Every finding on record at Laurel Ridge Center

Based on review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness.Findings include: During an observation on 8/17/26, from approximately 9:20 a.m., through 9:35 a.m., the following was observed: [NAME] blankets on floor near dish machine identified to be placing dish racks after running through dish machine instead of on side racks.Deep freezer had a pan under fan pipe which were leaking, and one box of beef was under dripping from pipe attached by ice.During an interview on 8/17/26, at approximately 9:35 a.m., the Certified Dietary Manager Employee E42 confirmed that the facility failed to prevent the potential for cross contamination and food borne illness in the main kitchen.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing halls (A hall and B hall). Findings include: Review of the facility policy Homelike Environment dated 6/29/26, with a previous review date of 3/12/25, indicated residents are provided with a safe, clean, comfortable and homelike environment that de-emphasizes the institutional character of the setting. During an observation on 8/17/26, from 11:00 a.m., through 11:42 a.m., the following was observed: The window blinds of rooms 15, 16, 17, 18, 20 and 25 were broken and/or falling off windows. During an observation on 8/17/26, at approximately 1:20 p.m., of resident room [ROOM NUMBER] the privacy curtain between A and B bed was soiled with a large brown stain. During an observation on 8/18/26, at approximately 9:40 a.m., Resident room [ROOM NUMBER] had broken blinds and the walls behind both resident beds had unfinished repairs leaving patched drywall. During an interview on 8/20/26, at approximately 9:50 a.m., the Maintenance Director Employee E4 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing units. 28 PA. Code 201.14(a) Responsibility of Licensee28 PA. Code 201.18(b) Management

Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for four of six residents (Resident R7, R16, R17, and R34). Findings include: On 3/5/26, the MRRs for Residents R7, R16, R17, and R34 were requested, for the months of January 2026, through July 2026. During an interview on 8/20/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility was unable to locate the MRRs for Residents R7, R16, R17, and R34. During an interview on 8/20/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly for four of six residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a Covid-19 and/or pneumococcal immunization for three of five residents reviewed for Covid-19 and pneumococcal immunizations (Residents R7, R21, and R26).Findings include: A review of facility policies, Covid-19 Vaccination and Pneumococcal Vaccination, dated 3/12/25, indicated the facility will provide the opportunity to receive Covid-19 vaccinations following the Centers for Disease Control and Prevention (CDC) recommendations and the opportunity to receive the appropriate pneumococcal vaccine to all residents. A review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses that included COPD (chronic obstructive pulmonary disease-lung disease that restricts breathing), and heart failure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/29/26, indicated the resident was not up to date for the Covid-19 vaccine. A review of R7's electronic clinical record Immunizations documentation on 8/20/26 at 10:30 a.m., did not include information that the Covid-19 vaccine was offered or declined. A review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with diagnoses that included respiratory failure and cardiac arrythmia (abnormal heart rate). A review of the MDS dated [DATE], indicated the resident did not receive the pneumococcal vaccine and was not up to date for the Covid-19 vaccine. A review of R21's electronic clinical record Immunizations documentation on 8/20/26 at 10:30 a.m., did not include information that the pneumococcal and the Covid-19 vaccines were offered or declined. A review of the clinical record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses that included respiratory failure and malnutrition. A review of the MDS dated [DATE], indicated the resident was not up to date for the Covid-19 vaccine. A review of R26's electronic clinical record Immunizations documentation on 8/20/26 at 10:30 a.m., did not include information that the Covid-19 vaccine was offered or declined. During an interview on 8/20/26 at 11:00 a.m., the Infection Control Nurse (ICN) Registered Nurse (RN) Employee E11confirmed the above findings, and that the facility failed to document each resident was offered a Covid-19 or pneumococcal immunization for Residents R7, R21, and R26. 28 Pa. Code 211.5(f)(i)-(xi) Medical records.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Abuse/Neglect training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16). Findings include:During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for resident abuse neglect and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing resident abuse/neglect rights training annually as required.

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16). Findings include:During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for infection control and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing infection control training annually as required.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R24). Findings include: Review of the facility policy Resident Rights dated 6/29/26, with a previous review date of 3/12/25, indicated that Federal law specifies that nursing homes must protect and promote basic rights to all residents of this facility. These rights include the residents' right to be treated with dignity and respect and be free from abuse and neglect. Review of the clinical record revealed Resident R24 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 8/3/26, included diagnoses of cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) typically caused by damage to the brain before or at birth), seizure disorder, and muscle weakness. Review of Section C: Cognitive Patterns indicated that Resident R24 has both short term and long-term memory issues and an interview was not conducted. Review of Section H: Bladder and Bowel indicated Resident R24 is usually incontinent of bladder and bowel. During an observation on 8/17/26, at approximately 1:40 p.m., of a wound care treatment for Resident R24, Licensed Practical Nurse (LPN) Employee E1 performed the dressing change and then took a marker from her pocket and wrote the date and her initials on the dressing attached to Resident R24's right hip. During an interview on 8/17/26, at approximately 1:42 p.m., LPN Employee E1 confirmed the observation and that the facility failed to maintain Resident R24's dignity by writing directly on the dressing attached to his hip. During an observation on 8/18/26, at approximately 7:40 a.m., Resident R24's tray was placed on his bedside table, Nurse Aide (NA) Employee E2 entered the room at approximately 7:56 a.m., to assist Resident R24 to eat, 16 minutes later. The Surveyor stopped the feeding and obtained a new tray for Resident R24 to be provided with a warm meal. Resident R24's roommate had eaten his meal while Resident R24 watched. During an interview on 8/18/26, at approximately 8:00 a.m., NA Employee E2 confirmed that the facility failed to feed Resident R24 in a timely manner while his roommate was eating his meal and providing a warm meal. During an interview on 8/19/26, at 10:15 a.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R24). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical record review, resident observations, resident interview and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for two of ten residents (Resident R24 and R37).Findings include: Review of the facility policy, Activities of Daily Living dated 6/29/26, with a previous review date of 3/12/25, indicated, the Center must provide the necessary care and services to ensure that a patient's activities of daily living abilities are maintained or improved and do not diminish unless unavoidable. These include hygiene, mobility, elimination, dining and communication. During an observation on 8/17/26, at approximately 9:35 a.m., Resident R24 was observed lying in his bed on his left side with a wedge behind his back uncovered with a saturated dressing on his right hip and a soiled brief which appeared to be leaking onto his sheets. During a second observation on 8/17/26, at approximately 11:09 a.m., Resident R24 was in the same position with the same brief and dressing on his hip. During an interview on 8/17/26, at approximately 12:32 p.m., Resident R37 stated that he does not get changed per his request and especially not timely for therapy. He has put on call bell, and it gets turned off staff stating they're short staffed and he waits for a while before they come to changed him. During an observation on 8/17/26, at approximately 1:20 p.m., Resident R24's dressing was being changed by Licensed Practical Nurse (LPN) Employee E1 and she confirmed the dressing was saturated and Resident R24's brief was leaking onto his bed and he needed changed. During an interview on 8/17/26, at approximately 45 p.m., the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided for two of ten residents. 28 Pa. Code: 210.10(d) Resident Care Policies.28 Pa. Code: 211.12(d)(1) Nursing service.

Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for care and services for two of 29 residents reviewed (Resident R4 and R42). Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for care and services for two of 29 residents reviewed (Resident R4 and R42). Review of the facility policy Physician/Advanced Practice Provider (APP) Orders dated 6/29/26, indicated orders are accepted from authorized physicians and implemented. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 7/16/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and osteomyelitis (a serious infection and inflammation of the bone and bone marrow). Review of a physician order dated 7/13/26, indicated that Resident to have sippy cup, scoop dish, and weighted and built-up utensils for all meals. Review of Resident R4's current plan of care for diabetes initiated 7/15/26, indicated Resident to use straw handle cup for all meals. During an observation on 8/18/26, Resident R4 did not have a sippy cup on breakfast tray. During an interview on 8/18/26 at 8:40 a.m., the Certified Dietary Manager (CDM) Employee E42 stated that the facility staff take the cups and do not return them, also that the facility does not have enough to cover all the residents requiring a sippy cup for each meal. Review of the clinical record indicated that Resident R42 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of congestive heart failure and kidney disease. Review of a physician order dated 5/26/26, indicated clotrimazole (antifungal) external ointment 1% apply to right shoulder 2 times a day for dermal mycosis (skin fungal infection). Review of a nurse progress note dated 8/17/26, indicated the clotrimazole application was missed on 8/15/26. Review of Resident R42's Treatment Administration Record (TAR) indicated on 8/15/26 the clotrimazole was not given. Review of a physician order dated 7/26/26, indicated monthly lab diagnostics to be completed monthly one time a day on 8/3/26 for diagnoses of anemia. Review of a nurse progress note dated 8/4/26, indicated a missed lab draw for 8/3/26. Review of Resident R42's TAR dated 8/3/26 indicated the lab was not completed. During an interview on 8/20/26 at 9:00 a.m., the Director of Nursing confirmed the above findings and that the facility failed to follow a physician order for care and treatment for residents R4 and R42.

Based on the review of facility policy and clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 29 residents (Residents R1and R29). Findings include: Review of the facility policy, Nursing Documentation dated 6/29/26, indicated the facility will communicate the patient's status complete, comprehensive, and accessible accounting of care and monitoring provided. Documentation of nursing care is recorded in the medical record and reflective of the care provided by nursing staff. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 8/13/26, included diagnoses of diabetes, kidney disease, and heart attack. Review of a nurse progress note dated 8/10/26 indicated Resident R1 missed medications on 8/9/26 at 22:00. Review of Resident R1's Medication Administration Record (MAR) indicated all medications were given on 8/9/26 at 22:00. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE] with diagnoses that included stroke and diabetes. During an interview with the Director of Nursing on 8/20/26 at 9:00 a.m. revealed showers are documented completed on the documentation survey report. Review of the MDS dated [DATE], indicated Resident R29 required moderate assistance for showering. Review of the POC (point of care) nursing documentation indicated the resident receives showers on Monday and Fridays. Review of the documentation survey report for July and August 2026 did not include documentation that Resident R29 received showers on Monday and Fridays. During an interview on 8/20/26 at 9:00 a.m., the Director of Nursing confirmed the above findings that the facility failed to maintain records that were complete and accurate for Residents R1 and R29. 28 Pa. Code: 211.5(f)(g)(h) Clinical records. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, observations, clinical record reviews and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change observation for one of three residents (Resident R24) and failed to prevent cross contamination during a medication administration observation for one of three residents (Resident R37).Findings include: Review of Center for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, stated washing your hands with soap and water include the following:-Wet hands with water.-Apply the manufacturer recommended amount of product to your hands.-Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.-Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet.-Avoid using hot water to prevent drying of the skin Review of the facility policy Dressing: Applying Dry and Moist Dressings, dated 6/29/26, with a previous review date of 3/12/25, indicated steps of the procedure which included preparation of a clean, uncluttered, disinfected surface for placement if dressing supplies. Placing the supplies on the cleaned surface, cleaning scissors prior to use and performing hand hygiene between tasks of dressing change. Once dressing change is completed, the contaminated waste is to be removed and placed in the appropriate receptacle. Review of the facility policy Medication Administration General Guidelines last reviewed 6/29/26, with a previous review date of 3/12/25, indicated to administer medications as prescribed in accordance with manufactures' guidelines, good nursing principles and practices. If touching tablets is necessary, hands are washed with soap and water and gloves applied prior to handling tablets. During an observation of a dressing change for Resident R24's right hip on 8/17/26, at approximately 1:20 p.m , through 1:30p.m., the following was observed: Licensed Practical Nurse (LPN) Employee E1 did not clear area for treatment supplies, did not clean the area or place a barrier.LPN Employee E1 did not complete hand washing prior to dressing change.The Soiled dressing was removed; she removed gloves placed all into a trash can near bed of roommate.LPN Employee E1 then donned clean gloves, with no hand washing or use of gel. LPN Employee E1 then cleansed wound with saline soaked sponge, put soiled sponge in can, removed gloves and donned clean gloves with no handwashing or gel use.LPN Employee E1 cut a piece of kerlix from a roll with unclean scissors and used a Q-Tip to place kerlix. Santyl ointment was not placed into wound, as per order.LPN placed the outer dressing and taped the dressing. LPN Employee E1 removed a marker from her pocket and wrote the date and her initials directly on the dressing on Resident R24. Once the dressing was completed, LPN Employee E1 pushed the trash can back next to the roommate's bed and was walking out when the State Agency stopped her and asked her to remove the bag and take it to the soiled utility room and place in infectious box. During an interview on 8/17/26, at approximately 1:30 p.m., LPN Employee E1 confirmed that the facility failed to prevent cross contamination during the dressing change for Resident R24. During an observation on 8/18/26, at approximately 9:45 a.m., LPN Employee E1 opened the bottle of over-the-counter Claritin and dropped the tablet directly into her unwashed ungloved hand, she then opened the over-the-counter senna bottle and dropped the tablet into her unwashed ungloved hand, then opened the bottle of Vitamin D tablets and dropped the tablet directly into her unwashed, ungloved hand, each tablet placed into the medication cup. During an interview on 8/18/26, at approximately 9:50 a.m., LPN Employee E1 confirmed that the facility failed to prevent cross contamination during medication administration. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for five of five nurse aide (NA) personnel records (NA Employee E6, E7, E8, E9 and E10). Findings include:Review of NA Employee E6's personnel file indicated a date of hire on 6/11/00.Review of NA Employee E6's personnel record failed to include an annual performance evaluation at least every 12 months as required.Review of NA Employee E7's personnel file indicated a date of hire on 5/7/07.Review of NA Employee E7's personnel record failed to include an annual performance evaluation at least every 12 months as required.Review of NA Employee E8's personnel record indicated a date of hire on 8/18/15.Review of NA Employee E8's personnel record failed to include an annual performance evaluation at least every 12 months as required.Review of NA Employee E9's personnel record indicated a date of hire on 1/15/21.Review of NA Employee E9's personnel record failed to include an annual performance evaluation at least every 12 months as required.Review of NA Employee E10's personnel record indicated a date of hire on 3/18/13.Review of NA Employee E10's personnel record failed to include an annual performance evaluation at least every 12 months as required.During an interview on 8/18/26, at approximately 1:30 p.m., the Staffing Coordinator/Human Resources employee E5 confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for five of five nurse aide personnel records (NA Employee E6, E7, E8, E9 and E10).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(2) Personnel records.

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of three quarterly meeting (March 2026 to July 2026). Findings Include:Review of the facility policy Quality Assurance Performance Improvement Plan (QAPI) reviewed 6/29/26, with a previous review date of 3/12/25, indicated QAPI plan provides guidance for overall quality improvement to promote excellence in quality of care, quality of life, patient choice, person directed care and patient transitions.During an interview on 8/20/26, at approximately 11:40 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members as required. 28 Pa Code201.18(e)(1)(2)(3)(4)Management28 Pa Code211.12(d)(3)(5)Nursing Services

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16). Findings include:During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for resident rights and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing resident rights training annually as required. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications. This failure resulted in an Immediate Jeopardy situation for four of 25 residents (Residents R1, R2, R3, and R4).Findings include: Review of the Facility Assessment for 2026, Quarter 1, indicated the facility will provide intravenous medications and treatment for infections. Under the Acuity - Care Requirements section indicated, We also admit residents with IV medications. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/21/26, included diagnoses of Diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and Osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of Section O: Special Treatments, Procedures, and Programs indicated Resident R1 had been receiving intravenous therapy at the time of admission. Review of hospital discharge paperwork dated 6/18/26, included a note from the infectious disease physician that indicated Resident R1 was ordered ceftaroline ( Teflaro, broad-spectrum cephalosporin antibiotic administered intravenously for treating complicated skin and soft tissue infections). I am going to recommend IV antibiotics for several weeks along with clinical follow up. I do want to cover more broadly than just anaerobes. So, in addition to the Flagyl (antibiotic and antiprotozoal medication) I would like to have some aerobic Gram-negative and Gram-positive coverage with ceftaroline. Review of Resident R1's plan of care initiated 6/19/26, revealed Patient has osteomyelitis and is receiving IV antibiotics indicated the facility will, Administer antibiotics as ordered. Review of Resident R1's physician's order dated 6/18/26: Ceftaroline Fosamil Intravenous Solution Reconstituted Use 300 mg intravenously two times a day for sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Review of Resident R1's June 2026 medication administration record (MAR) revealed Resident R1 did not receive ceftaroline, from admission [DATE]) through 6/24/26, when he was hospitalized to allow him to receive the missed antibiotic medication. Review of Resident R1's electronic MAR progress notes for the scheduled ceftaroline doses were documented as follows:-Medication not available / on back order from pharmacy, or-Not received from pharmacy pending insurance coverage, or-Pending pharmacy, or-Awaiting pharmacy. Review of Resident R1's progress notes failed to address the medication not being provided until note written by Registered Nurse (RN) Employee E3 dated 6/23/26, at 4:48 p.m. revealed, LM (left message) for [infectious disease physician] about antibiotic changes. Review of Resident R1's progress note dated 6/24/26, at 10:19 a.m. revealed infectious disease physician wanted Resident R1 to remain on the originally ordered antibiotic. Review of a progress note dated 6/24/26, at 11:23 a.m. revealed Resident R1 was transferred to the hospital to receive medication. Interviews conducted with staff on 7/7/25, revealed all notifications to provider will be through Care Communications (the electronic communication platform) or if by telephone, a progress note will be entered into the electronic medical records system. Review of Resident R1's progress notes dated 6/18/26, through 6/24/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R1 not receiving his ceftaroline. Review of Care Communications revealed one entry related to Resident R1 not receiving his IV antibiotic, written by RN Employee E2, dated 6/22/26, at 11:47 p.m., Spoke with pharmacy regarding resident's iv ax (IV antibiotics) that was supposed to be stared on 6/18 for SEPSIS. They said that they left a message on Friday regarding a co-pay of $1,324.00 that would need approved. That is a Corporation issue - he was accepted on that antibiotic and needs to be on it!! Has he been getting it???? If he hasn't, there WILL be big problems!!! SOMEONE SHOULD BE FIRED. I don't know why pharmacy has such a problem getting antibiotics for our residents. Review of an electronic communication written by Resident R1's attending physician dated 6/26/26, at 7:14 p.m. indicated, Is anyone at the pharmacy going to be held accountable for this debacle? Totally unacceptable what happened because of them in my opinion. There was notification to me via the communication board 6 days after the patient was there that they didn't send an IV antibiotic. And the reason they gave, was because of COST!!! Good luck defending that in court when we agreed to accept him and treat him. But beyond that and much more important is that the fact that this gentleman did not receive proper treatment because of them. I do not know anybody who would be willing to accept this as a valid reason if it were one of their family members. I'm really not sure what it is about this pharmacy and delivering medications that are ordered. They delay controlled substances being delivered even though they have valid prescriptions confirmed electronically. Maybe I am mistaken, but I thought the main job of having this pharmacy was to deliver us medications that we order. If there is a problem, contact me immediately. I have NEVER had an issue with someone reaching out to me especially if it has to do with an antibiotic or medication not being covered. I get called for much less relevant issues and I am fine with that. Review of emergency room documentation dated 6/24/26, revealed Resident R1, Presents secondary to his nursing facility being unable to secure the ceftaroline. I spoke with the staff at [facility] and they advised that the patient has not yet received a dose of this antibiotic despite being at the facility since Thursday (6/18/26). They contacted the pharmacy and the pharmacy does not have an ETA for the antibiotic. They then spoke with [Infectious disease] office who spoke who advised that there were no alternatives. Patiently was subsequently sent here for admission for his IV antibiotics. Review of the hospital Discharge summary dated [DATE], revealed Resident R1, presented due to inability to receive IV antibiotics at SNF. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS 4/29/26, dated included diagnoses of Hepatic Encephalopathy (decline in brain function caused by severe liver disease), Heart Failure (progressive heart disease that affects pumping action of the heart muscles), and End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of Section N: Medications indicated Resident R2 received antibiotic medication. Review of Resident R2's plan of care initiated 4/23/26, failed to include a care plan developed for the use of a gastrointestinal antibiotic. Review of Resident R2's physician's order dated 4/23/26, revealed Resident R2 was to receive Rifaximin (antibiotic that stays in gastrointestinal tract) 550 mg two times a day for hepatic encephalopathy. Review of June 2026 MAR and progress notes revealed Resident R2 did not receive rifaximin for 14 of 60 scheduled doses, on:6/1/26, PM dose: documented to see nurse's note on MAR. No nurse's note in EMR (electronic medical record).6/2/26, PM dose: Not available. On order.6/3/26, PM dose: Pending pharmacy.6/5/26, AM dose: Unable to find and resident has an appointment.6/9/26, AM dose: Unable to find, not in Pyxis.6/10/26, AM dose: On order.6/24/26, PM dose: Pending pharmacy.6/25/26, PM dose: Med on order.6/26/26, PM dose: Pending pharmacy.6/27/26, PM dose: Pending pharmacy.6/28/26, AM dose: On back order.6/28/26, PM dose: Pending pharmacy.6/29/26, AM dose: On back order.6/29/26, PM dose: Pending pharmacy. Review of Resident R2's progress notes dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin on the above dates. Review of Care Communications dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R2 had not received his ordered antibiotics. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cancer, bacteremia (presence of bacteria in the bloodstream), and Klebsiella pneumoniae (a bacterium that can cause pneumonia, urinary tract infections, bloodstream infections, and other serious illnesses, often exhibiting antibiotic resistance). Review of hospital discharge paperwork dated 6/3/26, indicated Resident R3 was to receive intravenous ceftriaxone (Rocephin, antibiotic medication) and intravenous Linezolid (Zyvox, an antibiotic used to treat various bacterial infections, including pneumonia and skin infections). Review of the Clinical admission Assessment completed on 6/4/26, under the Care Planning section indicated Administer antibiotic therapy as prescribed was documented as not active. Review of the plan of care initiated 6/5/26, for Patient is receiving PO (by mouth) antibiotics related to abdominal wound infection indicated to Administer antibiotic as ordered. Further review of the plan of care failed to reveal goals and interventions developed for the use of intravenous antibiotic medications. Review of physician's orders dated 6/5/26, 6/6/26, 6/13/26, and 6/23/26, indicated Resident R3 was to receive ceftriaxone, two grams intravenously one time a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive Ceftriaxone on:6/05/26: Unable to complete/ on back order from pharmacy.6/11/26: Documented as held. Resident at CT scan, returned at approx. 1:30 p.m., no request to provider to see if it should be provided. 6/14/26: Medication not available/ on back order from pharmacy.6/15/26: Unavailable.6/24/26: Documented to see nurse's note on MAR. No nurse's note in EMR. Review of physician's orders dated 6/4/26, 6/5/26, 6/6/26, and 6/10/26, indicated Resident R3 was to receive linezolid, 600 mg intravenously two times a day. Review of physician's orders dated 6/22/26 and 6/23/26, indicated Resident R3 was to receive linezolid, 300 mg intravenously two times a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive linezolid IV infusions on:6/5/26, PM dose: Documented to see nurse's note on MAR. No nurse's note in emr.6/6/26, AM dose: awaiting from pharmacy.6/07/26, AM dose: not available.6/07/26, PM dose: Documented to see nurse's note on MAR. No nurse's note in emr.6/08/26, AM dose: Documented to see nurse's note on MAR. No nurse's note in emr.6/08/26, PM dose: med not available.6/09/26, AM dose: called pharmacy about IV ATB Linezolid Resident has not received this ATB since admission 6/6 reported to MD.6/09/26, PM dose: On order.6/10/26, PM dose: No documentation.6/11/26, AM dose: Documented as held. Resident at CT scan, returned at approx. 1:30 p.m., no request to provider to see if it should be provided. 6/16/26, PM dose: Documented as held. No note stating reason.Review of Resident R3's progress notes did not include a reason for the omissions. Review of Resident R3's progress notes dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid on the above dates. Review of Care Communications dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R3 had not received her ordered antibiotics. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), osteoarthritis (degeneration of the joint causing pain and stiffness), and history of cancer. Review of the plan of care initiated 5/23/25, for Patient has a suspected/actual infection, UTI (urinary tract infection) and is at risk for sepsis failed to include any updates after 10/14/25,Review of a physician's order dated 6/6/26, at 7:40 a.m. indicated Resident R4 was to receive meropenem (broad-spectrum intravenous antibiotic used to treat serious bacterial infections) one gram intravenously three times per day. The medication was scheduled to be received at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with the first dose to be given on 6/6/26, at 2:00 p.m. Review of Resident R4's MAR and progress notes indicated that Resident R4 did not receive meropenem IV infusions on:6/6/26, 2:00 p.m. dose: med not available6/6/26, 10:00 p.m. dose: No documentation.6/7/26, 6:00 a.m. dose: unable to get IV access, med not delivered.6/7/26, 2:00 p.m. dose: awaiting on medication from pharmacy; Supervisor aware.6/7/26, 10:00 p.m. dose: pending pharmacy.6/8/26, 6:00 a.m. dose: no IV site to administer medication. Review of Resident R4's progress notes dated 6/5/26, through 6/10/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem on the above dates. Review of Care Communications dated 6/5/26, through 6/10/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem. On 7/8/26, at 9:20 a.m. the Nursing Home Administrator (NHA) and the Interim Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 7/8/26, at 3:20 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions: R1 has been discharged from the facility. Upon identification that the resident did not receive the prescribed antibiotic for six days due to unavailability, the resident was immediately assessed by licensed nursing staff and founder of no adverse reaction. The provider was notified of the delaying antibiotic therapy period out of concern for further delay and potential for worsening infection, the patient was transferred to the hospital for evaluation with received prescribed antibiotic. R2 for the month of June, the patient was found to have missed 14 out of 60 doses of Rifaximin. Upon identification, the patient was immediately assessed with no adverse reaction to the patient. The patient is now receiving the medication as prescribed by the provider. R3 has been discharged from the facility The resident was found to have missed several doses of their prescribed antibiotic. Upon identification, the patient was immediately assessed with no adverse reaction. The patient's antibiotic stop date was extended to ensure that the patient received the required doses prescribed by the provider. An initial audit of the current residents will be conducted by the Director of Nursing or designee for the past seven days to verify medications were available from the pharmacy and administered as per MD (Doctor of Medicine) orders. Any residents identified with unavailable meds will have the provider notified and mediation will be adjusted if indicated as per provider. Will be completed by 7/8/26. The DON/designee conducted mandatory re-inservicing for facility licensed nurses and licensed agency nurses prior to the start of their next shift on the Medication Shortage, with the focus on notification to the provider and pharmacy for missing medications, medication administration, ordering of medications, and medication error policies. Education will include the process for obtaining medications from RxNow (medication dispensing machine) cabinet and notifying physician, or medication change if indicated. The DON/designee will review new admissions on the following day to verify medications were delivered and administered as per the MD orders. Pharmacy and provider will be notified of any identified unavailable medications. Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting - Completed 7/7/26. NHA/DON/designee sched a meeting on 7/8/26, with the pharmacy consultant to review concerns with medication availability and will schedule weekly x4 meetings, then monthly x2, to review any identified trends. The Admissions Director will review scheduled admissions prior to arrival to verify medication availability from the pharmacy. If medication is not available, the Admissions Director will notify the hospital for a medication adjustment prior to discharge from the hospital. DON or designee to conduct weekly x4, then monthly x2 audits of five residents on each medication cart to verify medications were available from the pharmacy and administered as per MD orders. Results of the audits to be presented at the QAPI meetings for review and recommendations. Review of resident clinical records and facility provided audit on 7/9/26, confirmed that all residents were reviewed for missed medications and the attending physician was notified. Review of facility-provided sign-in sheets, dated 7/8/26, and 7/9/26, confirmed reeducation was provided to all licensed nurses provider notification, actions to take if medications are not available, ordering medications, and documentation. During interviews conducted on 7/9/26, confirmed two of two registered nurses and two of two licensed practical nurses received reeducation on provider notification, actions to take if medications are not available, ordering medications, and documentation. Review of facility documents confirmed a meeting was completed with the NHA, DON, and the pharmacy consultant on 7/8/26, in which the process for reordering medications, pharmacy communication, procedure for missed medications, incomplete and/or inaccurate prescriptions, and the use of the RxNow dispensing unit were reviewed. The Immediate Jeopardy was lifted on 7/9/26, at 11:30 a.m. when the action plan implementation was verified. During an interview on 7/9/26, at approximately 12:15 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the facility failed to implement procedures to ensure availability of prescribed medications. This failure resulted in an Immediate Jeopardy situation for four of 25 residents 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 211.9(a)(1) Pharmacy Services28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to notify the medical provider of the inability to provide ordered antibiotic medications for four of 25 residents (Residents R1, R2, R3, and R4). Findings include: Review of the facility policy, Physician / Advanced Practice Provider (APP) Notification dated 5/15/26, indicated an effective process for next day notification must be in place and communicated to all physicians/APPs and licensed nurses. During staff interviews completed on 7/7/25, indicated all notifications to provider will be through Care Communications (the electronic communication platform) or if by telephone, a progress note will be entered into the electronic medical records system. Review of a physician's order for Resident R1 dated 6/18/26: Ceftaroline Fosamil Intravenous Solution Reconstituted Use 300 mg intravenously two times a day for sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Review of Resident R1's June 2026 medication administration record (MAR) indicated that Resident R1 did not receive ceftaroline, from admission [DATE]) through 6/24/26, when he was hospitalized to allow him to receive the missed antibiotic medication. Review of Resident R1's progress notes dated 6/18/26, through 6/24/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R1 not receiving his ceftaroline. Review of Care Communications revealed one entry related to Resident R1 not receiving his IV antibiotic, written by RN Employee E2, dated 6/22/26, at 11:47 p.m., Spoke with pharmacy regarding resident's iv ax (IV antibiotics) that was supposed to be stared on 6/18 for SEPSIS. They said that they left a message on Friday regarding a co-pay of $1,324.00 that would need approved. That is a Corporation issue - he was accepted on that antibiotic and needs to be on it!! Has he been getting it???? If he hasn't, there WILL be big problems!!! SOMEONE SHOULD BE FIRED. I don't know why pharmacy has such a problem getting antibiotics for our residents. Review of an electronic communication written by Resident R1's attending physician dated 6/26/26, at 7:14 p.m. indicated, There was notification to me via the communication board 6 days after the patient was there that they didn't send an IV antibiotic. If there is a problem, contact me immediately. I have NEVER had an issue with someone reaching out to me especially if it has to do with an antibiotic or medication not being covered. I get called for much less relevant issues and I am fine with that. Review of Resident R2's physician's order dated 4/23/26, indicated Resident R2 was to receive Rifaximin (antibiotic that stays in gastrointestinal tract) 550 mg two times a day for hepatic encephalopathy. Review of June 2026 MAR and progress notes indicated that Resident R2 did not receive rifaximin for 14 of 60 scheduled doses, on 6/1/26, 6/2/26, 6/3/26, 6/5/26, 6/9/26, 6/10/26, 6/24/26, 6/25/26, 6/26/26, 6/27/26, 6/28/26 x 2 doses, and 6/29/26 x 2 doses. Review of Resident R2's progress notes and the Care Communications log dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin on the above dates. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R2 had not received his ordered antibiotics. Review of Resident R3's physician's orders dated 6/5/26, 6/6/26, 6/13/26, and 6/23/26, indicated Resident R3 was to receive ceftriaxone, two grams intravenously one time a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive Ceftriaxone on 6/5/26, 6/11/26, 6/14/26, 6/15/26, and 6/24/26. Review of physician's orders dated 6/4/26, 6/5/26, 6/6/26, and 6/10/26, indicated Resident R3 was to receive linezolid, 600 mg intravenously two times a day. Review of physician's orders dated 6/22/26 and 6/23/26, indicated Resident R3 was to receive linezolid, 300 mg intravenously two times a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive linezolid IV infusions on 6/5/26. 6/6/26, 6/7/26 x2 doses, 6/8/26 x2 doses, 6/9/26 x 2 doses, 6/10/26, 6/11/26, and 6/16/26. Review of Resident R3's progress notes and the Care Communications log dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid on the above dates. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R3 had not received her ordered antibiotics. Review of a physician's order dated 6/6/26, at 7:40 a.m. indicated Resident R4 was to receive meropenem (broad-spectrum intravenous antibiotic used to treat serious bacterial infections) one gram intravenously three times per day. The medication was scheduled to be received at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with the first dose to be given on 6/6/26, at 2:00 p.m. Review of Resident R4's MAR and progress notes indicated that Resident R4 did not receive meropenem IV infusions on 6/6/26, 2:00 p.m. 6/6/26, 10:00 p.m., 6/7/26, 6:00 a.m., 6/7/26, 2:00 p.m., 6/7/26, 10:00 p.m., and 6/8/26, 6:00 a.m. Review of Resident R4's progress notes and the Care Communications log dated 6/6/26, through 6/9/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem on the above dates. During an interview on 7/9/26, at approximately 12:15 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the failed to notify the medical provider of the inability to provide ordered antibiotic medications for four of 25 residents. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 211.9(a)(1) Pharmacy Services28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nurses exhibited skills and competency for ten of 18 licensed practical nurses (Employees E4, E5, E6, E7, E8, E9, E10, E11, E12, and E13) by having failed to provide order medications that were available in the medication dispensing machine for 16 of 50 residents (R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19).Findings include: Review of the facility policy, Medication Administration dated 5/15/26, indicated, medications are administered as prescribed in accordance with good nursing principles and practices. Review of the facility-provided document from the facility-contracted pharmacy entitled, Proper Medication Administration indicated, Circle initials if the medication was not available and provide a detailed explanation Follow electronic processes for documenting omissions and refusals if using e-MARs (electronic medication administration records). Review of the Licensed Practical Nurse (LPN) job description indicated the LPN will administer medications and perform treatments per physician orders. Resident R2's ordered midodrine:-6/22/26: Documented to see nurse's note on MAR. No nurse's note in EMR, by LPN Employee E11 Review of the facility provided RxNow (medication dispensing machine) inventory list included midodrine as a stocked item. Resident R5's ordered heparin:6/19/26: awaiting from pharmacy documented by Agency LPN Employee E56/23/26: unable to find mediation / on back order from pharmacy documented by LPN Employee E46/29/26: pending pharmacy documented by Agency LPN Employee E67/03/26: not available documented by LPN Employee E7 Review of the facility provided RxNow inventory list included heparin as a stocked item. Resident R6's ordered Risperdal:6/9/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4Resident R6's ordered mirtazapine:6/9/26: Medication not available documented by LPN Employee E46/13/26: Medication not available/ on back order from pharmacy documented by LPN Employee E46/19/26: Unable to find medication documented by LPN Employee E4Resident R6's ordered trazodone:6/12/26: waiting on pharmacy documented by Agency LPN Employee E5Resident R6's ordered benztropine mesylate:6/19/26: Medication not available documented by LPN Employee E4 Review of the facility provided RxNow inventory list included Risperdal, mirtazapine, trazodone, and benztropine mesylate as stocked items. Resident R7's ordered enoxaparin:6/21/26: Documented to see nurse's note on MAR. No nurse's note in EMR, by Agency LPN Employee E86/22/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included enoxaparin as a stocked item. Resident R8's ordered omeprazole:6/3/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included omeprazole as a stocked item. Resident R9's ordered Lexapro:6/5/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4Resident R9's ordered Namenda:7/3/26: not able to administer on order documented by LPN Employee E7Resident R9's ordered Plavix:7/6/26: not available to give documented by LPN Employee E7Resident R9's ordered pantoprazole:7/7/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included Lexapro, Namenda, Plavix, and pantoprazole as stocked items. Resident R10's ordered Synthroid:6/30/26: not available to administer documented by LPN Employee E9 Review of the facility provided RxNow inventory list included Synthroid as a stocked item. Resident R11's ordered pregabalin:6/11/26: unavailable documented by Agency LPN Employee E106/11/26 (second dose): unavailable documented by Agency LPN Employee E10Resident R11's ordered penicillin:6/26/26: pending pharmacy documented by Agency LPN Employee E66/27/26: Unable to find medication documented by LPN Employee E46/27/26: pending pharmacy documented by Agency LPN Employee E6 Review of the facility provided RxNow inventory list included pregabalin and penicillin as stocked items. Resident R12's ordered omeprazole:6/24/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included omeprazole as a stocked item. Resident R13's ordered famotidine:6/9/26: Medication not available documented by LPN Employee E46/16/26: Unable to find medication documented by LPN Employee E46/9/26: Medication not available/ on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included famotidine as a stocked item. Resident R14's ordered morphine ER:6/22/26: (10:00 p.m. dose) Documented to see nurse's note on MAR. No nurse's note in EMR, by LPN Employee E116/23/26: (10:00 a.m. dose) Medication not available/ on back order from pharmacy documented by LPN Employee E46/23/26: (10:00 p.m. dose) pending script/pharmacy documented by Agency LPN Employee E6 Review of the facility provided RxNow inventory list included morphine ER as a stocked item. Resident R15's ordered clopidogrel (Plavix): 6/16/26: unable to find medication documented by LPN Employee E4 Review of the facility provided RxNow inventory list included Plavix as a stocked item. Resident R16's ordered clopidogrel (Plavix): 6/16/26: unable to find medication / on back order from pharmacy documented by LPN Employee E4 Review of the facility provided RxNow inventory list included Plavix as a stocked item. Resident R17's ordered linagliptin (Tradjenta): 7/6/26: on order not available to administer documented by LPN Employee E7 Review of the facility provided RxNow inventory list included Tradjenta as a stocked item. Resident R18's ordered atorvastatin:7/4/26: Not received from pharmacy at this time documented by Agency LPN Employee E11Resident R18's ordered Losartan:7/5/26: Documented as held by LPN Employee E13. No documentation in the progress notes associated with this order. A progress note dated 7/5/26, at 3:24 p.m. indicated, Not received from pharmacy but did not include what medication this note was associated with. Review of the facility provided RxNow inventory list included atorvastatin and Losartan as stocked items. Resident R19's ordered Losartan: 7/5/26: Medication on order documented by LPN Employee E13. Review of the facility provided RxNow inventory list included Losartan as a stocked item. During an interview on 7/9/26, at approximately 11:00 a.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that Agency nurses do not have access to the RxNow dispensing machine, but all nurse supervisors do, and there is always a nurse on shift with access to the RxNow. During an interview on 7/9/26, at approximately 11:30 a.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the facility failed to ensure that nurses exhibited skills and competency for ten of 18 licensed practical nurses by having failed to provide order medications that were available in the medication dispensing machine for 16 of 50 residents 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.9(a)(1)(f)(4) Pharmacy Services.28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the former Director of Nursing (DON) failed to implement procedures to ensure availability of prescribed medications. This failure resulted in a resident who was ordered intravenous antibiotic medication to be rehospitalized to receive the ordered medication (Resident R1). This failure created an Immediate Jeopardy situation for four of 25 residents who failed to receive medications (Resident R1, R2, R3, and R4).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and compassion to patients, residents and families. Responsible for assuring that the center operates in full compliance with Federal and State regulations while Doing the Right Things, which will result in high levels of performance in each of the [Corporation] Strategic Focus Areas. The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. Review of the facility-provided Director of Nursing (DON) job description indicated, The Director of Nursing leads the Center clinical team to fulfill the organization's mission, vision and values. This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities, nursing practice, and clinical education and development, including continuous improvement of nursing services and staff to meet patients/residents and their families' needs and expectations. The DON communicates a shared vision for clinical excellence and ensures the realization of high quality and cost-effective health care services that are consistent with [Corporation] evidence-based practices and policies, regulatory and other legal requirements, and philosophies. This position is responsible for driving, supporting and modeling a service-oriented culture focused on top of license practice, interprofessional collaboration, employee engagement, quality, patient safety, service excellence, fiscal responsibility, and the overall patient/resident experience. The DON collaborates with the Administrator and Center Leadership Team to drive business excellence, including strategic planning, budget preparation, and effective oversight of resource utilization. Based on findings identified in this report, the facility failed to prevent the failed to implement procedures to ensure availability of prescribed medications. The NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 7/9/26, at approximately 12:15 p.m. the NHA and current DON confirmed that facility administration failed to implement procedures to ensure availability of prescribed medications. This failure resulted in a resident who was ordered intravenous antibiotic medication to be rehospitalized to receive the ordered medication (Resident R1). This failure created an Immediate Jeopardy situation for four of 25 residents who failed to receive medications. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R1).Findings include: Review of the facility policy, Medication Administration dated 3/12/25, indicated medications are administered in accordance with written orders of the prescriber. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/31/26, included diagnoses of hemiplegia (paralysis on one side of the body) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R1's progress notes from admission to discharge (3/24/26 - 5/1/26) documented 14 times that Resident R1 was alert and oriented to person, place, and time. No progress notes were present in the clinical record to indicate a lesser level of orientation. Review of the plan of care dated for insulin dependent diabetes dated 3/25/26, indicated for staff to, Monitor for signs and symptoms of hyper/hypoglycemia (low/high blood sugar levels). Review of a physician's order dated 4/27/26, indicated Resident R1 was to receive insulin aspart (rapid-acting medication to treat high blood sugar) per a sliding scale before meals and at bedtime. Review of Resident R1's blood sugar level documentation from admission [DATE]) through 4/29/26, failed to reveal an early morning (approximately 6:00 a.m.) blood sugar level of greater than 306 mg/dL, approximately nine hours after the last administration of insulin. Review of Resident R1's blood sugar level documentation revealed a check completed on 4/29/26, at 5:27 p.m. and the next check on 4/30/26, at 7:30 a.m. Review of Resident R1's medication administration record (MAR) for April 2026 failed to reveal documentation that Resident R1 had his blood sugar checked or insulin provided on 4/29/26, scheduled for 9:00 p.m. Review of a progress note dated 4/30/26, at 12:39 a.m. indicated, The resident upset stated never received insulin on last shift from the nurse blood BS of 595, RN supervisor reached out to doctor for further instruction. Review of a progress note dated 4/30/26, at 1:15 a.m. indicated Resident R1 received six units of insulin aspart. Review of a progress note dated 4/30/26, at 8:16 a.m. indicated, This writer [Registered Nurse (RN) Employee E1] was notified by [Licensed Practical Nurse (LPN) Employee E2] resident refused BG (blood glucose) check. This RN went to the resident, and he did let this writer check his BG which was at 249. This writer was reported to that his sugar was 595 overnight. MD (Doctor of Medicine) notified of current glucose. Review of Resident R1's blood sugar record indicated that Resident R1 had a blood sugar level of 595 mg/dL inaccurately documented for 4/30/26, at 8:41 a.m. Review of a Late Entry progress note created by LPN Employee E3 on 4/30/26, at 2:33 p.m. indicated, This nurse worked 3-11 shift yesterday. Resident A&O (alert and oriented) able to make needs known, checked sugar at suppertime Accu Check was 250 meds and insulin given per order. Resident didn't eat our meal, OOB (out of bed) to w/c (wheelchair) in dining room with family - family brought in pizza and resident ate. During last med pass gave sliding insulin and long-acting insulin per orders, missed noting accucheck (blood sugar check) at time was 358. Resident had no complaints all shift.Further review of the clinical record failed to reveal documentation of a blood sugar level of 358, failed to reveal documentation of insulin provided to the resident or what units provided, and failed to reveal documentation or other information to indicate why Resident R1's blood sugar level was 595 mg/dL at approximately 12:30 a.m., three hours after insulin would have been provided when, as documented in the blood sugar level record, it had never been higher than 306 mg/dL at approximately nine hours after insulin was provided.During an interview on 5/23/26, at approximately 5:30 p.m. the Nursing Home Administrator confirmed the facility failed to ensure that residents are free of significant medication errors for one of four residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy Services.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, incident reports, facility documents, employee statements, and staff interview it was determined that the facility failed to ensure that a resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). for one resident (Resident R1). This failure created an immediate jeopardy situation for one of 14 ambulatory residents. This was identified for past non-compliance for Resident R1. Findings include: Review of facility policy Elopement of Patient defined elopement as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included sequelae of cerebral infarction (long-term effects and complications that occur after a stroke), high blood pressure, and difficulty walking. Review of Resident R1's Minimum Data Set (MDS- a periodic review of resident needs) dated 7/25/25, indicated the diagnoses were current. Further review of the MDS Section C: Cognitive Patterns; Brief Interview for Mental Status; Question C0500 indicated a BIMS score of 15. Review of facility submitted documentation indicated the following: On 8/2/25, the Director of Nursing (DON) was notified of patient missing. At 12:21 a.m. a facility-wide search revealed Resident R1 was not able to be located in or around the facility. DON directed staff in the facility to notify the police department. The police spotted his car on a traffic camera on 8/2/25, at 11:15 a.m. The police located Resident R1 on 8/2/25, at approximately 5:55 p.m. Review of a physician order dated 7/18/25, indicated resident may leave the facility unaccompanied utilizing transportation arranged by the facility. Review of an Elopement Evaluation assessment completed on 7/18/25, indicated Question 5 Does the resident wander? was answered 'No'. Question 13 Risk for Wandering/Elopement identified indicated a Risk for Wandering/Elopement Identified was checked and initiated a risk for wandering/elopement care plan. Review of the care plan dated 7/18/25, indicated the following: Identify if there is a certain time of day wandering / elopement attempts occur Ensure the safety of resident and others. Evaluate elopement risk. Evaluate medication schedule and possible pharmacological causes of wandering Initiate visual supervision during acute episodes. Provide emotional support regarding new onset wandering. Review of Nurse Aide (NA) Employee E1 undated witness statement indicated after dinner when they picked up Resident R1's meal tray he was lying in bed. Around 6:30 p.m. on 8/1/25, they were at the nurses station and saw Resident R1 walked past them going towards the dining room. They did rounds around 9:15-9:30 p.m. and noticed Resident R1 was still not in bed so they asked NA Employee E5 where he was, and she stated Resident R1 was probably still in the dining room. It was normal behavior for Resident R1, so they continued with their rounds. Review of NA Employee E2's undated witness statement indicated they saw Resident R1 at the front desk on 8/1/25, between 5:30-6:15 p.m. asking for the code to the front door, but they did not hear anyone respond. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement dated 8/2/25, indicated they last saw Resident R1 on 8/1/25, between 4-5:00 p.m. at the nurse's station. Review of NA Employee E4's undated witness statement indicated they last saw Resident R1 walking down the hall on 8/1/25, between 4-4:30 p.m. with a family member. Review of NA Employee E5's witness statement dated 8/2/25, indicated they saw Resident R1 with his mother and the Physician Assistant (PA) before dinner around 5:00 p.m. on 8/1/25. He rang for a blanket around 7:00 p.m. and was given a snack around 7:45-8:00 p.m. They did not see him after that but didn't think anything about it because Resident R1 goes all over the building and outside. Review of LPN Employee E6 witness statement dated 8/2/25, indicated they arrived at work at 11:00 p.m. on 8/1/25. They were alerted by NA Employee E8 that a resident was missing at 12:15 a.m. on 8/2/25. They checked the inside and outside of the facility with other staff members. Review of LPN Employee E7's witness statement dated 8/2/25, indicated when the NA did 12:00 a.m. rounds, Resident R1 was not found in his room or anywhere in the building. They provided Resident R1 with his medication around 7:00 p.m. on 8/1/25. All responsible parties notified of Resident R1 leaving the facility. Review of NA Employee E8's witness statement dated 8/3/25, indicated when they arrived on shift 8/1/25 (11:00 p.m. - 7:00 a.m.), they walked down the hall to check on the residents, Resident R1's bed was empty. They thought Resident R1 was in the bathroom. When they did another check down the hall Resident R1's bed was still empty, so they looked in the bathroom and Resident R1 was not in there. Review of Registered Nurse (RN) Employee E9's undated witness statement indicated Resident R1 was observed walking up and down the hallway with his walker on 8/1/25, at approximately 8-9:00 p.m. Resident R1 stated he was trying to strengthen his legs. He did not have any belongings with him at the time. He was alert and displaying no unusual behaviors. He was observed joking and laughing with staff. RN Employee E9 did not witness Resident R1 leave the building. A telephone interview was attempted with Resident R1 on 8/20/25, at 10:10 a.m., the call went straight to voicemail. A return call was not received. During a telephone interview on 8/20/25, at 10:15 a.m. Resident R1's mother stated she did not know where Resident R1 went when he left the facility but thought he might have called someone to pick him up, she was unsure how he left the facility. She stated that Resident R1 had mental health issues and his roommate yelled mom repeatedly all night and there was another incident that occurred at the facility on 8/1/25, that might have stressed Resident R1 to much so he decided to leave. Review of the clinical record did not include any mental health diagnoses. During an interview on 8/20/25, at 10:53 a.m. the DON stated Resident R1 picked his car up from the hospital where he left it when admitted to the facility. The police finally caught Resident R1 on 8/2/25, at 6:15 p.m. approximately 22 hours after he left the facility. She stated that staff do not complete every two-hour checks on all residents, just the incontinent residents. She confirmed staff should have realized Resident R1 was not in the facility sooner than three or four hours. During an interview on 8/20/25, at 1:15 p.m. NA Employee E1 stated they gave Resident R1 dinner between 4:45-5:00 p.m., between 5:15-6:00 p.m. they passed meal trays and assisted the residents who needed fed. They picked up Resident R1's tray between 5:45-6:00 p.m. and he was in his room. Around 6:00 p.m. they were at the nurses' station assisting another resident with a concern and Resident R1 walked past them. NA Employee E1 stated Resident R1 never really sat down, he was always walking. The last time they observed Resident R1 was around 8-8:30 pm when he was given a snack and then he walked to the dining room. When they did rounds, they got to Resident R1's room approximately 9:00 p.m. and noticed he was not there. They asked NA employee E5 where he was and was told he was probably still sitting in the dining room. They did not go check; they took their co-workers word he was still there. NA Employee E1 stated that when they did rounds, they usually by-passed Resident R1's room because NA Employee E1 stated Resident R1 was always walking in the hallways, he never sat down and was always on the move. The staff only do two-hour rounds on incontinent residents. During an interview on 8/20/25, at 1:45 p.m. RN Employee E9 stated she saw Resident R1 walking in the hallway with his walker between 8-9:00 p.m. he spoke to another nurse about trying to strengthen his legs. He did not have anything except his phone with him. She stated that she checked the doors every time they alarmed, and it was not due to any residents exiting the building. It was family/visitors leaving the facility. She stated it was possible that Resident R1 had the door codes. RN Employee E9 stated she had to pull two NA's to a resident room due to an incident regarding a different resident. She conducted the whole house audit on 8/2/25, when Resident R1 was noted to be missing. During an interview on 8/20/25, at 10:20 a.m. NHA (Nursing Home Administrator) and DON confirmed that the facility failed to ensure that a resident received adequate supervision which resulted in an elopement for one of three residents (Resident R1). They do not know how or where Resident R1 left the facility. They do not know an exact time Resident R1 left the facility but gave a time frame from 8-9:00 p.m. This was identified for past non-compliance for Resident R1 with a compliance date of 8/2/25. On 8/20/25, at 2:03 p.m. the NHA and the DON were notified that Immediate Jeopardy was called due to inadequate supervision of a resident that resulted in an elopement on 8/1/25, and facility staff were provided an Immediate Jeopardy template at that time, and a corrective action plan was requested. On 8/20/25, at 3:47 p.m. an immediate action plan was received and accepted which included the following interventions: Immediate Action: Upon identifying Resident R1 was not able to be located, the facility initiated a facility wide search. Midnight census sheet printed, whole house audit completed, all residents located except for Resident R1. Facility Door codes were changed by the maintenance director on 8/2/25: all facility entry locations checked, and alarms and wander guard system determined to be functioning as desired without any concerns. Resident council meeting held on 8/2/25, residents made aware that they must notify staff prior to leaving the facility for ANY reason and that a Release of Responsibility form must be signed for any LOA from the facility. Elopement drill completed by the DON on 8/2/25. An elopement audit was conducted on all residents in the facility. The residents that continued to be an elopement risk had care plans reviewed and updated accordingly to show new elopement assessments were completed.Facility elopement assessment updated for current residents on 8/2/25. Care plan verified to reflect elopement status as applicable. Elopement binder verified to be accurate with current identified elopement risk residents and their photos and binder is present at the nurses station. - Completed 8/2/25. Systemic Changes: Facility staff educated on Elopement policy as well as educated on the facility elopement assessment and staff educated on the facility door entry code and that no staff are permitted to release the code to any resident, family members, or visitors. Monitoring: The facility DON and/or designee will ensure that Elopement Drills will be completed on every shift for 72 hours, then three times a week for eight weeks, then weekly for four weeks, then monthly for three months. Nursing supervisor and/or designee will ensure that there is a head in bed/resident accountability check at every shift change. Initiated on 8/2/25, ongoing audits for three months. The results of the audits will be reviewed at the monthly Quality Improvement Committee for evaluation, recommendations, and interventions as deemed appropriate. Review of facility documentation included the following: Education for all employees in all departments on elopement policy and procedure. Facility Elopement Drills were being completed as stated above. During interviews eight staff to include nurses, nurse aides, maintenance, activities, dietary, and business office confirmed they received education on elopements, they understood the education, and feel they know what to do in case of another elopement. The facility has demonstrated compliance with the above since 8/2/25. Information was reviewed via Plan of Correction documentation. This IJ started on 8/1/25 and completion was demonstrated by 8/2/25. During an interview on 8/20/25, at 3:47 p.m. NHA and DON and review of the facility's immediate actions, education and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance on 8/2/25, ensuring residents are provided adequate supervision to ensure their safety.