) tachy (fast) and irregular. A nursing note on (MONTH) 7, (YEAR), at 9:06 a.m. revealed the resident was, cool and clammy, (respirations) rapid and shallow, Eyes open laying in bed. Apical rate (heart rate) rapid and irregular. The Certified Registered Nurse Practitioner (CRNP) was in the facility and assessed the resident at 7:30 a.m. Resident CL1 then, sat on the toilet, then became limp and unresponsive (nursing) lifted her back into her wheelchair. Resident's head was hanging forward, unable to manage oral secretions, eyes deviated upward and right. The resident's vital signs at this time showed a pulse of 128 (normal is ,[DATE] beats per minute) and a respiratory rate of 26 (normal is ,[DATE] breaths per minute). The CRNP was contacted again and an order was obtained to send the resident to the emergency room . Review of Resident CL1's death summary from the hospital record revealed the resident was noted to be, anemic and coagulopathy (a bleeding disorder that affects the way the blood clots) with an INR of 7. CT (a computerized scan that allows doctors to see inside the body. It uses a combination of X-rays and a computer to create pictures of the organs) abdomen showed a bleed likely originating from the abdominal wall with blood collecting in the pelvis. Her coagulopathy was quickly reversed and she was admitted to the ICU (intensive care unit) for continued care workup .Throughout the day she was resuscitated with multiple blood products, but continued with ongoing blood loss. Hemostasis (internal stability) was unable to be achieved and her condition declined. Further review of the resident CL1's death summary revealed the resident expired on (MONTH) 8, (YEAR), at 4:07 a.m. of Hemorrhagic shock and multi-system organ failure. During an interview conducted with the Director of Nursing (DON) on (MONTH) 20, (YEAR), approximately 12:10 p.m. confirmed that upon facility investigation of Resident CL1's significant medication error it was revealed that the miscellaneous section on the resident's, [MEDICATION NAME] Anticoagulant Record was not consistently utilized by all nursing staff to document and communicate between nursing staff, physician and Certified Registered Nurse Practitioner, the order of the second anticoagulant medication [MEDICATION NAME]. Immediate Jeopardy, past non-compliance, was identified to the Director of Nursing on (MONTH) 20, (YEAR), at approximately 2:00 p.m. The facility submitted a corrective action plan which included immediate discipline of the nurses involved in the significant medication error and medication pass competencies prior to returning to work. The DON/designee completed an audit to identify any resident on anticoagulant bridge therapy. The facility implemented a requirement of PT/INR parameters to be entered in the residents' electronic Medication Administration Record [REDACTED]. The DON/designee completed random audits of [MEDICATION NAME] orders, ensuring parameters were included in the electronic medication record as ordered. Review of the facility documentation showed that the corrective action had been fully implemented and completed on (MONTH) 27, (YEAR), at which time the Immediate Jeopardy situation was removed. The facility failed to ensure that Resident CL1 was free of a significant medication error which resulted in Resident CL1 receiving seven additional doses of an anticoagulant medication, becoming unresponsive, requiring transfer to the hospital and expiring with a [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure that medications were stored in a locked compartment and not accessible to residents, resulting in actual harm to one of 19 residents reviewed (Resident CL 1). Findings include: Review of facility policy Administration of Medications Using Medicine Carts, revised June 19, 2015, revealed that staff are to never leave the medicine cart unlocked when it is outside your line of vision and never leave any medication on top of the medication cart if the cart is outside of your line of vision. Review of Resident CL 1's initial MDS (Minimum Data Set - periodic assessment of resident needs) dated October 23, 2015, indicated that the resident had both short and long term memory deficits and was moderately impaired for decision making. The MDS included [DIAGNOSES REDACTED]. Review of change in condition progress note dated November 28, 2015, revealed that around 5:40 p.m. the Registered Nurse (RN) was notified that the resident was having emesis (vomiting). Resident continued to have emesis. At 6:10 p.m. the resident had emesis, yellow in color with undigested food. The resident's skin was clammy, the resident was hard to understand, and became combative with staff members. The RN was notified. Upon arrival the RN assessed the resident and asked staff to check the resident's drawer. Medications found not belonging to the resident including three packets of Lorazepam (Benzodiazepine used to treat anxiety disorders) without the medication, Mytabs (medication used to relieve painful pressure caused by excess gas in the stomach and intestines), half a bottle (50 milliliters) of liquid Baclofen (muscle relaxant), and a full bottle (400 milliliters) of Lopressor (medication used to treat high blood pressure). Review of RN's progress note dated November 28, 2015, revealed that the nurse was called to assess the resident for a change in condition at approximately 6:05 p.m. and arrived on the unit at 6:10 p.m. Resident was responsive to verbal stimuli, but fluctuating consciousness noted, as well as multiple episodes of emesis. The resident's right pupil was dilated and the left pupil was within normal limits. The physician was notified at 6:20 p.m. and an order was obtained to transfer the resident to the hospital. Resident CL 1 left the facility at 6:45 p.m. and continued to be arousable to verbal stimuli at that time. Review of hospital History and Physical dated November 28, 2015, revealed the resident presented with acute respiratory failure secondary to apparent Benzodiazepine overdose. Reportedly she was able to get a large volume of Lorazepam. Worsening somnolence (sleepiness) in the emergency department and decision was made to intubate (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) to protect the airway overnight. Multiple episodes of vomiting. admitted to the intensive care unit for ventilator support. Resident was discharged from the hospital to home on December 10, 2015. Review of the pharmacy packing slip revealed that five cards containing 24 tablets of Lorazepam 0.5 milligrams were delivered for Resident R1 on November 18, 2015, and signed as received by the licensed staff. Interview with the Nursing Home Administrator (NHA) on January 8, 2016, at 9:20 a.m. revealed that the Lorazepam had been delivered on November 18, 2015, signed for and secured by the licensed staff. None of the medications found in Resident CL 1's possession were prescribed for that resident. The facility did an investigation, but was unable to determine how the resident obtained the medications. The resident was ambulatory, had improved in her cognitive status and was due to be discharged to home on November 30, 2015. The NHA confirmed that this incident should not have happened. An additional interview with the NHA at 12:10 p.m. revealed that five cards of Lorazepam were delivered, one card was being used by Resident R1, three cards were found with Resident CL 1, and one card has not been located. Facility failed to properly secure medications to prevent access to residents, resulting in Resident CL1 having ingested a dose of a psychoactive medication resulting in actual harm to the Resident CL1. Observation of the 7th floor nursing unit, on January 7, 2016 at 2:15 pm, revealed an unattended and unsecured medication cart. A second observation of the 7th floor nursing unit, on January 7, 2016 at 2:35 pm, revealed the same medication cart was again unlocked and the top drawer had been left opened. Employee E7, who represented self as a pharmacy employee, said that she was responsible for this cart and had no explanation as to why the medication drawer was left opened or why the cart was not secured. Observation of the 6th floor nursing unit, on January 8, 2016 at 1:40 pm, revealed an unattended treatment cart in the hallway, however; further observation revealed that the access key for entry into this treatment cart was being stored on top of the cart next to several wound treatment supplies. Interview with licensed Employee, E3, on January 8, 2016 at approximately 1:42 pm, confirmed that the supplies should be secured and that the key to the treatment cart should not be left on the cart. Observation, on the 8th floor nursing unit, on January 8, 2016 at 1:50 pm, revealed one of two treatment carts unattended and unsecured with the top drawer open and accessible. At approximately 1:42 pm, licensed Employee E2, returned to this treatment cart and reported that she went to the back nursing room to check on something. Further observations of the 8th floor nursing unit, on January 8, 2016 at 1:47 pm, revealed an unsecured, cardboard box measuring approximately 3' by 3,' which had been stored on counter space of the nursing station; this box contained an unlimited supply of treatment supplies. A subsequent interview with licensed Employee E2 confirmed that E2 had pulled this box of treatment supplies from the back room and was storing these supplies at the nursing station for easier access. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 4/16/15 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 6/18/15, 4/16/15, 9/3/14

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the proper assessment of a resident after a fall incident and failed to provided a resident with the diet ordered by the physician for one of 31 residents reviewed which resulted in actual harm to Resident CL1; and failed to follow a physician's recommendation to acquired a needed medical test for one of 30 residents reviewed. (Resident Y5) Findings include: Review of Resident CL1 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. deficiency in the brain either by alcohol use, poor nutrition, kidney [MEDICAL TREATMENT], anorexia, over severe dieting and could have long [MEDICATION NAME] effect on a person memory capabilities), and dysphagia (the inability to swallow food and liquids correctly causing the probability of aspiration -choking). Review of Resident CL1 quaterly assessment MDS (minim data set-assessment of care and needs) date June 6, 2015 identified the resident with a BIMS (Brief Interview for Mental Status) of '15' which indicated that the resident had no cognitive deficit. Further review of the assessment identified the resident requiring supervision for ambulation off the unit with the assistance of one person and required supervision for transferring with the assistance of two people. Review of the speech therapy discharge summary dated June 11, 2015 revealed that the resident diet was changed to mechanical soft with nectar thick liquids due a regular texture diet not being appropriate for the resident. Review of the information submitted by the facility on August 8, 2015 revealed that Resident CL1 attended a social activity at the facility where ice cream was served. The resident was observed with changes in breathing and was provided oxygen. Review of Resident CL1 ' s clinical medical record revealed a nursing progress note dated August 8, 2015 at 6:26 p.m. stating, Called to floor for report of decreased pulse oxygen. Pulse ox upon report to floor is 77% on 3 liters of oxygen. Oxygen increased to 8 liters, pulse ox only comes up to 81%. Coarse lung sounds noted, resident denies distress but increased wheezing noted. Pulse 128, resp. 24, BP 140/58, temp. 98.3 Resident reportedly ate ice cream at the ice cream social although he is on nectar thick liquids. Nurse Practitioner contacted, advised of assessment, orders, history and that the resident is a full code. Request and received orders to send resident to local hospital emergency room for treatment. Review of August 2015 physician's orders [REDACTED]. Review of the facility's investigation into the incident revealed that the activities personnel (Employee E15) who was conducting the ice cream social gave the resident ice cream even though he was ordered a thickened liquid diet. Further review of facility's employee counseling documentation dated August 11, 2015, noted that Employee E15 indicated that she was not aware that the resident diet had changed prior to the ice cream event, and the information was not updated in the system the activities department used for diet tracking. Employee E15 also noted that on August 11, 2015 that she was not aware that ice cream was inappropriate for a resident to eat with a [DIAGNOSES REDACTED]. An Employee Counseling Form was also reviewed for Employee E16 dated August 11, 2015 who was responsible to update the diet lists for the activities department and the employee admitted to not updating the diet list prior to the ice cream social on August 8, 2015. Review of the hospital discharged summary dated August 24, 2015 confirmed that the resident was admitted to the hospital with [REDACTED]. The resident was started on a tube feeds via a peg tube (a tube that passes into a patient's stomach through the abdominal wall, to provide means of feeding when oral intake is not adequate ) placement. The facility failed to ensure that the resident was not provided a food item that was not appropriate for the diet ordered by the physician for the resident which resulted in actual harm to the Resident CL1 requiring hospitalization for aspiration pneumonia and the placement of a peg tube. Furthermore, review of facility documentation to a fall incident sustained by Resident CL1 on August 8, 2015 at 2:45 p.m. prior to the resident eating ice cream revealed that the resident fell on to the floor as he entered the ice cream social. A written interview account from employee E15 written by the Nursing Home Administrator on August 9, 2015 indicated that the resident fell in the lounge where the ice cream social was being held, and after falling, Employee E13 and a family member of another resident picked up the resident off the ground prior to having medical personnel check his status for injuries. According to an Employee Counseling Form dated August 11, 2015 for Employee E15, the staff put the resident in a safety risk where the activity aide always should call for nursing help and not lift or help the resident off the floor. This is a safety risk; nursing should have been notified immediately, to check his status before moving him . Review of Resident CL1 ' s clinical medical record revealed a nursing progress note dated August 8, 2015 at 6:03 p.m. stating that the activities aide observed the resident sitting on the floor in the King Street Lounge. Resident stated he missed the chair. There was no documented evidence that facility staff notified nursing staff after the resident felt to conducted an assessment and identified any possible injuries on the resident. Review of Resident Y5's [DIAGNOSES REDACTED]. Review of Resident Y5's progress notes dated May 30, 2015 at approximately 7:00 p.m. revealed that the resident was found sitting on the floor after falling and told staff that she was trying to get to the bathroom. The resident was complaining of pain in the right thigh. The physician ordered an x-ray of the right leg and hip. The results of the x-ray revealed a fracture to the right greater trochanter with no displacement ( a thick process at the lateral upper end of the femur -leg bone- projecting upward to the union of the neck and shaft). Resident Y5 was sent out to the hospital however the x-ray in the hospital did not identify a right leg fracture and the resident was returned to the facility with instructions to consult with orthopedic specialist and repeat an x-ray of the right pelvis and hip two weeks from the first x-ray (June 13, 2015). Review of the clinical record failed to reveal a repeat x-ray or documentation that staff had consulted with the attending physician concerning the order recommended by the orthopedic physician. Employee E14 confirmed on October 28, 2015 at 10:00 a.m. that the facility failed to clarify or carry out the order for the resident's x-ray. 28 Pa Code 201.18(b)(1)(e)(1) Management Previously cited: 07/30/2015, 06/18/2015, 04/16/2015, 09/03/2014 28 Pa Code 211.10(c)(d) Resident Care Policies Previously cited: 06/18/2015, 04/16/2015, 09/03/2014 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited: 06/18/2015, 04/16/2015, 09/03/2014

Based on clinical record review, facility policy and procedure review, and staff interviews it was determined the facility failed to ensure that care was provided in a manor to prevent accidents causing actual harm to one of three residents reviewed (Resident: R1) Findings Include: Review of facility policy titled Fall Prevention/Management dated [DATE] and last reviewed [DATE] revealed on admission the licensed nurse will complete the fall risk assessment in the electronic documentation system. It will then be completed quarterly, annually, or with any significant change. If the assessment indicates that the resident is high or moderate risk for falls, then measures will be implemented for that resident to assist with the prevention of injury/fall and documented on the care plan. Review of resident R1 ' s demographic sheet revealed the resident was admitted to the facility on [DATE] and died at the facility on [DATE]. Further review of the demographic sheet revealed the resident was diagnosed with [REDACTED]. over anticipated events). Review of Resident R1s Annual Minimum Data Set (MDS- Periodic Assessment of resident care needs and status) dated [DATE] revealed the resident was coded as two person physical assist every time during the seven day look back period under the areas of Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Further review of the MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicates the resident was cognitively intact. Review of Resident R1 ' s care plan related to resident needing positioning daily with the use of passive range of motion exercises to both lower extremities daily. The care plan stated the resident required assistance of two staff to reposition and turn in bed, initiated [DATE] and ongoing. Under toilet use, the resident required total assistance of two staff for incontinence care initiated on [DATE] and ongoing. Review of Resident R1 ' s physician recapitulation orders dated [DATE] revealed an order for [REDACTED]. Physician orders [REDACTED]. Review of Resident R1 ' s lab results revealed the resident ' s PT/INR level on [DATE] was 2.1 (for a person who is receiving Jantoven target range is ,[DATE]. Further review of the physician orders [REDACTED]. Review of Resident R1 ' s nurses ' notes revealed a note dated [DATE] at 5:51 p.m. stated that during care, the resident was positioned on her right side and slid off bed onto floor. The fall was witnessed. Resident R1 sustained an 8 centimeter x 5 centimeter (cm) hematoma (bruise), (nurses ' note of [DATE] related this was a facial bruise); abrasion on right knee 2 cm x 2.5 cm; red areas on upper back, shoulder, and lower neck area blanchable (when a patient's skin loses redness with pressure). Resident R1 ' s nurses ' note dated [DATE] at 11:59 p.m. stated left eye now swollen shut with a large surrounding ecchymotic (bruise) area. Resident continues to be alert and responsive, no complaint of nausea or vomiting. Nurses ' note dated [DATE] at 4:24 a.m. revealed resident complained of headache and generalized pain. Left side hematoma continues with left eye swollen. Areas are blue and purple in appearance. Left neck with black and purple appearance. Left shoulder has small black ecchymotic area. Review of Resident R1 ' s physician progress notes [REDACTED]. She did have an elevated blood pressure at the time but has since lowered. She has significant bruising today to the forehead where she continues to have a very large hematoma as well as left eye, cheek, and neck. She is alert at baseline mentation today. She stated " I wish this didn ' t happen to me. " She does have pain to the area on the forehead today. Resident R1 ' s physician progress notes [REDACTED]. She is confused at baseline but seems more so today. She was able to state that the facility is Conestoga View but cannot recall what happened to her a few days ago. Yesterday she could clearly recall the event of her fall out of bed. Resident stated that her head hurts; her vital signs today Blood Pressure ,[DATE] (normal ,[DATE]) temperature 100.0 Fahrenheit. Review of the nursing progress notes revealed an entry dated [DATE] at 8:02 p.m. stating that the resident is alert but unable to answer questions like usual. She continues to have increased Blood Pressure ,[DATE] and temperature 102.4. Review of Resident R1 ' s physician progress notes [REDACTED]. Physician note stated family wished comfort care DNR (Do Not Resusitate). Nursing notes dated [DATE] at 1:38 p.m. t stated that resident has continued to have neuro changes; she is unable to follow commands or form words other than " yes " . She is awake but sleepy. Further review of progress notes revealed an entry dated [DATE] at 4:49 p.m. that resident ceased respirations at 3:20 p.m. Interview conducted with nursing Employees E3 and E4 on [DATE] at 12:30 p.m. revealed that when providing care to a resident who is designated as needing two person assist when turning in bed there should be one staff member on each side of the bed to prevent the resident from falling out of bed. Interview with the DON on [DATE] at 2:15 p.m. confirmed that the care plan for resident R1 indicated that the resident needed to have the assistance of two staff members while providing care to the resident in bed. The DON further confirmed that the staff member who provided care to the resident on the evening of [DATE] did not follow the care plan by having two CNA's provide positioning and continence care which resulted in the fall, significant bruising, change in mental status and possible subdural hematoma. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE] 28 Pa Code: 211.5(f) Clinical records Previously cited [DATE] 28 Pa Code: 211.10(d) Resident care policies Previously cited [DATE] 28 Pa Code: 211.12(c)(d)(1)(5) Nursing services Previously cited [DATE]

Based on review of clinical records, event reports, incident reports and select facility policy and staff interview, it was determined that the facility failed to implement planned safety interventions to prevent falls and elopement for three of 30 sampled residents (Resident 84, 115 and 420). Findings include: A review of the facility Lift, Transfer and Repositioning policy, last reviewed by the facility January 31, 2011, revealed gait/transfer belts will be used where assistance is required for ambulation and transfers activities, anytime a resident requires weight bearing assistance. Clinical record review revealed that Resident 84 had [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be severely, cognitively impaired, required extensive assistance for bed mobility and transfers and assistance for activities of daily living. A review of a resident care plan for risk for falls initially dated October 28, 2009, revealed an approach to transfer in and out of bed with extensive to total assist of 1-2 staff: stand and pivots with assistance; or use of Sabina lift (type of mechanical lift) with 1 assist. A review of an incident report dated March 12, 2011 at 9:20 PM, and an Event Report submitted to State Survey Agency dated March 18, 2011 revealed that on March 12, 2011 a nursing staff member assisted the resident to bed, when the resident sat on the floor. The licensed nursing staff assessed the resident and found that she had good range of motion, no apparent injuries and denied pain. A review of nurses notes dated March 12, 2011 at 9 PM revealed "Resident placed self on the floor, sitting on buttocks when being assisted into bed. Resident upset due to the fact she was not in bed earlier. No injuries noted. " The resident was assisted by one nurse aide, Employee 1, at the time she sat on the floor on March 12, 2011. The next day, March 13, 2011, the resident's leg was ecchymotic (black and blue), but the resident continued to deny pain. The physician examined the resident's lower extremity on March 15, 2011. Nurses notes dated between March 12, 2011 and March 18, 2011 revealed Resident 84's right lower leg area was ecchymotic and swollen. The notes also indicated that the resident had difficulty standing with staff assistance. Further nurses notes dated March 18, 2011, at 12:30 PM revealed " increasing edema (swelling) and ecchymosis noted. The physician was notified and an ankle X-ray was ordered." A review of a radiology report dated March 18, 2011 revealed that Resident 84 had sustained a recent right ankle fracture. A review of an employee warning discipline record for Employee 1 (a nurse aide) dated March 20, 2011 revealed that "on March 12, 2011 you were assisting (Resident 84) into bed, when she sat down on the floor. You did not use a gait belt (belt that reduces strain on caregiver's back and provides a secure holding point for patients during transfer) per facility policy. As a result of this incident, the resident sustained [REDACTED]." This employee was suspended as a result of this incident. During an interview September 28, 2011 at 2 PM the Director of Nursing confirmed that Employee 1, nurse aide did not follow the facility's gait belt policy for transfers resulting in Resident 84's fall with injury. Clinical record review revealed that Resident 115 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's care plan for risk for falls, dated November 11, 2010, revealed the approach to transfer with assist of 1, as needed, with walker and locomotion via wheelchair and auto lock brakes on wheelchair. A review of a facility incident report and event report submitted to the State Survey Agency dated June 15, 2011, at 8:30 PM revealed that Resident 115 was found on the floor at the sink, in her bathroom. The resident complained of right shoulder pain. The physician was contacted and ordered an X-ray of the right shoulder. A review of a radiology report dated June 16, 2011, revealed anterior right shoulder dislocation. A resident statement dated June 15, 2011 at 8:30 PM revealed "she was standing at the sink and went to sit down and the wheelchair went out from under her. She thought she had locked the wheelchair." A review of the corresponding incident investigation completed by the facility dated June 16, 2011, revealed that Resident 115 was care planned for auto-lock brakes to her wheelchair. The resident received a new drop-seat wheelchair from occupational therapy on May 31, 2011. The anti-lock brakes were not on the new chair when issued. Maintenance request was sent for anti-lock brakes to be applied (sent by therapy on June 3, 2011). Therapy department was not aware that the anti-lock brakes were never applied to the chair until after the report of the fall on June 16, 2011. A review of documentation from the facility's maintenance supervisor dated June 17, 2011 revealed no evidence of notification of the need for anti-lock brakes to be applied to the resident's new drop-seat wheelchair per therapy on June 3, 2011. The facility's investigation indicated that follow-up education was conducted with the therapy department related to not issuing new equipment until all safety mechanisms appropriate and or care planned for a resident are available and in place, and to the maintenance department on appropriate follow up communication required when requested work orders can not be completed for any reason. During an interview September 28, 2011 at 9:45 AM, the Director of Nursing confirmed that the anti-lock brakes were not on Resident 115's wheelchair at the time of the fall on June 15, 2011. A review of the facility policy and procedure entitled Elopement Risk Assessment reviewed by the facility in March 1, 2011, revealed that an elopement assessment will be completed within 8 hours of admission. All residents will have a "Wandering/Exit Seeking Resident Profile" completed as per policy and given to the receptionist. A care plan will be developed to include the resident's potential for elopement related to previous history, behavioral/medical history, current physical ability and current behavior/cognitive status. The level of supervision required based upon the assessment and specific approaches to keep the resident safe. The team will address the resident for risk of elopement and implement specific interventions as needed such as, redirection with conversation and activities, involve family members in redirection and by phone, encourage attendance in activity programs, apply Alpha Watch (bracelet which locks door to facility when resident is near), every 15 minute monitoring and 1 to 1 supervision on unit. The elopement assessment will be reviewed during care plan meetings and at least quarterly or following an attempted elopement. Review of an event submitted to the State Survey Agency on October 10, 2010, revealed that Resident 420 had exited the facility at 1:01 PM that date and per video surveillance, a maintenance man let him out of the facility's front door. The resident was across the driveway in the area of the flagpole, which is approximately 100 feet away from the facility front door. Video surveillance determined the resident was brought back to the facility with security at 2:30 PM on this date. A review of the resident's clinical record revealed that the resident was identified at risk for elopement on August 3, 2010. The elopement assessment indicated the resident was able to ambulate with a device. The resident did not have an Alpha watch bracelet in place when he was identified as an elopement risk on August 3, 2010, or at the time of elopement on October 10, 2010. The facility also did not have a plan of care in place at this for the resident's risk for elopement. A review of the clinical record documentation dated October 7, 2010 at 9:00 PM indicated that the resident had his coat on and was in his wheelchair with his walker attached to the back of it; he stated he was getting out of here. Due to the resident not being able to speak and understand English clearly, a Spanish speaking staff member was called to speak to the resident and calm him down. Nursing alerted security of this resident's desire to leave the facility. Nursing documentation of October 10, 2010 at 3:15 PM revealed that the resident was on the pathway by the East parking lot by the bench. At this time, once returned to the building, an Alpha watch bracelet was applied to the resident to alert the facility of attempts to leave unsupervised. A review of the incident/accident report included a statement written by Employee 10, an LPN on October 10, 2010, which indicated that when this employee went into the resident's room, he was making his bed and stated "I'm leaving." Employee 10 told the resident, not to leave that "we love you here." Employee 10 indicated that he was unable to be redirected. Employee 11's (nurse aide) statement indicated that she observed the resident packing his stuff and he refused lunch on October 10, 2010. She also stated that another resident recognized him, while look outside from a window, and the resident was sitting outside by the road. The incident/accident report revealed that Employee 12, a maintenance worker, assisted resident out the door and was unaware that the resident was not to be outside unsupervised. This employee was inserviced on proper supervision of residents on October 13, 2010 During an interview with the director of nursing on September 29, 2011, at 10:00 AM along with a review of the incident/accident report revealed that on the day of the elopement the maintenance man allowed the resident to leave the building due to the front door being open and multiple people going in and out. Facility security tapes confirmed that the resident wheeled himself outside of the facility at 1:01 PM to the flagpole area. When staff realized he was not on his nursing unit he was observed from the eighth floor window and was escorted by security back to the building at 2:30 PM. Employee 13, a nurse aide, who was assigned to this resident at that time on October 10, 2010, returned from her lunch break and was unable to locate the resident. The facility failed to implement their established Elopement Risk Assessment Policy for Resident 420. 28 Pa Code 211.11(a)Resident care plans previously cited 8/2/10 28 Pa Code 211.10(d) Resident care policies previously cited 1/21/11, 8/23/10 28 Pa Code 211.12(d)(1)(3)(5) Nursing services previously cited 8/2/10, 4/22/11, 1/21/11, 1/10/11