Every finding on record at Meadowview Rehabilitation and Nursing Center

Based on review of resident records, staff interviews and review of facility documentation and policies, it was determined that the facility failed to conduct a complete and thorough investigation to rule out abuse and/or neglect for a resident who sustained multiple fractures for one of four residents reviewed (Resident R2).Findings include: Review of the facility policy titled, Abuse, revised September 2022 states, The facility prohibits the mistreatment, neglect, and abuse of residents/patients. Possible indicators of physical abuse include an injury that is suspicious because of the source of the injury is not observed the extent or location of the injury is unusual or because of the number of injuries either at a single point in time or over time. Review of Resident R2's clinical record revealed the resident was admitted to the facility in May 2019 and has a diagnosis of high blood pressure, cognitive communication deficit, paranoid schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), and delusional disorder (false beliefs in something that is untrue). Review of Resident R2 nursing progress notes revealed the resident had witnessed a fall on June 30, 2026, in a common area within the facility. Resident R2 was assessed by nursing that documented the resident as having no injuries, and no complaints of pain. Review of an incident dated June 30, 2026, submitted to the State Survey Agency reported that Resident R2 with a BIMS score of 3 (Brief Interview for Mental Status of 3 indicates severe cognitive impairment) had a witness fall on June 30, 2026, and did not display any signs of pain or discomfort until July 6, 2026. On July 6, 2026, the resident complained of pain, physician orders were obtained for x-rays of the resident's left hip, shoulder and knee. Continuing review of Resident R2 clinical record revealed the last time Resident R2 was documented experiencing pain was on July 2, 2026, and Tylenol was given with positive results. Continuing review of Resident R2 clinical record revealed, four days later, on July 6, 2026, the resident is documented as experiencing extreme pain and physician ordered x-ray results are positive for fractures. Resident R2 nursing progress notes dated July 7, 2026, indicated the resident was sent to the hospital and diagnosed with fractures of the clavicles, pelvis, sacral, Pulmonary embolism (PE - is a blood clot that forms and travels to the lungs), and volvulus (refers to a twisting of an organ or structure). On July 24, 2026, at 3:30 p.m. during an interview with the Director of Nursing (DON) confirmed that Resident R2's last report of pain after the fall on June 30, 2026, was on July 2, 2026. Further review of Resident R2 clinical records revealed no further investigation was made when the resident reported a new onset of pain. During the same interview the DON confirmed that an investigation to rule out abuse or neglect was not conducted. 28 Pa. Code 211.12 (d)(1) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility provided documentation, review of policy and interview with staff, it was determined that facility did not ensure that training related to psychosocial needs/behavioral health needs was provided for nine of 10 employees reviewed. (Employee E17, E18, E19, E20, E21, E22, E23, E24, and E25)Findings include: Review of facility policy 'Behavioral - Mental Health Care - Substance Use Services,' revised March 19, 2025, revealed that Training: facility will provide an effective training program for all staff which includes training on behavioral health care and services, mental disorders, psychosocial disorders, PTSD, and/or SUD, that is appropriate and effective as determined by staff need and the facility assessment; facility staff includes all facility staff (direct and indirect care functions), contracted staff, and volunteers . Further review of policy revealed that a behavioral health training as determined by the facility assessment should include, at a minimum, the competencies and skills necessary to provide the following: Person-centered care and services that reflect the resident's goals for care;Interpersonal communication that promotes mental and psychosocial well-being;Meaningful activities which promote engagement and positive meaningful relationships;An environment and atmosphere that is conductive to mental and psychosocial well-being;Individualized, non-pharmacological approaches to care;Care specific to the individual needs of residents that are diagnosed with a mental, psychosocial, or substance use disorder, history of trauma and/or post-traumatic stress disorder, or other behavioral health condition Further review of policy states that the facility will have staff who provide services to residents with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and person-centered care plans. Review of facility assessment, completed on November 7, 2025, revealed that facility has 67 - 69 residents with behavioral health needs and 1 - 2 residents with active or current substance use disorder. Further review of facility assessment revealed that competency's related to 'caring for residents with mental and psychosocial disorders' are to be provided annually and as needed. Review of facility provided annual in-services and competencies revealed no evidence of training provided related to psychosocial needs, mental/behavioral health or substance use disorders for licensed practical nurses - Employees E17, E18, E19, E20, E21, E22, E23, E24,and E25. Interview with facility's staff educator, employee E26, on Thursday, April 16, 2026, at 1:00 pm, confirmed that facility has not been providing appropriate annual training based on facility assessment and Behavioral - Mental Health Care - Substance Use Services policy. 28 Pa Code 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility meal test tray, review of resident council meeting minutes, resident interviews, and staff interview it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.Findings Include: A meal test tray was completed on April 15, 2026. While in the kitchen trays of coffee cups were seen being prepared by a dietary staff at 12:45 p.m. The test tray left the kitchen at 1:18pm and went out to the B wing unit. The test tray was served at 1:24 p.m. The test tray contained a plate of baked ziti, broccoli, and garlic bread. The baked ziti was tasted and was not appetizing. The baked ziti was too overdone that is disintegrated without having to chew it. There were two beverages served, a milk and a coffee. The coffee temperature was 174.2 degrees. Interview with the Food Services Director Employee E7 revealed the coffee was poured directly out of the coffee urn. Typically, the coffee is poured into the cup, a lid put on, and it sits for 10 minutes. The Food Services Director Employee E7 was asked to provide point of service coffee temperature records. Employee E7 provided a Hot Beverage Temp log that states, pour at 7:10 a.m.- 11:20 a.m. and 4:10 p.m. The record was completed for April 1, 2026 through April 15, 2026. Hot water and coffee temperatures were taken for breakfast, lunch, and dinner. For every temperature taken it has 140 degrees Fahrenheit written. Employee E7 was asked who takes the temperature for dinner service and he stated, my cook does. All signatures on the Hot Beverage Temp log appear to be the same. Hot Beverage Temp logs were requested for January, February, and March. Employee E7 was able to provide January and March. Employee E7 was only able to provide January and March. Breakfast, lunch, and dinner for January and March read 140 degrees Fahrenheit for all of the dates listed. A re-test of the coffee was made at 1:34 p.m. A cup of coffee was poured and a lid was placed on the cup at 1:34 p.m. The Food Services Director Employee E7 was then asked to test the temperature at 1:44 p.m. which would be ten minutes later. The temperature of the coffee in the cup was taken ten minutes after it was poured and it was 172.5 degrees Fahrenheit. The Food Services Director Employee E7 confirmed the above findings at 1:46 p.m. Review of Food Committee Meeting Minutes from February 24, 2026 states, burgers are cooked too hard food cannot be burnt. Further review of Food Committee Meeting Minutes from February 24, 2026 states, cold coffee on her tray- Coffee and hot water are both being temped in the kitchen before service. Coffee will not be sent on a tray with a temperature higher than 140 degrees Fahrenheit due to burn safety precautions. One rack of coffee or hot water at a time are being prepared. Review of Food Committee Meeting Minutes from Janauary 20, 2026 states, Resident R209-states he would like 2 sandwiches at lunch. Resident Council was held on April 16, 2026 at 11:00 a.m. Resident R209 was admitted to the facility July 4, 202. R209 had a MDS (Minimum Data Set) a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate the health, functional capabilities, and needs of residents completed on February 2, 2026 and Resident R209 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Resident R209 states, the food here is horrible, it's so horrible I get two grilled cheese sandwiches everyday for lunch and dinner. Resident R165 was admitted to the facility on [DATE]. R165 had a MDS (Minimum Data Set) a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate the health, functional capabilities, and needs of residents completed on February 13, 2026 and Resident R165 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Resident R165 stated during resident council, the food her is always cold it can be hard to eat. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management28 Pa code 201.18 (b)(1) Management.

Based on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in one of the five nursing units observed (C Wing).Findings Include: Review of facility policy titled, Resident Rights last revised April 6, 2026 states, Policy: Employees shall treat all residents with kindness, respect, and dignity. Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence b. Safe and home-like environment Interview held with Resident R114 on April 13, 2026 at 12:13 p.m. resident states that the facility has a problem with a hole in the bathroom on C-wing and it has not been fixed. A tour was taken of the C wing common bathrooms on April 14, 2026 at 10:03 a.m. The Tub Room was observed first and there was a hole in the wall behind door when you enter into the room. The second common bathroom was labeled Century Bath and had an Out of Order signed on the door. There was a hole behind the bottom base of the toilet. There was a hole in wall behind door. The bathroom had a sharps container that was overflowing with disposable razors. Employee E13 confirmed the above findings on April 14, 2026 at 10:06 a.m. During Resident Council Meeting held on April 15, 2026 at 11:00 a.m. revealed several residents stated that they did not currently have locked drawers. Resident R107 was admitted to the facility on [DATE]. Resident R107 stated that he has never had a lock for valuable items. Resident R107 stated that maintenance keeps saying that they ordered locks. Resident R107 also stated that the C-wing bath had a hole in the bottom of the shower until this week they fixed because you all are here, but there are still holes in the walls. The counter is not easy to access for me to shave my face. Resident R107 had a MDS (Minimum Data Set- assessment of resident's care needs) completed on April 8, 2026, and Resident R107 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On April 16, 2026, at 11:54 a.m. it was observed with the Director of Maintenance, Employee E12 two drawers with key locks but Resident R107 stated he did not have a key. There were also two drawers with pad locks. A pad lock was located on the handle of a bedside drawer but Resident R107 stated he did not have a key for it. Resident R107 stated that he has nice items in his larger linen closet and would like a lock and key for this area. Resident R107 was asked if he had one ever and he stated no I haven't. Interview held with Director of Maintenance Employee E12 on April 16, 2026, at 12:03 p.m. confirmed there are a whole bunch of keys unlabeled in the maintenance office I just have not had the time to go through yet to see what is what. Interview held with the Regional Director of Maintenance Employee E13 on April 16, 2025 at 12:11 p.m. Employee E13 was asked who was in charge of asking the resident if they would like a locked drawer at the time of admission Employee E13 stated, It is nursing and admissions. After they know they want one they put it into TELS (their electronic system) and we will handle it right away. Interview held with the Director of Admissions Employee E6 on April 16, 2025, at 1:31 p.m. Employee E6 was asked if a part of the admissions process there is a current form regarding offering residents a locked drawer? Employee E6 stated yes there is. When asked if Employee E6 was currently completing them at the time of admission and having the resident sign off she stated, no, it's maintenance that asks and makes sure to provide the resident with a locked drawer. Resident R114 was admitted to the facility on [DATE]. 2025. Resident R1114 had a MDS completed on April 3, 2026, and Resident R114 had a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. Resident R114 stated that she has not been given a lock for her any drawer and she would like one. When asked if she was ever offered one she stated, no. Resident R18 was admitted to the facility on [DATE]. Resident R18 had a MDS completed on March 9, 2026, and Resident R18 had a BIMS score of 15 indicating no cognitive impairment. Resident R18 stated, I was never given a locked drawer or offered one. 28 Pa. Code 201.18 (b)(1) Management

Based on a review of resident's clinical records, facility documentation and staff interviews, it was determined that the facility failed to ensure that one of one residents were free from verbal abuse (Resident R246).Findings include: Review of facility policy Abuse Policy-Prevention and Management revised September 8, 2022, revealed verbal abuse includes, but is not limited to oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. The policy continues by saying Examples of verbal abuse include, but are not limited to:Harassing a resident;Mocking, insulting, ridiculing;Yelling or hovering over a resident, with the intent to intimidate;Threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends; andIsolating a resident from social interaction or activities.The policy states any mistreatment, neglect and abuse of residents/patients.by anyone including staff, family, visitors, etc. is prohibited and the facility is responsible for providing a safe resident environment and protecting residents from abuse. Review of Resident R246's clinical record revealed that Resident R246 was initially admitted to the facility on [DATE], and then readmitted from the hospital on March 5, 2026. Further review of Resident R246's clinical record revealed the diagnoses of included muscle wasting and atrophy (decrease in size of body tissue, organs or muscle), Urinary tract infection ( UTI), hydronephrosis (swelling of kidney due to urine retention, caused by an obstruction or blockage in urinary tract), other artificial openings of urinary tract status (nephrostomy tube of right kidney), chronic kidney disease Stage 4 ( CKD, severe), and personal history of other malignant neoplasm of kidney (kidney cancer). Review of Resident R246's clinical records reveal she had a BIMS (Brief Interview for Mental Status, a screening tool used in Long Term Care to assess cognitive function) revealed Resident R246 had a score of 15, indicating resident had no cognitive impairment (cognitively intact). Review of Resident R246's written statement revealed that during care on the commode, nurse aides Employees E31 and E32 were assisting resident, when Employee E31 pulled Resident R246's pants down forcefully, causing her to cry out for Employee E31 to be careful, as she did not want her to pull on her right-sided nephrostomy tube. However, per Resident R246's account, the force of the pulling did pull on the nephrostomy tube and caused bleeding. She then called the supervisor, Employee E30, who came to speak to the resident; the nurse aide Employee E31 tried to talk over the resident, the supervisor dismissed the nurse aide from the room and as she exited she stated That's why no one wants to work on this floor and said resident was causing trouble. The resident admitted ly replied to the aide if she didn't like her job, to find another one. Review of written statement and documentation from the supervisor, Employee E30, revealed he was called to Resident R246's room by the charge nurse, Employee E33, to come speak with Resident R246. After speaking to the resident, who told him the above narrative and added that the nurse aide stated the resident was abusing the CNAs (nurse aides) and would not allow Resident R246 to abuse her, the supervisor asked nurse aide Employee E31 if she made these statements, and Employee E31 confirmed she had. He told the aide this was not the way to speak to residents, and the nurse aide said it's the truth. He then told her to leave. The supervisor stated the behavior of the aide was disrespectful and rude. This supervisor was unavailable for interview. Review of Nurse aide, Employee E32 written statement who was assisting Employee E31, confirmed the exchange between Employee E31 and Resident R246 (which she witnessed), and added that Employee E31 stated to the resident I'm not on your tube, let me do my job unless you want someone else to come do it. Review of written statement and documentation by the Charge nurse, Employee E33, revealed the nurse aide Employee E31 admitted to the charge nurse what she said to Resident R246, and the charge nurse added that the nurse aide continued arguing with Resident R246 from the hallway, calling her a liar and accusing resident of abusing staff, then the aide stated she did not need to deal with this and left the floor, stating that she was leaving. Review of the incident report made by the Director of Nursing, Employee E2, to the Pennsylvania Department of Health on March 2, 2026 , revealed the nurse aide Employee E31 had been suspended pending the investigation (from March 3 to March 5), and terminated after conclusion of the investigation for rude, disrespectful behavior towards a resident during care. The allegation of verbal abuse by nurse aide, Employee E31 of resident R246 was substantiated. Resident R246, was unavailable for interview, as the resident was discharge from the facility on March 6, 2026. Interview with Assistant Director of Nursing, Employee E3, at 1:35 PM on April 16, 2026, confirmed the substantiated allegations of verbal abuse and the termination of Employee E31. Interview with the Unit Manager for E Unit, Employee E23, at approximately 1:00 PM on April 16, 2026, who documented on the nursing assessment of the nephrostomy tube at 16:00 the day following the incident (March 3), revealed she had spoken with the resident about the incident and confirmed verbal abuse by nurse aide Employee E31. She additionally confirmed that the nurse aide involved (Employee E31) had been terminated. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.29(j) Resident rights

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included the minimum information necessary to properly care for a resident related to urinary catheter within 48 hours of admission for one of one resident reviewed. (Resident R232)Findings include: Facility policy titled Care Planning Process and Care Conference, revised on March 19, 2025, indicates that An interdisciplinary baseline care plan will be initiated upon admission by the admitting nurse and completed within 48 hours. The policy further indicates that this is Care Plan is to include such initial needs/problems such as ADL's, falls, skin tears, risk for skin breakdown, nutritional status, behaviors, pacemaker, anticoagulants, psychotropic medication use etc. Include a care plan related to the resident's primary diagnosis. Review of Resident R232's clinical record revealed Resident R232 was originally admitted to the facility on [DATE] and then readmitted on [DATE] after a hospital stay. The resident was readmitted to the faciltiy with an indwelling urinary catheter. The resident's diagnoses include to benign prostatic hyperplasia or BPH (enlarged prostate), presence of urogenital implants (penile implant), Alzheimer's Disease (a type of Dementia, cognitive impairment) and Dementia, urinary tract infection and retention of urine. Review of Resident R232's care plan dated April 9, 2026 revealed to monitor new foley for amount/ color and odor. There were no interventions related to the care of the indwelling foley catheter such as instructions for replacement/indications of need for other replacement or when to seek medical attention. R Interview on April 16, 2026, at 1:52 PM with Employee E27, Licensed Practical Nurse (LPN) revealed the absence of a Care Plan for the foley catheter for Resident R232. 28 Pa. Code 211.10(d) Resident care policies

Based on review of policy, review of clinical records and review of facility provided documentation, it was determined facility did not ensure to develop and implement a resident centered care plan for one of 36 residents reviewed related to substance use disorder. (Resident R245)Findings include:Review of facility policy 'Care Planning Process and Care Conference,' revised on March 19, 2025, indicated that to foster the philosophy of the facility, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, the facility will develop a comprehensive, resident centered care plan for each resident/patient. Care plan development, renewal and revision will be based upon the results of the resident assessment. Review of facility policy 'Behavioral - Mental Health Care - Substance Use Services,' revised March 19, 2025, states that Individualized Assessment and Person- Centered Planning includes assessing psychosocial well-being , mood state, and behavioral symptoms by the interdisciplinary team (IDT). Further review of policy revealed that facility must assess the resident who had an overdose for their history of substance use and risk for using substances while in the facility, which could lead to an overdose in the facility. Relapse of substance use can be common in residents with SUD and may result in overdose.The comprehensive care plan should contain interventions, if appropriate, to prevent substance use in the facility as well as interventions for when substance use is suspected or identified.Care plan interventions should include increased monitoring and supervision, increased supervision of visitors, and notification of the physician and/or practitioner. Review of psychosocial evaluation/supportive care, completed on March 18, 2024, at 10:43 am, revealed that Resident R245 has a history if substance abuse and risks associated with drug abuse and accidental overdosing and triggers were discussed. Further review of psychosocial evaluation revealed that Resident R245 had a mental disorder, psychosocial adjustment difficulty, had a history of serious accident, was physically threatened - including situations that were extremely frightening, as well as witnessed extremely frightening situations. Review of Resident R245 past medical history revealed diagnosis of chronic pain syndrome, anxiety, severe sepsis with septic shock, alcohol abuse, major depressive disorder, other psychoactive substance dependance, schizophrenia. Review of Resident R245 clinical record revealed that on December 2, 2025 Resident R245 was transferred to hospital and tested positive for amphetamines, barbiturates, methadone, opiates, and phencyclidine. Review of Resident R245 care plan revealed no evidence of coping skills or relapse prevention strategies for drug abuse were developed. 28 Pa Code 211.12(d)(5) Nursing services 28 Pa Code 211.10(c)(d) Resident care policies

Based on review of facility policy, clinical record, facility documentation, and interview with staff, it was determined the facility did not ensure adequate supervision for one resident with a history of substance use disorder (SUD). (Resident R245). Findings include: Review of facility policy 'Behavioral - Mental Health Care - Substance Use Services,' revised March 19, 2025, states that behavioral health encompasses a resident's whole emotional and mental well-being which includes, but not limited to the prevention and treatment of mental health disorders, and SUD. Residents demonstrating change/s in behavior shall be evaluated to ensure that appropriate interventions, (both non-pharmacological and pharmacological) as needed, are instituted in a timely manner. Further review of policy identifies substance use disorder as a recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability and failure to meet major responsibilities at work, school or home. Residents with SUD may try to continue using substances during their stay. Staff should assess the resident for risk for use in the facility and have knowledge of signs and symptoms of possible substance use. Steps the facility may take if substance use is suspected: Increase monitoring and supervision in the facility to maintain the health and safety of the resident suspected of substance use, as well as all residents;Monitoring for symptoms such as but not limited to feeling of exhilaration, increased alertness, increased energy and restlessness, frequent leaves of absence with or without staff knowledge, behavior changes or aggression, mood changes, particularly after interaction with visitors or absence from the facility , rapid or rambling speech, dilated pupils, irritability, anxiety, unresponsiveness, inability to communicate or follow commands, decreased respiratory rate, pinpoint pupils if overdose is suspected;Facility efforts to help residents such as individual counseling services, access to group counseling, 12 step program, support groups or access to a medication assisted treatment (MAT) program, if applicable;Restricted or supervised visitation, if the resident's visitor(s) are deemed to be a danger to the resident, other residents, and/or staff. Review of facility policy 'Visitation, Non-Pandemic/Epidemic conditions,' revised August 19, 2025, under 'Visitation and illegal substance use,' revealed that it is important for facility staff to have knowledge of signs, symptoms, and triggers of possible illegal substance use; such as changes in resident behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and/or loss of consciousness, etc. This may include asking residents, who appear to have used an illegal substance (e.g., cocaine, hallucinogens, heroin), whether or not they possess or have used an illegal substance. Further review of policy revealed that if the facility determines through observation that a resident may have access to illegal substances that they have brought into the facility or secured from an outside source, the facility should not act as an arm of law enforcement. To protect health and safety of residents, facility may need to provide additional monitoring and supervision. Review of Resident R245's clinical record revealed he was initially admitted to facility on March 2, 2020 for back pain with past medical history of intravenous drug abuse involving heroin, hepatitis C, PSH of plates in head from trauma (Paroxysmal Sympathetic Hyperactivity is a syndrome of autonomic nervous system dysfunction-characterized by fever, hypertension, and tachycardia-often occurring after traumatic brain injury (TBI), anxiety. Review of facility provided investigation report, completed on December 3, 2025, at 12:04 pm, revealed that Resident R245 alert and oriented to person, place and time, and had a brief interview for mental status (BIMS) score of 15. Resident R245 was also able to ambulate with a rolling walker. Review of Resident R245's clinical record revealed a physician note dated 11/26/2025, stating that Nurses note that while he (Resident R245) often is fine, he has periods of being out of it or agitated, especially after leave of absence (LOA). Further review of investigation report revealed that on Sunday, 11/30/25, at approximately 11:20 pm, [Resident R245's] roommate came to the desk and stated that the resident was in the bathroom for a long time. Nursing staff went to the room and observed the resident on the toilet and having some tremors. He was able to respond to his name. His vital signs were stable. Nursing staff attempted to assist resident off the toilet and he became aggressive with them. Resident R245 then calmed down and allowed them to assist him off the toilet. Staff questioned the resident if he took anything because this behavior is not (his/her) norm. The resident stated 'no.' The MD (physician) was called and orders were received to send the resident to the hospital, however the resident refused to go to the hospital. [Resident R245] had a visit from his wife on 11/28/25, and according to his room mate he gave her money and she left. The roommate could not report if she gave (him/her) anything. [Resident R245's] wife did visit him occasionally and they would go out to eat. There were no alterations in his behaviors after these visits. On 12/2/25 [Resident R245] had a temperature of 100F (Fahrenheit), heart rate of 48 ([NAME] heart rate is 60-100). [Resident R245] agreed to go to the hospital. 911 (Emergency Medical Services) was called and the resident was sent to ER (Emergency Room) at approximately 03:22 am. A drug screen was done and the hospital notified facility it was positive for amphetamines, barbiturates, methadone, opiates, and phencyclidine. Further review of progress notes revealed clinical nurses note, dated 12/1/2025, at 01:12 am, stating that Resident R245 was found urinating on himself, shaking uncontrollably not related to seizure activity, in and out of coherence but alert when staff attempted to assist resident with changing and back to bed. Resident lashed out swinging violently and pushing staff away. He was escorted to bed, MD notified and received call back at approximately 6:00 am with a new order to send [Resident R245] to hospital for evaluation. However, [Resident R245] continued to refuse to be sent out for evaluation. Further review of clinical nurses note, dated 12/1/2025, at 3:50 pm, revealed that unit manager was notified that Sunday into Monday resident was observed combative and aggressive toward staff - resident wife is believed to have given him a substance, resident noted with tremors but per RN (Registered Nurse) the vitals were within normal limits, and is ambulating to and from bathroom. Nurse attempted to assist [Resident R245] from bathroom to bed but (he/she) again became combative, yelling . continued to refuse to be sent to ER for evaluation. MD gave new orders to discuss that wife must visit resident going forward in supervised area and supervised visits need to be scheduled, Review of physician orders revealed that a verbal order was given by MD, Employee E14, on December 1, 2025, at 9:00 am for supervised visits. Interview with Licensed nurse, Employee E15, on 4/15/2026, at 11:00 am, confirmed that she received a verbal order at 9:00 am on December 1, 2025, for Resident R245 to have supervised visits; Employee E15 also confirmed that on December 1, 2025, Resident R245 had an unsupervised visit from wife, from 2:35 pm to 3:40 pm. Further review of facility provided investigation report revealed that on either Thursday or Friday (11/27/25 or 11/28/25) Resident R245's wife came for his car but he wasn't allowed to go out on the leave. That night Resident R245 slept the entire night. Throughout the weekend he was mumbling but would say he wasn't. Resident R245 was in the bathroom off and on for long intervals. He was walking to the bathroom by himself. Resident R245 was asked what he took but he wouldn't tell. Resident R245 mentioned being stressed because his wife was smoking crack again. Facility failed to supervise and monitor a resident with extensive history of drug abuse and mental/behavioral health disorders. 28 Pa Code 211.12(d)(1)(5) Nursing services28 Pa Code 211.10(a)(c) Resident care policies

Based on clinical record reviews, interviews with staff, reviews of facility policies and procedures, and hospital records, it was determined the facility failed to assess, monitor, and implement intervention to ensure that nutritional and hydration needs were met for one of 11 residents reviewed. (Resident R1). This failure resulted in actual harm to Resident CL1 who did not consume sufficient fluid and caloric intake resulting in abnormal blood values, requiring transfer, and admission to the hospital for the treatment of dehydration/electrolyte imbalance. (Resident CL1) Findings include:Review of facility policy titled nutrition assessment dated [DATE], revealed the facility staff were responsible for ensuring each resident maintained acceptable parameters of nutritional and hydration status. The policy indicated the facility staff were responsible for recognizing and addressing the nutritional and hydration needs of each resident. The facility staff were to provide a diet based on the resident's clinical condition when there was a nutritional indication. If the resident was unable to provide food and beverage preferences; then the necessary information will be obtained from the resident's representative. Continue review of the policy revealed that a registered dietitian would complete a nutritional assessment for each resident to determine if the resident was at risk for inadequate nutrition or hydration. The registered dietitian was responsible for assessing each resident's height, weight, food and fluid intake and collaborating this assessment with other facility staff members (nurse practitioner, nursing staff, physician, speech pathologist, social worker, psychiatrist, pharmacist) to identify risk factors for nutrition and hydration issues. The registered dietitian would be responsible for observing, assessing and monitoring the food and fluid intake of each resident. Nursing staff were to document and observe each resident daily and able to provide the registered dietitian with each resident's daily nutritional intake. The registered dietitian was responsible for developing interventions and care planning to meet each resident's medical and nutritional needs. Review of Resident CL1's comprehensive assessment (MDS-assessment of care needs) dated August 4, 2025, indicated Resident CL1 had diagnoses of Coronary Artery Disease (narrowing of the blood vessels which supply the heart with blood and oxygen), Dementia (irreversible, disease of the of the brain resulting in loss of reality), Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform) and Malnutrition. Review of Resident CL1's psychiatric evaluation dated August 13, 2025, revealed the resident thought process was illogical, tangential (thinking is fractured), and delusional with poor concentration abilities. Review for Resident CL1's September 2025 physician orders revealed an order dated May 22, 2025, for regular diet and Mighty Shake (liquid nutritional supplement) four ounce, three times a day with meals. Continued review of physician's orders revealed an order dated September 15, 2025, for Boost (nutritional supplement) eight-ounce, three times a day. Review of Resident CL1's nursing documentation dated September 19, 2025, and September 24, 2025, revealed Resident CL1 continued to refuse the nutritional supplements. Clinical record review for September 24, 2025, for Resident CL1 revealed the nurse practitioner was asked by the nursing staff to evaluate Resident CL1 due to poor oral intake. The nurse practitioner documented Resident CL1 was refusing the nutritional supplement (Boost), because the resident did not like milk. The nurse practitioner's plan was to have the registered dietitian evaluate, assess, monitor, and nutrition care plan for Resident CL1's poor by mouth intake and declining to drink the nutritional supplement. Interview conducted with the Registered Dietitian, Employee E5, at 10:30 a.m., on October 21, 2025, confirmed that the last nutritional assessment complete by a Registered Dietitian was August 5, 2025. Further interview with the Registered Dietitian, Employee E5 revealed the food and nutrition department was not notified about the dietary consult that was requested by the nurse practitioner on September 24, 2025, related to Resident CL1's poor by mouth intake and declining to consume nutritional supplement. Review of nutritional assessment dated [DATE], revealed Resident CL1 was 69 inches in height, weighed 123 pounds with an ideal body weight was 160 pounds +/- 10%. The dietary progress note indicated that Resident CL1 was at risk for malnutrition and dehydration. The nutritional care plan was for Resident CL1 was to gain 1 to 2 pounds of weight a week toward a healthy BMI (body mass index). The nutritional care plan revealed, nutritional supplementation would be provided and the resident would be monitored and encouraged to eat greater than 75% of most meals. Based on Resident CL1's weight of 123 pounds and height of 69 inches Resident CL1 had a body mass index of 18.1 which placed the resident in a category of being under weight. Based on Resident CL1's weight of 123 pounds and ideal body weight of 160 pounds +/- 10%. This resident's caloric needs were 1500 to 1950 calories a day. Based on Resident CL1's weight of 123 pounds and goal weight of 160 +/- 10% this resident's baseline fluid needs without fluid restriction were 1500 milliliters (ml) to 1800 milliliters a day. Review of the Resident CL1 food consumption records from September 24, 2025, through October 9, 2025, revealed the nursing staff documented Resident CL1 refused either the lunch or dinner meal on September 24, 25, 26, 27, and September 28, 2025, as well as the follow dates on October 1, 2, 3, 4, 5, and October 8, 2025. All three meals were documented as refused on October 6, and October 7, 2025. Clinical record review for September 24, 2025, through October 9, 2025, revealed the nursing staff documented poor fluid intake for Resident CL1. Resident CL1 was consuming less than 1500 to 1800 ml of fluid a day of the nutritional supplements as ordered by the physician as follows:-September 24, 2025, 557ml-September 25, 2025, 536 ml-September 26, 2025, 437 ml -September 27, 2025, 951 ml -September 28, 2025, 634 ml -September 29, 2025, 694 ml -September 30, 2025, 664 ml-October 1, 2025, 399 ml -October 2, 2025, 457 ml-October 3, 2025, 279 ml -October 4, 2025, 634 ml -October 5, 2025, 288 ml -October 6, 2025, 467 ml -October 7, 2025, 240 ml -October 8, 2025, 634 ml -October 9, 2025, 240 ml Clinical record review revealed on October 8, 2025, the facility staff received notification from the laboratory services of elevated blood levels as follows: chloride level- 128 (normal 99 to 109 milliequivalents per liter-MEQ/L), sodium- 170 normal was (135 to 145 MEQ/L) and BUN 48 normal was 10 to 26 MG/DL. Review of nursing notes dated October 8, 2025, revealed, the licensed practical nurse contacted the nurse practitioner about the elevated laboratory studies received at the facility on October 8, 2025. The licensed nurse indicated, the nursing staff was waiting for a call back from the nurse practitioner about the elevated chloride, sodium and blood urea nitrogen levels (Blood urea nitrogen (BUN) is a medical test that measures the amount of urea nitrogen in your blood, which helps assess kidney function and overall health). Review of physician notes dated October 9, 2025, revealed that the nurse practitioner examined the resident at the request of the nursing staff who were reporting that Resident CL1 had poor by mouth intake, dry lips and mouth. The nurse practitioner gave an order for Intravenous hydration. The nurse was unable to insert the IV line for Resident CL1. The nurse practitioner gave an order for the resident to be sent to the hospital emergently. Interview with nurse practitioner, Employee E7, on October 21, 2025, at 2:00 p.m., confirmed that on October 9, 2025, the nurse practitioner became aware of the elevated blood levels of chloride, sodium, and blood urea nitrogen that were drawn and available for review on October 8, 2025. On October 9, 2025, the nurse practitioner ordered (IV fluids) intravenous glucose solution be placed for Resident CL1 to provide D5W (Dextrose- a form of glucose) at 80 ml/hour. Review of Resident CL1's nursing note completed by Licensed nurse, Employee E6 dated October 9, 2025, at 8:25 a.m. revealed UM (Unit Manager) received call from NP (Nurse Practitioner) regarding resident lab results. Order given to start line administer D5E @ 80ml/hr (hour). This nurse as well as another UM attempted to insert line, resident resistive to receiving line placed. Resident continuously pulled away and became combative. Nursing attempted to re-educate resident on the need of fluids and risk of refusal/ resident stated understanding and continued to pull back . HOB (Head of the bed) elevated to prevent SOB (shortness of breath). Re-position ineffective .STAT (immediate) Potassium per NP order and resident spit out medication. NP made aware of above and gave verbal order to send resident to [hospital]. Interview with the Licensed nurse, Employee E6, at 11:00 a.m., on October 21, 2025, confirmed the nursing staff were not able to follow the nurse practitioner's orders. The licensed nurse confirmed that the nurse practitioner then gave orders for Resident CL1 to be sent to the hospital emergently. Review of Resident CL1's hospital record for October 9, 2025, revealed Resident CL1 presented from the facility with hypernatremia (high sodium level in the blood) and dehydration. The facility failed to assess, monitor, and implement interventions to ensure Resident CL1 maintained optimal nutrition and hydration. This failure resulted in actual harm to Resident CL1 who was not receiving sufficient fluid and caloric intake resulting in abnormal blood values, requiring transfer to hospital and admission with diagnoses of hypernatremia and dehydration. 28 PA. Code:201.14(a)(b) Responsibility of licensee28 PA. Code: 201.18(b)(1) Management28 PA. Code:211.10(c) Resident care policies28 PA. Code:211.12(c)(d)(1)(2)(3)(5) Nursing services

Based upon review of resident records, and interviews with residents and staff determined the facility failed to follow a resident's care plan consistent with the resident's rights that meets a resident's mental and psychosocial needs by failing to ensure one resident does not receive male care givers as indicated of 15 resident records reviewed (Resident R2). Findings include:Resident R2 was initially admitted to the facility June 2019 diagnosed with post traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event).Resident R2's care plan dated September 23, 2023, for ineffective coping due to past traumatic events that triggers include male care givers. Per the sister's request is not to have a male aide.Review of documentation received from the facility stated on May 1, 2025, Resident R2 made allegations of abuse when a male aide, Employee E9 was assigned to the resident.Interview with Employee R9 on October 21, 2025, at 3:00 p.m. confirmed the aide was assigned Resident R2 on May 1, 2025, and stated he was aware Resident R2 was not to receive care from male aides. Interview with Resident R2 on October 22, 2025, at 10:00 a.m., confirmed the resident did not want male aides to assist with care. 28 Pa Cre 211.109d) Resident care policies28 PA. Code 211.12(d)(1)(5) Nursing services

Based on interviews with residents and staff, review of clinical records, facility documentation and in accordance with accepted professional standards and practices, the facility failed to maintain medical records that were accurately documented for one of 15 resident records reviewed (Resident R1).Findings include:Review of Resident R1's clinical records revealed the resident was alert and oriented and admitted to the facility on [DATE], diagnosed with atherosclerotic heart disease.Review Resident R1's nursing note dated October 13, 2025, indicated the resident said the aide pushed her while putting her in bed. The resident was noted with a large hematoma (blood leaks outside the blood vessels, usually due to injury) to her forehead and was given an icepack.Review of documentation received from the facility indicated the resident's skin was intact with no discoloration.Interview on October 22, 2025, at 4:00 p.m. unit supervisor, registered nurse, Employee E14 worked the night of the incident and assessed Resident R1 immediately afterwards. E14 confirmed the injury on the resident's forehead. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, reviews of clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one of eight residents' clinical records reviewed. (Resident R2)Findings include:Review of Resident R2's clinical record revealed the resident was admitted to the facility on July10, 2025, with diagnosis of Combined Systolic and Diastolic Heart Failure (a condition where the heart has difficulty both pumping blood out [systolic dysfunction] and filling with blood [diastolic dysfunction], Pericardial Effusion (a condition where excess fluid accumulates in the pericardium, the sac-like structure that surrounds the heart), Pleural Effusion (a condition where excess fluid accumulates in the space between the lungs [pleural cavity and the chest wall], and Thrombocytopenia (a condition characterized by a low platelet count in the blood. Platelets are essential for blood clotting, so their deficiency can lead to excessive bleeding and bruising).Review of Resident R2's clinical record revealed a form, Pennsylvania Orders for Life Sustaining Treatment (POLST), dated [DATE], that indicated the resident's code status as DNR (Do Not Attempt Resuscitation). Review of Resident R2's electronic clinical record revealed a physician order, dated [DATE], indicated; Do Not Resuscitate (DNR).Review of the Nursing Progress note for Resident R2, by a Licensed Nurse, Employee E5, dated [DATE], indicated as follows: Around 0300, during rounds, [Resident R2's] roommate notified this nurse that resident did not look well. Upon entering room, [Resident R2] was noted with slow shallow breathing. SpO2: 84 (SpO2 is oxygen saturation, it is a measurement of the percentage of hemoglobin in the blood that is saturated with oxygen, for a healthy individual, the normal SpO2 should be between 96% to 99%). [Resident R32] was given with Oxygen via mask. Nursing supervisor was called to assess resident. Before nursing supervisor could enter unit, [Resident R2] was noted with foam coming from mouth and unresponsive. Code Blue/911 was immediately called (Code Blue refers to a hospital medical emergency requiring immediate resuscitation for a patient in cardiac or respiratory arrest). CPR initiated by nursing staff until/during paramedics' arrival (CPR, or cardiopulmonary resuscitation, is a life-saving emergency procedure performed when a person's heart has stopped beating or their breathing has ceased). [Resident R2] was given 4-5 rounds of epi but was unsuccessful (epi is a medical abbreviation for epinephrine, also known as adrenaline. In a cardiac arrest, epinephrine is administered to increase blood pressure and heart rate, which helps improve blood flow to the heart and brain). TOD (Time of Death) was called by Physician. Call was placed to emergency contact. The nurse spoke with resident's sister to inform family of resident's untimely passing and for further arrangements for pick-up.On [DATE], at 1:22 p.m., interview with the Director of Nursing confirmed that the facility failed to implement the Physician Order pertaining to Resident R2's code status/ DNR status.28 Pa Code 201.18(a)(b)(1)(3) Management28 Pa Code 211.12(d)(5) Nursing services

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for eight of 35 residents reviewed (Residents R169, R91, R178, R25, R131C, R45, R199 and R110). Findings include: A review of the Food and Nutrition Services Test Tray and Accuracy Evaluation form Revised November 19, 2019, revealed that the standard for cold food is 45 degrees or less and for hot food 135 degrees or more. Interview with Resident R169 on April 7, 2025, at 10:35 a.m. revealed that he thinks that the food sucks, that it is not always hot, you should try it. Interview with Resident R91 on April 7, 2025, at 10:41 a.m. revealed that he does not like the food, that it is too soft and mushy. Interview with Resident R178 on April 7, 2025, at 10:50 a.m. revealed the meals are bad, the food is never right, doesn't taste right, it's the kitchen not the nursing staff. Interview with Resident R131 on April 7, 2025, at 11:05 a.m. revealed that the food here tastes like garbage. Interview with Resident R25 on April 7, 2025, at 11:09 a.m. revealed that they serve crappy food, it's all the same for everyone, how can that be good for you. Interview on April 7, 2025, at 11:53 a.m. Resident R45 stated that the food was not tasteful and often served cold. Interview on April 7, 2025, at 11:55 a.m. Resident R199 stated that the food was often served cold. Interview on April 7, 2025, at 1:34 p.m. Residents R110 and R106 stated that the food does not taste good and that it is often served cold. Observations during a test tray conducted on April 8, 2025, revealed that the tray cart left the kitchen at 12:08 p.m. and the last tray was passed at 12:28 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E3, revealed that the turkey was only 109 degrees, the sweet potato was only 103.5 degrees, the corn was only 116 degrees, the mixed fruit cup was 61 degrees and the skim milk was 53.5 degrees all outside the acceptable temperature range for palatability. An interview with the FSD, on April 8, 2025, at 12:35 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on the review of closed clinical records, facility policies and interview with staff, it was determined that the facility failed to ensure that an appropriate discharge was documented in the resident's clinical record for one of four closed records reviewed. (Resident R523) Findings Include: Review of Resident R523's Minimum Data Set (MDS - federally mandated resident assessment and care screening) assessment dated [DATE] revealed that the resident was discharged from the facility and the resident was not anticipated to return to the facility. It was revealed that the discharge was unplanned and the resident was discharged to the hospital. Review of clinical record for Resident R523 on April 8, 2025 revealed that there was no documentation available in the clinical record to indicate a reason for residents discharge. Review of a discharge summary completed by the nurse practitioner dated March 3, 2025 but signed as completed on April 9, 2025 revealed that resident was not seen within the 72 hours from admission, because the resident was admitted during the weekend. The resident was transferred back to the hospital before the resident was able to be assessed. Interview with the admission Director, Employee E8, on April 8, 2025 at 2:00 p.m. stated resident was admitted to the facility on [DATE] after business hours. Employee E8 stated resident was discharged to the hospital because he did not have proper insurance paperwork and insurance. Interview with the Nursing Home Administrator, on April 8, 2025 at 2:30 p.m. confirmed that the resident's transfer to the hospital was not due to imminent safety risk of the resident or medical concern. Nursing Home Administrator confirmed that the physician oversees resident's care and a physician order or notification was required prior to the transfer to the hospital. Review of clinical record for Resident R523 on April 8, 2025 revealed that there was no physician order for hospital transfer. There was no evidence in the clinical record that the physician was aware or the transfer or notified of the transfer. 28 Pa. Code 201.29(f) Resident rights 28 Pa. Code 210.25 Discharge policy 28 Pa. Code 211.5(a)(c)(3) Medical records.

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer in writing, for one of four clinical records reviewed. (Residents R136) Findings Include: Review of Minimum Data Set (MDS - federally mandated resident assessment and care screening) assessment dated [DATE] revealed that the resident was discharged from the facility and the resident was not anticipated to return to the facility. It was revealed that the discharge was unplanned and he was discharged to the hospital. Review of clinical record for Resident R523 on April 8, 2025 revealed that there was no documentation available in the resident's clinical record to indicate a reason for residents discharge. Review of a discharge summary completed by the nurse practitioner dated March 3, 2025 but was signed until April 9, 2025 revealed that resident was not seen within the 72 hours from admission, because he was admitted during the weekend. The resident as transfer back to the hospital. Further interview with the Administrator on April 8, 2025 at 2:30 p.m. confirmed that the facility failed to notify the resident/resident's representative of the transfer and reasons for the move in writing and in a language and manner they understand. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on clinical record review, review of facility policies and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of five residents reviewed (Residents R184). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate. Review of facility policy, Social Service Assessment - PASRR dated revised June 28, 2024, revealed, The PASRR Level I form is completed by the hospital, the facility, or the Area Agency on Aging (AAA) office no later than the day of admission. Family members may assist in this process. The PASRR Level I form is to be used as a worksheet. You are to make any additions or corrective changes directly on the PASRR Level I form itself. Date and initial/ sign to indicate that a change has been made to the form. Nursing Facilities are responsible to make sure the form is filled out correctly at the time of admission. Review of Resident R184's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 6, 2025, revealed that the resident was admitted to the facility on [DATE], and has diagnoses including schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things) and anxiety disorder (intense, excessive, persistent worry or fear). Review of psychiatric notes for Resident R184 revealed a progress note, dated March 28, 2025, which indicated that the resident requires antipsychotic medication for the ongoing management of schizophrenia. Review of Resident R184's PASRR Level I revealed that the facility completed it on November 2, 2023, and indicated that Resident R184 did not have a neurocognitive disorder (such as dementia) and that the resident did not have a serious mental illness diagnosis (such as schizophrenia, depression and anxiety). Interview on April 10, 2025, at 9:43 a.m. Employee E6, social worker, confirmed that Resident R184's PASRR assessment did not include the mental health diagnoses that were noted in the resident's clinical record. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.10(c) Resident care policies

Based on clinical record review and review of facility documentation, it was determined that the facility failed to developed a comprehensive care plan with measurable objectives for a resident who exhibited aggressive behaviors towards other residents for one of 35 clinical records reviewed. (Resident R325) Findings include: Review of Resident R325's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnosis of history of transient ischemic attack (mini stokes), cerebral infraction, depression (major loss of interest in pleasurable activites), schizophrenia (mental disease characterized by loss of reality), and bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy). Review of Resident R325's admission Minimum Data Set (MDS- assessment of resident needs) dated February 12, 2025 revealed that the resident had a BIMS (Brief Interview of Mental Status) score 11, which indicated moderate impairment. The resident was assessed with no upper and lower physical impairments. Review of Resident R72 's quarterly MDS dated [DATE] revealed that the resident was assessed with a BIMS of 14 which indicated that the resident was cognitive intact. Continue review of the MDS revealed that the resident had no upper or lower physical impairments. Resident R72's diagnosis included anxiety and cerebral vascular accident (stroke). Review of R325's nursing note dated March 20, 2025 at 2:36 p.m. revealed that the resident was observed with behaviors in supervised lounge area on unit. As another resident was walking by with walker, this resident stood up out of wheelchair, yelled out words in Spanish, staff went to altercation to intervene by the time staff approached residents, this resident then slapped resident that was walking by and then resident punched this resident in L (left) eye. Residents were immediately separated, full body assesment completed. Redness to L (left) eye noted, resident c/o (complain) pain, PRN (as needed) Tylenol administered Review of staff statement obtained from nurse aide, Employee E15 revealed both residents were in the TV Room where they stated arguing, that's when [Resident R325] hit [Resident R72] and [Resident R72] responded back hitting [Resident R325]. Review of Resident R46 March 2025 physician orders revealed the resident was admitted to the facility on [DATE] with the diagnoses of morbidly obesity, difficulty walking, connective communication deficit, Type 2 diabetes (failure of the body to produce insulin), anxiety, depression and post traumatic stress disorder (a mental condition that's caused by an extremely stressful or terrifying event). Review of Resident R46's incident documentation dated March 26, 2025 noted nursing observed resident getting struck in the face unprovoked by another resident. Staff immediately intervene and separated resident, supervisor was made aware, full body assessment completed, bruising to R (right) eye noted, c/o (complain) pain .Resident stated that the other resident was in his way while trying to go out for smoke break and when asked to move, stood over hitting 3-4 times in face. Review of staff statements revealed an statement from nurse aide, Employee E14 noted that Resident R325 and Resident R46 exchanged words and Resident R325 stood up and hit Resident T46 multiple times myself and other employee broke it up and he got wheeled away then he stood up and tried to fight an employee and nurses came and got the situation under control. Review of Resident R325's care plan revealed that a care plan was developed on March 21, 2025 I am potential to be physically aggressive r/t (related to) history of harm to others. The only two approaches listed to address the resident physical aggressiveness towards residents were I will be monitored by nursing staff throughout the day and I will be redirected to ensure I am not in the lounge area at same time as the other resident whom I had an altercation with. The facility failed to developed a comprehensive care plan with measurable objectives to address Resident 325's aggressive behavior towards other residents. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to revise a resident's care plans, related to accuracy of information, for one of 35 residents reviewed (Resident R184). Findings include: Review of facility policy, Care Planning Process and Care Conference dated revised March 19, 2025, revealed, Care plan development, renewal and revision will be based upon the results of the resident assessment. Review of Resident R184's care plan, dated April 3, 2024, revealed that the resident had an indwelling suprapubic catheter (a tube that has been surgically inserted into the bladder to drain urine). Review of Resident R184's Significant Change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 6, 2025, revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that the resident did not have a urinary catheter. Continued review of Resident R184's care plan, dated April 3, 2024, revealed that the resident takes anticoagulant (blood thinning) medication secondary to atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Continued review of Resident R184's Significant Change MDS, dated [DATE], revealed that the resident did not have a diagnosis of atrial fibrillation and did not take an anticoagulant medication. Further review of Resident R184's care plan, dated June 24, 2024, revealed that the resident was dependent on staff for activity participation and had diagnoses including post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and head injury. Further review of Resident R184's Significant Change MDS, dated [DATE], revealed that the resident did not have diagnoses of post-traumatic stress disorder or head injury. Interview on April 10, 2025, at 10:20 a.m. Employee E5, licensed nurse, confirmed the above findings and stated that Resident R184's care plan needed to be revised. 28 Pa Code 211.10(a) Resident care policies

Based on the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 35 residents reviewed. (Resident R175). Findings Include: Review of Resident R175's nursing notes dated March 7, 2025 revealed that unit manager spoke to resident regarding his low hemoglobin, in the past was on Epoetin alfa injection which the resident was refusing. Per resident, he would take the shot if it prevented him from going to emergency for transfusions. Physician was aware and had new order to place injection. Review of physician order for Resident R175 dated March 9, 2025 revealed an order for Epoetin Alfa-epbx Injection Solution 10000 UNIT/ML, inject 1ML subcutaneously one time a day every Tuesday Thursday and Sunday for anemia. Review of medication administration record for Resident R175 revealed that the resident did not receive the medication on March 16, 2025 and March 23, 2025. Review of practitioner progress note dated March 20, 2025 revealed that the resident was seen for discussion of lab results, and chronic disease condition. Hemoglobin trending down 7.2 on March 20, 2025. Patient agreed to Epoetin Alfa-epbx after multiple discussion with patient and nursing. Interview with Employee E9, unit manager on April 10 2025 at 12:07 p.m. confirmed that the resident missed two doses on March 16, 2025 and March 23, 2025. Employee E9 stated there was there were no documented reason for not administering the medication for these days. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, a review of facility policies and resident and staff interviews, it was determined that the facility failed to make certain the highest practicable level of pain management was maintained for two of 35 residents reviewed (Resident R9 and R132). Findings include: Review of facility policy Administering Medications revealed that Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include but not limited to chronic ulcer to the left ankle with fat layer exposed. Continued review of medical records for Resident R9 including the quarterly assessment MDS (an assessment of care needs) dated March 9, 2025, revealed a Brief Interview for Mental Status evaluation which revealed that resident had a BIMS score of 15 indicating he was cognitively intact. Interview with Resident R9 on April 7, 2025, at 11:30 a.m., revealed that the resident was rocking in pain holding his left leg and pull the bandage on the wound on his left ankle exposing an open woud that was red. He said that he is always in pain and counts on his pain medication. He said that a few weeks back they ran out of his 10 mg scheduled pain medication and he does not know how they can let this happen, that he counts on this every day and when he did not get it he really suffered only getting 5 mg pain meds for breakthrough pain. He said that this had happened on several occasions and he does not know how this could happen, that when they get down to the last 10 pills they should place the order for more. A review of Resident R9's physician orders revealed a December 28, 2024, physician's order for Oxycodone HCl 10 MG tablet, give 1 tablet by mouth every six hours for severe wound pain. A review of Resident R9's electronic medication administration record (EMAR) for March 8, 2025, revealed a 9 code, which means see nurses note, on the midnight dose, on the midnight, noon and 5 p.m. doses. Further review of the EMAR for March 9, 2025, revealed a 9 code on the midnight dose. A review of the following nurse's notes for Resident R9 revealed the following: March 8, 2025, at 1:16 a.m. for Oxycodone 10 mg was awaiting delivery from the pharmacy. March 8, 2025, at 2:25 p.m. Resident R9 approached the nursing station asking if his Oxycodone 10 mg arrived from the pharmacy. The nurse checked the narc drawer and let the resident know it had not arrived. The resident was advised that the script was faxed over to the pharmacy and that the medication should be here tonight. A review nursing notes of the March 9, 2025, at 4:29 a.m. for oxycodone 10 mg was awaiting pharmacy delivery. Interview on April 10, 2025, at 11:15 a.m. with the Director of Nursing, Employee E2, who physically checked the narc book on the unit and confirmed that the Oxycodone 10 mg medication for Resident R9 was not delivered until 5:00 a.m. on March 9, 2025. And that Resident R9 missed these four doses of the Oxycodone 10 mg. Review of Resident R132's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include but not limited to intervertebral disc degeneration of the lumbar region (a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (vertebrae), causing pain in the back or neck and frequently in the legs and arms). Continued review of medical records for Resident R132 including the quarterly assessment MDS dated [DATE], revealed a Brief Interview for Mental Status evaluation which revealed that resident had a BIMS score of 14 indicating she was cognitively intact. Interview with Resident R132 on April 7, 2025, at 12:05 p.m., during resident screening revealed that she was in pain from her bad back and her hip, and that she was still waiting for her pain medication which had run out the other day. A review of Resident R132's physician orders revealed an April 2, 2025, physician's order for Oxycodone HCl 10 MG tablet, give 1 tablet by mouth every eight hours for pain. A review of Resident R132's EMAR for Oxycodone 10 milligrams revealed a code of 9 on the following dates: April 3, 2025, at 2:00 p.m., April 4, 2025 at 10:00 p.m., April 5, 2025 at 2:00 p.m., and 10 p.m. dose, April 6, 2025, at on the 6:00 a.m., and 10 p.m.; April 7, 2027 at 6:00 a.m., 2:00 p.m. and 10:00 p.m. and on April 7, 2025, at 6:00 a.m. A review of the following nurse's notes for Resident 132 revealed the following under Oxycodone 10 mg: April 3, 2025, at 2:46 p.m. waiting for MD to fax new prescription to pharmacy, MD is aware; April 3, 2025, at 9:34 p.m. awaiting pharmacy, April 4, 2024, at 1:56 p.m. awaiting a new script; April 4, 2025, at 9:36 p.m. awaiting pharmacy; April 5, 2025, at 5:34 a.m. awaiting pharmacy; April 5, 2025, at 8:45 p.m. awaiting order from pharmacy; April 6, 2025, at 7:06 a.m. awaiting order from pharmacy; April 6, 2025, at 2:16 p.m. awaiting arrival; April 6, 2025, at 9:43 p.m. on order from pharmacy; and April 7, 2025, at 6:15 a.m. awaiting order from pharmacy. Interview on April 10, 2025, at 11:15 a.m. with the Director of Nursing, Employee E2, who physically checked the narc book on the unit and confirmed that the Oxycodone 10 mg medication for Resident 132 was not delivered until 10:00 a.m. on April 7, 2025. and that Resident R132 missed these ten doses of the Oxycodone 10 mg. 28 Pa Code:201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, review of video footage and interviews with staff, it was determined that the facility failed to ensure that one of four residents reviewed was free from verbal, physical and psychological abuse from a nursing staff. (Resident R1) This failure resulted in an immediate jeopardy situation for Resident R1 who was rough handled, yelled at with the use of profane language, struck in the chest sustaining injuries to the fourth finger on the right hand and chest area and demonstrated signs of fear when approached by nursing staff. Findings include: Review of facility policy on Abuse Prevention and Management, with revise date of September 8, 2022, revealed that under section Policy: The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation, exploitation of resident/patient property by anyone, including staff, family, friends, visitors, etc. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected and alleged resident patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes, but is not limited to, freedom from corporal punishment and involuntary seclusion. Under section Protocol: Abuse, neglect and misappropriation/exploitation of resident funds and property education is completed upon hire and at least annually for all employees. Advocacy numbers are posted within the facility. The shift supervisor is identified as responsible for immediate initiation of reporting process. The administrator, director of nursing, and risk manager, if applicable, are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation/exploitation of policy standards and procedures: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. Under section definition: The following definitions are pursuant to the Interpretive guidelines for freedom from abuse, neglect and exploitation. Physical abuse includes hitting, slapping, pinching, scratching, spitting, holding, roughly kicking, etc. It also includes controlling behavior through corporal punishment. Staff to resident abuse When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. The facility is responsible to ensure that all staff are trained and are knowledgeable and how to react and respond appropriately to resident behavior. All staff are expected to be in control of their own behavior or to behave professionally and should appropriately understand how to work with the nursing home population. Facility cannot disown the acts of staff since the facility relies on them to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. Review of facility policy on Dementia dated November 2016, reveals that under section Policy: Our main focus and the care of the resident with dementia is in functioning, not etiology or pathology. It is important to have a basic understanding of dementia and various origins and diagnosis that accompany it. However, the overall goal of our daily work is to improve its resident's function, regardless of the individual's physical and mental diagnosis. It is the responsibility of each staff member to have a sound general knowledge of what is pathologically, happening to the resident and how much medication and treatments affect them. We provide care with dignity, understanding and acceptance. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Further review of Resident R1's clinical record revealed that Resident R1 had diagnoses of General Anxiety Disorder, Cognitive Communication Deficit, Vascular Dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior), Unspecified Psychosis, Major Depressive Disorder. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated October 24, 2023, revealed that the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 2 which suggested that the resident had severe cognitive impairment. Continued review of the assessment revealed that the resident did not demonstrate any physical or verbal behavioral symptoms. Review of Nurse Practitioner's note dated December 21, 2023, time stamped at 1:37 p.m. revealed that Pt (patient) in physical altercation on locked memory unit. Pt with significant cognitive impairment and is unable to make all needs clearly known. Answers with confused conversation. Vital signs stable. Scratch to right pointer finger, and redness noted to sternum. Tender to touch upon exam. No other apparent injuries. Plan: 1: monitor VS (vital signs) every shift x 24 hours, 2: neuro checks Every 4 hours x 24 hours, 3: monitor for change in behavior. Contingency Plan: obtain CXR (chest X-ray) if anything changes. Review of clinical nurses note dated December 21, 2023, time stamped at 1:44 p.m. revealed that a police officer arrived at the facility. The Director of Nursing, Employee E2 spoke with the police officer and informed him of the details of the incident. The police officer collected copies of all statements obtained and was provided a copy of the photos of resident's chest, arm and hand. Facility will continue to monitor resident's skin for any further discoloration or bruising that may occur. Review of clinical nurses note dated December 21, 2023, time stamped at 3:53 p.m. revealed that Resident R1 was S/P (status/post) physical altercation. At approximately 12 pm staff was preparing residents for lunch. Resident R1 was noted being resistive with staff when being redirected. A CNA (nurse aide) was observed forcefully pushing resident into the dayroom and down into the chair. Staff then observed CNA punch the resident in the chest. The incident was immediately reported to the DON (Director of Nursing) 911 (Emergency Medical Services) was called and adult protective services made aware. The unit manager and the nurse practitioner assessed resident and noted with redness to upper chest area and skin tear to left 4th finger. Area cleaned and treatment applied. Resident expressed pain to chest area on assessment. PRN (as needed) pain management given and tolerated well. Observation of the Unit-D layout conducted on December 28, 2023, at 10:50 a.m. revealed that the entrance to Unit D was locked and a code was needed to open the door. Further, there was a hallway leading from the entrance of the unit towards the nurse's station. Further, at an angle to the left, the hallway continues towards the far end of Unit D. Further observation revealed a day room (resident lounge) in front of the nurse's station and another room labelled Day Room was to the right next to the nurse's station. Observation of the facility's Video footage for Unit D conducted on December 28, 2023, at 12:38 p.m. with the Maintenance Director, Employee E6, revealed that there were two video footages covering Unit D (camera #1 and camera #2). Interview with the Maintencance Director, Employee E6 revealed that one camera (camera#1 was at the end of the hallway facing towards the nurse's station and the other camera (Camera #2) was located in front on the nurse's station facing the entrance of the Unit. Further, Employee E6 revealed that there was no camera in the resident's lounge in front of the nurse's station and that there was no camera in the dayroom located next to the nurse's station. Observation of the footage from Camera #1 located on the far end of Unit-D hallway, oriented towards the direction of the nurse's station revealed that on December 21, 2023, at: 12:07 p.m. a male employee wearing a blue top who was identified by Assistant Director of Nursing as nurse aide, Employee E4, was observed coming out of a room and walking down the hall (with his back from the camera and walking away from the camera) with Resident R1. Further observation revealed that Resident R1 was right in front of nurse aide, Employee E4 and Employee E4 was holding Resident R1's arm from behind and roughly handling him and pushing him causing him to stumble. Further, Resident R1 was observed, in a half-running pace with unsteady gait while nurse aide, Employee E4 was pushing him along. Nurse aide, Employee E4 and Resident R1 were eventually observed going into a doorway which was the resident lounge. Observation of the footage from Camera #2 located in front of the nurse's station oriented towards the entrance of Unit-D revealed that on December 21, 2023, at: 12:10 p.m., a female staff member identified by the Maintenance Director, Employee E6 as nurse aide, Employee E5 taking Resident R1 by the hand to the hallway. Nurse aide, Employee E5 then and left resident in front of the nurse's station and Employee E5 walked out of view of the camera. At 12:11 p.m , two females, one wearing a beige top (identified by Employee E6 as the Nursing supervisor, Employee E7) and one wearing a gray top with a black over coat and light blue pants walked into the unit and met Resident R1 in the hallway where Employee E5 left him. Both Employee E7 and the other female, stopped on front of the Resident R1. At 12:12 p.m., nurse aide, Employee E5 returned wearing blue gloves took resident to a room (Employee E6 identified the doorway as Resident R1's room) with Nursing supervisor, Employee E7. At 12:28 p.m., Employee E5 left the unit. At 12:39 p.m., DON (Director of Nursing) Employee E2 walked into the unit. At 12:47 p.m., Employee E2 and Employee E4 was observed leaving the unit. Based on the video footage nurse aide, Employee E4 was observed passing meal trays. Nurse aide, Employee E4 was on the D-unit from 12:10 p.m. to 12:47 p.m. Review of Nurse aide, Employee E5's written statement dated December 21, 2023, revealed that Employee E5 was in the Day Room (lounge). Nurse aide, Employee E4 came in with Resident R1 and Employee E4 was yelling at Resident R1. Nurse aide, Employee E4 sat Resident R1 in a chair and punched him in the chest. He then proceeded to say I will light you the F*** Up in here! Stop playing with me! Nurse aide, Employee E4 then walked out. Nurse aide, Employee E5 got up to take a minute to process what she had just witnessed. As Employee E5 walked past Resident R1, the resident flinched and put his hands over his face. Employee E5 noticed he was bleeding from his right hand and blood was all over Resident R1's pants. Employee E5 took Resident R1 to clean him up and Employee E5 bandaged Resident R1's hand up and informed the charge nurse of what she saw. Employee E5 then took a 10-minute break to collect her thoughts and bringing her anger down and reported the incident to the DON (Director of Nursing), Employee E2. Review of Licensed nurse, Employee E8's witness statement dated December 21, 2023, revealed that at approximately at 11:30 a.m. on December 21, 2023, Employee E8 saw nurse aide, Employee E4 trying to guide Resident R1 out of the hallway into the day room by his arm. Resident R1 was screaming and resisting. Nurse aide, Employee E4 was trying to move Resident R1 so that the maintenance staff can move the beds. Employee E4 was able to get the patient inside the day room by holding him. A few minutes later Licensed nurse, Employee E8 saw nurse aide, Employee E5 coming out of the same day room, and she stated that the other nurse aide did something to Resident R1, but she was not specific. Resident R1 had blood on his pants. Nurse aide, Employee E4 walked past licensed nurse, Employee E8 and stated: There patients are acting new today because there's new stuff here. Like I won't F*** them up! Telephone interview with Nursing Supervisor, Employee E7 conducted on December 28, 2023, at 11:22 a.m. revealed that on December 21, 2023, at approximately 12:00 p.m. to 12:30 p.m. Employee E7 went out of the facility to get food. Further Nursing Supervisor, Employee E7 revealed that during her break at 12:37 p.m. Employee E7 received a call from the Director of Nursing instructing her to return to the facility because of the abuse incident. Employee E7 walked into the building at approximately 12:50 p.m. to 12:55 p.m. Employee E7 saw nurse aide, Employee E4 sitting in the nursing office. Further, interview with Nursing Supervisor, Employee E7 revealed that the abuse was not reported to her and that she didn't know about the abuse until Employee E2 called her and informed her about it. Telephone interview with Licensed nurse, Employee E8 conducted on December 28, 2023, at 1:01 p.m revealed that Employee E8 was working on Unit-D on December 21, 2023. Further Employee E8 revealed that he was on his first day of orientation on December 21, 2023, and that he didn't know the staff and residents. Further interview with Licensed nurse, Employee E8 revealed that he was not aware of what happened until the supervisor came to tell him. Further, Employee E8 revealed that nurse aide, Employee E5 did not report to him that a resident was abused by a staff member. Further Employee E8 revealed that he knew something happened because he can hear commotion but wasn't sure what it was. He did not witness nurse aide, Employee E4 hit Resident R1. Interview with Nursing Home Administrator, Employee E1 conducted on December 28, 2023, at 9:35 a.m. confirmed that nurse aide, Employee E4 struck Resident R1 on the chest on December 21, 2023, and that Employee E4 had since been terminated. Interview with Assistant Director of Nursing, Employee E3 conducted on December 28, 2023, at 9:55 a.m. confirmed that nurse aide, Employee E4 struck Resident R1 on the chest on December 21, 2023. Further Employee E3 also revealed that nurse aide, Employee E4 handled Resident R1 roughly and pushing Resident R1 while he was taking him to the lounge where Employee E4 was witnessed striking Resident R1 after. Further interview with Assistant Director of Nursing, Employee E3 revealed that Resident R1 sustained redness on his chest area. Further Employee E3 produced and showed surveyor a photo from Employee E3's telephone of a person's chest with redness on it. Employee E3 identified the photo as that of Resident R1's chest taken after Resident R1 was alleged struck by Employee E5 on the chest. Nurse aide, Employee E5 was called on December 28, 2023, at 10:17 p.m. via telephone to conduct a telephone interview. A message was left on Employee E5's voicemail requesting for her to return the call. No returned called was received. The above investigation revealed that Resident R1was verbally abused by nurse aide, Employee E4 as evidenced by Employee E4's using profane language directed towards Resident R1 as witnessed by Employee E5. Resident R1 was handled roughly by nurse aide, Employee E4 and was subsequently struck by Employee E4 in the chest. Resident R1 sustained injuries to the fourth finger on his right hand and chest area as evidenced by the redness observed during an examination following alleged physical abuse. Resident R1 also showed signs of pain to the chest area as evidence by tenderness of the area when touched during physical examination. Further, although Resident R1 was not able to communicate due to his cognitive deficits, Resident R1 showed signs of fear after the alleged physical abuse as evidenced by his reaction as described by nurse aide, Employee E5 in her witness statement as Employee E5 walked past Resident R1 the resident flinched and put his hands over his face. Based on the above findings, an Immediate Jeopardy was identified to the Nursing Home Administrator on January 4, 2024, at 9:15 a.m. for failure to ensure that a resident was free from verbal, physical and psychological abuse from a nursing staff. The Immediate Jeopardy template was provided to the Administrator and Director of Nursing on January 4, 2024 at 9:33 a.m. and an immediate action plan was requested. On January 4, 2024, at 3:54 p.m. the facility provided the following corrective action plan: Facility will ensure that all residents are protected from verbal, physical and psychological abuse. 1. The resident was immediately removed from the area and was taken to the day room across from the nurses station to be assessed for any injuries. Resident was medicated with pain medication as needed and left fourth finger skin tear was treated and bandaged. 2. DON was notified of abuse, she informed nursing staff to watch the perpetrator until assessment was completed. Perpetrator (nurse aide) was escorted off the unit and then escorted out of the facility and then terminated. Statements received from staff who witnessed the abuse incident as part of the investigation. 3. All staff will be educated on our abuse prevention policy prior to the start shift including recognizing and reporting of abuse. 100% education to all staff will be completed today 1-4-24 either in person or by phone. 4. All newly hired employees will attend general Orientation prior to working on the unit and are educated on abuse prevention and reporting abuse immediately. All new hires will be assigned to a mentor on the unit for 3 days and competency will be completed. No new hires since the occurrence on 12-21-23. 5. Agency staff receive orientation to include abuse training prior to the start of shift. 6. Complete House audit 100% conducted today 1-4-24 by nursing and social service department to ensure residents have not experienced abuse or any signs of physical or psychological abuse. 7. Random resident interviews/skin checks by social service or nursing staff will be conducted daily x1 week then weekly x 4 weeks and then monthly x 2 months. To ensure there are no signs of abuse. 8. Random staff will be given competencies prior to their shift to complete on Abuse Prevention/Reporting to ensure staff understand importance of abuse prevention and reporting. 9. Audits will be reviewed at Quality Assurance monthly by Nursing and Social Service to determine if further action is needed. On January 5, 2024, at 3:37 p.m. a second telephone interview was attempted with nurse aide, Employee E5 in regard to the incident that occurred with Resident R1 on December 21, 2023. Attempt was successful and Employee E5 stated that day she was working a double and she was inside of the day room that the resident watch television in. Employee E5 stated she was in the day room doing paperwork on her IPAD, because they bring in their own Ipad's to do paperwork as the facility computers are slow. Employee E5 stated that she heard some commotion in the hallway and she saw nurse aide Employee E4 come into the day room with Resident R1 and forcefully sat him down into the chair. Employee E5 stated that Employee E4 then began to doink Resident R1 in his head I will light you the F*** Up in here! Stop playing with me. Employee E5 stated she got up and said something to Employee E4 and Employee E4 started to pass out the lunch trays. Employee E5 then stated she got up to go to Resident R1 and he flinched and put his hands to his face. Employee E5 stated that she was able to talk with him and get him out of the day room. Once she got Resident R1 out of the day room she proceeded to talk the Resident R1 and she went to take him to the shower room to clean him off. Employee E5 stated Employee E7 was walking back and saw I was upset and stuff but I told her to give me a few minutes and Employee E7 said okay. Employee E5 stated she was in the shower room cleaning up Resident R1 and Employee E7 was initially outside the shower room door waiting for her. Employee E5 stated she was talking to Resident R1 to calm him down and bandaged his finger which took approximately twenty minutes. After coming out of the shower room Employee E5 stated Employee E7 was no longer there so she put Resident R1 in the other day room across from the nurse's station and asked Employee E8 to watch the resident. Employee E5 stated she then went upstairs to calm down after what she had just saw and as she was going to go outside Employee E23 asked what was wrong and said she would go report for me. I then went outside to cool down and a few minutes later the Director of Nursing Employee E2 and nurse aide Employee E23 came outside to get me. I then came back in and spoke to the Director of Nursing and wrote my statement. The implementation of the action plan was verified on January 5, 2024. Interviews conducted with facility staff from various department on January 5, 2024, reported they had all been in-serviced on the facility resident abuse prohibition policy, recognizing the signs of resident abuse, to whom to immediately report an allegation of resident abuse. The Immediate Jeopardy was lifted on January 5, 2023, at 4:08 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on record review and staff interview, it was determined that the facility failed to prevent resident to resident physical abuse between Resident R191, Resident R22 and Resident R86 which resulted in actual harm to Resident R22 who sustained a scratch under the left eye, chin and right arm, Resident R191 sustaining a scratch to left side of nose, gums, and bottom lip and Resident R86 sustaining a bruised forehead and a bruised right eye and lip for three of 38 residents reviewed. (Resident R191, Resident R22 and Resident R86) Findings include: Review of Resident R191's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R191's quarterly Minimum Data Set (MDS-a federally required assessment completed at a specific interval) dated March 4, 2022, revealed that resident had a BIMS (Brief Interview Of Mental Status) score of 3 which indicated that Resident R191 was cognitively impaired. Review of Resident R 22's annual MDS dated [DATE], revealed a BIMS summary score of 3 which indicated that the resident was cognitively impaired. The MDS noted that the resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R191's nursing note dated May 1, 2022, at 8:53 p.m. revealed that at approximately 8:33 p.m. Resident R191 was involved in a resident to resident altercation. Resident R191 was found in her room with blood coming from her mouth and side of nose. The resident's skin was assessed, and it was noted with a scratch to left side of nose, gums, and bottom lip. The nursing notes further stated that the resident remained in day room under staff supervision at this time. The resident denied having any pain or discomfort. Review of Resident R22's nursing note revealed that on May 1, 2022, at around 8:30 p.m., Resident R22 was involved in a resident-to-resident altercation with Resident R191. Resident R22 was walking towards the nurse's station with scratch under the left eye. The resident's skin was assessed, and more scratches were noted under the resident chin and a scratch on her right arm. Resident R22 remained in the day room under staff supervision. Review of the facility investigation report dated May 1, 2022, revealed that Resident R22 stated that she walked into the Resident R191's room and Resident R191 hit Resident R22 in the face. The investigation report noted that Resident R22 was confused but oriented to person. Review of witness statement dated May 2, 2022, completed by Licensed nurse, Employee E8, revealed that nursing assistant, Employee E9, reported to her that Employee E9 found Resident R191 was in her room with blood on her nose and lip and that Resident R22 was also in the room and that both residents were separated. Review of the facility investigation report provided by Director of Nursing (DON) on October 26, 2022, revealed that Resident R191 was confused but oriented to person and situation. Resident R191 stated that She (Resident R22) stole my clothes, so I beat her up. Review of Resident R191's care plans revealed that a care plan was initiated on March 3, 2022, for the potential to demonstrate physical behavior related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of resident's care plan revealed that it was not until May 9, 2022, that an intervention was developed for staff to intervene if the resident became agitated and before the agitation escalated. The resident was to be guided away from the source of distress, engage in conversation and staff to walk calmly away and reapproached. Further review of Resident R191's clinical record revealed that on August 11, 2022, at 6:57 a.m. the nurse was called to resident's room by aide due to hearing another resident screaming. Aide saw [Resident 191] standing over another resident [Resident R86] that wandered into [Resident R86] . room. Residents were redirected. Skin tear observed to resident's right hand and left forearm. Resident was cleaned up. Review of Resident R86's clinical record revealed a nursing note dated August 11, 2022, at 3:45 a.m. that nurse was called to Resident R191's room by aide upon hearing resident screaming. Resident R191 entered another resident's room at approx. 3:00 a.m. while wandering hall. Incident was not witnessed but nurse noticed scratch to resident's left cheek. [Resident R191] refused to stay in her own room and continued to wander halls trying to go in other resident's rooms throughout entire shift. Review of investigation report dated August 11, 2022, provided by DON on October 26, 2022, revealed that Resident R191 was involved in a resident-to-resident altercation with another resident (Resident R86). The predisposing factor was poor lighting. Review of Resident R191's clinical record revealed that there was no evidence that Resident R191's behavior care plan was revised with new interventions to prevent Resident R191 from physically abusing other residents after the incident of August 11, 2022, when Resident R191 in the middle of the night scratched the face of Resident R86. Review of Resident R191's nursing notes dated August 19, 2022, at 2:40 p.m. revealed that Resident R191 was involved in an altercation with another Resident R86. A one inch by one inch skin tear noted on Resident R191's right forearm .skin tear dressed with normal saline, Xeroform and cling dressing. Review of Resident R86's nursing note dated August 19, 2022, at 2:32 p.m. revealed that Resident R86 was involved in an altercation with another resident (Resident R191); removed from other individual. Refused vital signs, no injuries noted. Review of Resident 86's quarterly MDS dated [DATE], revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had moderate impairment for decision making. Review of incident report for Resident R191 dated August 19, 2022, revealed that Resident R191 was oriented to person and predisposing environmental factors were noise and crowding. Review of Resident R191's behavior care plan revealed that it did not have any new interventions developed after the incident of August 19, 2022, to prevent the resident from physically abusing other residents. Further review of Resident R191's clinical record revealed no documented evidence that psychiatric or psychogeriatric consultations were provided to aide in providing services and interventions to assist with the resident aggressive behaviors. Review of Resident R191 nursing note dated October 22, 2022, at 9:40 p.m. revealed that resident had a third resident to resident altercation with Resident R86. Nursing note indicated that nurse was called to resident's room by nursing assistant to assist with a resident to resident altercation. Resident R191 stated She was in my bed and I wanted her out. Resident was redirected, nurse assessed resident for injury reopened skin tear to left forearm, bruising to forehead and bruising to right eye and lip. First aid administered skin tear cleansed with normal saline solution, patted dry covered with gauze and wrapped with kling. Spoke with resident's power of attorney and . nurse on call was made aware. Resident denied any pain when asked and tolerated all medications well this shift no signs or symptoms of any distress present. Review of resident R 86's record revealed that she did not have any injuries. Review of Resident R22's current care plan revealed that the resident was diagnosed with vascular dementia. Review of the resident's care plan revealed a care plan for the resident to have the potential to demonstrate physical behaviors related to dementia. There were no goals and interventions developed until October 24, 2022, which included for the resident not to harm self or other and seek out staff when agitation occurs. Interview with DON employee E 2 on October 26, 2022, at approximately 10:15 a.m. revealed that the staff did not document their intervention and that moving forward the staff will improve their documentation. The facility failed to prevent resident to resident physical abuse between Resident R191, Resident R22 and Resident R86 which resulted in actual harm to Resident R22 who sustained a scratch under the left eye, chin and right arm, Resident R191 sustaining a scratch to left side of nose, gums, and bottom lip and Resident R86 sustaining a bruise forehead and a bruise right eye and lip. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 2101.29(j) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on record review and staff interview, it was determined that the facility failed to ensure that Resident R191, Resident R22 and Resident R86 who were diagnosed with dementia were provided timely interventions to ensure their safety after displaying aggressive behavior which resulted in actual harm to Resident R191 and Resident R22 sustaining multiple scratches on their faces and Resident R86 sustaining a bruise forehead and a bruise right eye and lip for three of 38 residents reviewed. (Resident R191, Resident R22 and Resident R86) Findings include: Review of Resident R191's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R191's quarterly Minimum Data Set (MDS-a federally required assessment completed at a specific interval) dated March 4, 2022, revealed that resident has a BIMS (Brief Interview Of Mental Status) score of 3 which indicated that Resident R191 was cognitively impaired. Review of Resident R 22's annual MDS dated [DATE], revealed a BIMS summary score of 3 which indicated that resident was cognitively impaired. The MDS noted that the resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R191's nursing note dated May 1, 2022, at 8:53 p.m. revealed that at approximately 8:33 p.m. Resident R191 was involved in a resident to resident altercation. Resident R191 was found in her room with blood coming from her mouth and side of nose. The resident's skin was assessed, and it was noted with a scratch to left side of nose, gums, and bottom lip. The nursing notes further stated that the resident remained in day room under staff supervision at this time. The resident denied having any pain or discomfort. Review of Resident R22's nursing note revealed that on May 1, 2022, at around 8:30 p.m., Resident R22 was involved in a resident-to-resident altercation with Resident R191. Resident R22 was walking towards the nurses station with scratch under the left eye. The resident's skin was assessed, and more scratches were noted under the resident chin and a scratch on her right arm. Resident R22 remained in the day room under staff supervision. Review of the facility investigation report dated May 1, 2022, revealed that Resident R22 stated that she walked into the Resident R191's room and Resident R191 hit Resident R22 in the face. The investigation report noted that Resident R22 was confused but oriented to person. Review of witness statement dated May 2, 2022, completed by Licensed nurse, Employee E8, revealed that nursing assistant, Employee E9, reported to her that Employee E9 found Resident R191 was in her room with blood on her nose and lip and that Resident R22 was also in the room and that both residents were separated. Review of the facility investigation report provided by Director of Nursing (DON) on October 26, 2022, revealed that Resident R191 was confused but oriented to person and situation. Resident R191 stated that She (Resident R22) stole my clothes, so I beat her up. Review of Resident R191's care plans revealed that a care plan was initiated on March 3, 2022, for the potential to demonstrate physical behavior related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of resident's care plan revealed that it was not until May 9, 2022, that an intervention was developed for staff to intervene if the resident became agitated and before the agitation escalated. The resident was to be guided away from the source of distress, engage in conversation and staff to walk calmly away and reapproached. Further review of Resident R191's clinical record revealed that on August 11, 2022, at 6:57 a.m. the nurse was called to resident's room by aide due to hearing another resident screaming. Aide saw [Resident 191] standing over another resident [Resident R86] that wandered into [Resident R86] . room. Residents were redirected. Skin tear observed to resident's right hand and left forearm. Resident was cleaned up. Review of Resident R86's clinical record revealed a nursing note dated August 11, 2022, at 3:45 a.m. that nurse was called to Resident R191's room by aide upon hearing resident screaming. Resident R191 entered another resident's room at approx. 3:00 a.m. while wandering hall. Incident was not witnessed but nurse noticed scratch to resident's left cheek. [Resident R191] refused to stay in her own room and continued to wander halls trying to go in other resident's rooms throughout entire shift. Review of investigation report dated August 11, 2022, provided by DON on October 26, 2022, revealed that Resident R191 was involved in a resident-to-resident altercation with another resident (Resident R86). The predisposing factor were poor lighting. Review of Resident R191's clinical record revealed that there was no evidence that Resident R191's behavior care plan was revised with new interventions after the incident of August 11, 2022, when Resident R191 in the middle of the night scratched the face of Resident R86. Review of Resident R191's nursing notes dated August 19, 2022, at 2:40 p.m. revealed that Resident R191 was involved in an altercation with another Resident R86. A one inch by one inch skin tear noted on Resident R191's right forearm .skin tear dressed with normal saline, Xeroform and cling dressing. Review of Resident R86's nursing note dated August 19, 2022, at 2:32 p.m. revealed that Resident R86 was involved in an altercation with another resident (Resident R191); removed from other individual. Refused vital signs, no injuries noted. Review of Resident 86's quarterly MDS dated [DATE], revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had moderate impairment for decision making. Review of incident report for Resident R191 dated August 19, 2022, revealed that Resident R191 was oriented to person and predisposing environmental factors were noise and crowding. Review of Resident R191's behavior care plan revealed that it did not have any new interventions after the incident of August 19, 2022. Further review of Resident R191's clinical record revealed no documented evidence that psychiatric or psychogeriatric consultations were provided to aide in providing services and interventions to assist with the resident aggressive behaviors. Review of Resident R191 nursing note dated October 22, 2022, at 9:40 p.m. revealed that resident had a third resident to resident altercation with Resident R86. Nursing note indicated that nurse was called to resident's room by nursing assistant to assist with a resident to resident altercation. Resident R191 stated She was in my bed and I wanted her out. Resident was redirected, nurse assessed resident for injury reopened skin tear to left forearm, bruising to forehead and bruising to right eye and lip. First aid administered skin tear cleansed with normal saline solution, patted dry covered with gauze and wrapped with kling. Spoke with resident's power of attorney and . nurse on call was made aware. Resident denied any pain when asked and tolerated all medications well this shift no signs or symptoms of any distress present. Review of resident R 86's record revealed that she did not have any injuries. Review of Resident R22's current care plan revealed that the resident was diagnosed with vascular dementia. Review of the resident's care plan revealed a care plan for the resident to have the potential to demonstrate physical behaviors related to dementia. There were no goals and interventions developed until October 24, 2022, which included for the resident not to harm self or other and seek out staff when agitation occurs. Interview with DON employee E 2 on October 26, 2022, at approximately 10:15 a.m. revealed that the staff did not document their intervention and that moving forward the staff will improve their documentation. The facility failed to ensure that Resident R191, Resident R22 and Resident R86 who were diagnosed with dementia were provided timely interventions to ensure their safety after displaying aggressive behavior which resulted in actual harm to Resident R191 and Resident R22 sustaining multiple scratches on their faces and Resident R86 sustaining a bruise forehead and a bruise right eye and lip. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 2101.29(j) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure that adequate assistance was utilized during the transfer of a resident resulting in actual harm of a skin tear requiring 12 sutures for one of 41 residents reviewed (Resident R121) and failed to ensure a resident was free of accident hazards regarding the administration of oral glucose and applesauce to an unconscious resident for one of 41 residents reviewed (Resident R111). Findings include: The Transfer Activities policy dated 7/19/18, revealed that staff should obtain assistance for a safe transfer if needed and/or documented. Review of Resident R121's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident R121's Annual Minimum Data Set assessment (MDS-a periodic assessment of care needs) with an assessment reference date of 8/24/18, identified transfer use (how a resident moves between surfaces including to or from the bed, chair, wheelchair, and standing position) as requiring extensive assistance (resident involved in activity, staff provide weight-bearing support) of at least two persons. Review of Resident R121's plan of care dated 5/17/18, indicated that for transfers the resident required the use of a Hoyer lift (a type of mechanical lift), but was revised on 8/27/18 (the day of the skin tear incident) to state that an assist of two persons was required for transfers. The Director of Nursing confirmed that the Kardex (a form of relaying information to staff) used by the nurse aides stated that Resident R121 was to be transferred with assist of two staff and with the Hoyer lift. Review of information dated 8/27/18, submitted by the facility dated 8/28/18, at 12:52 p.m. revealed an event that had occurred on 8/27/18, at 9:30 a.m. The report revealed that Nurse Aide (NA), Employee E6, attempted to transfer Resident R121 from the bed to the wheelchair without additional staff assistance and the use of a Hoyer lift that caused serious physical injury. The information submitted by the facility, identified above, reported by the Director of Nursing (DON), stated that an aide was transferring Resident R121 independently into his wheelchair from bed. A signed witness statement dated 8/27/18, revealed the following: NA Employee E6 was transferring the resident from his/her bed to the wheelchair. Resident R121's foot was twisted and stuck under the wheel of his wheelchair. NA Employee E6 removed Resident R121's foot from under the wheel and noticed a lot of bleeding. A progress note dated 8/27/18, at 1:33 p.m. revealed that a skin assessment was completed and Resident R121's right lower extremity had a skin tear measuring 10 x 0.5 centimeters. Resident R121 was sent to the emergency room at 1:00 p.m. on 8/27/18. A progress note dated 8/27/18, at 7:15 p.m. stated that Resident R121 returned to the facility with 12 sutures to the right lower extremity. The facility failed to maintain a safe environment and did not properly transfer a resident at risk for injury that resulted in actual harm to the resident who suffered a skin tear that required 12 sutures. Review of Resident 111's clinical record revealed the resident had a [DIAGNOSES REDACTED].) Review of Resident 111's progress notes revealed a nurse's note dated (MONTH) 18, (YEAR), which stated At (5:00 a.m.), resident was noted with blood sugar of 50 (normal is 70-120). Resident was unconscious, not responding to tactile touch or calls. Applesauce and oral glucose gel (a sugary substance given to raise blood sugar) was given with no good result when rechecked at 5:20 am. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 24, (YEAR), at 3:18 p.m. confirmed that giving Resident 111 applesauce and oral glucose gel while the resident was unconscious was an accident hazard to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/10/17, 09/01/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 08/10/17, 09/01/16 28 Pa Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/10/17, 09/01/16 28 Pa. Code 211.12(c) Nursing services Previously cited 08/10/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/13/18, 08/10/17, 01/06/17, 09/01/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 08/10/17, 01/06/17

Based on observations, clinical record review, staff interviews and review of facility policy and procedure, it was determined that the facility failed to obtain, follow and/or clarify physician's orders for medication administration, physician consultations and hospice service communications for five of 30 residents reviewed (Resident R56, R76, R79, R91, and R128). Findings include: Review of the facility's policy and procedure titled, Medication Administration, revised May 1, 2011, revealed that, if there is a discrepancy, check the original physician's order and notify the pharmacy. Do not give the medication until clarified. Review of Resident R76's physician's order sheet, dated June 2015, revealed that the resident was diabetic and was to receive [MEDICATION NAME], 8 units subcutaneous (fast acting meal time insulin) subcutaneously (injected under the skin) with meals. Observation of Resident R76, during medication pass at 8:30 a.m., on June 10, 2015, with Employee E3, a Licensed Nurse, revealed that blood sugar monitoring was completed at 8:40 a.m. with a result of 90 ml/dl. (milliliter per deciliter). Employee E3 did not administer the insulin as ordered. There was no physician's order or parameters to hold the insulin. Review of Resident R79's clinical record revealed that starting on May 4, 2015, the resident was receiving hospice (end of life) services for senile degeneration of the brain. Further review of the clinical record revealed that there was no coordinated plan of care between the facility and the hospice agency to be responsive to the unique needs of the resident and the expressed desire for hospice care. An interview with Employee E7, a Licensed Nurse, on June 12, 2015, confirmed this finding. A review of Resident R56's Minimum Data Set assessment (MDS - assessment of care needs) dated April 20, 2015, indicated that the resident had modified independence with decision making and disorganized thinking. The assessment also indicated that this resident was always incontinent of bowel. Clinical record documentation dated February 25, 2015, indicated that this resident was experiencing loose, foul smelling stools. The nursing progress note for February 25, 2015, indicated that the physician had ordered [MEDICATION NAME] (a medication used to treat infections of the abdomen) and that a [MEDICATION NAME] (the practice that specializes in the digestive system) evaluation be completed for Resident R56. There was no documentation to indicate that the [MEDICATION NAME] consult was scheduled or completed for the resident. This was confirmed during an interview with the B Unit Manager, Employee E7, at 10:30 a.m., on June 11, 2015. A review of Resident R56's bowel record for May 28, 2015 through June 11, 2015, revealed that Resident R56 continued to have loose stools documented by the nursing staff for May 28, 2015, June 1, 2015, June 3, 2015, June 4, 2015, June 6, 2015 and June 7, 2015. A review of Residents R91's MDS assessment dated [DATE], indicated that the resident was independent with decision making. The assessment also indicated that this resident had a [DIAGNOSES REDACTED]. An interview with Resident R91, on June 10, 2015, at 10:30 a.m., revealed that this resident tries to limit high potassium foods in her diet. On May 29, 2015, the physician ordered a laboratory study for a potassium level. On May 29, 2015, the potassium level was elevated at 5.7 mEq/l (normal range 3.5 to 5.0 mEq/l). The physician gave orders for the nursing staff to administer [MEDICATION NAME] (a medication that removes potassium in the intestine). The physician also directed the staff to recheck the blood potassium level on May 30, 2015. There was no laboratory study completed as ordered on May 30, 2015. This was confirmed with Employee E7, at 1:00 p.m., on June 10, 2015. A nephrologist (a physician who specializes in the care of the kidneys) evaluated Resident R91 on February 2, 2015. The consulting physician requested that Resident R91 be weighed every two weeks. If the results of the weights were greater than 5 pounds, the nephrologist requested to be notified by the facility. A review of Resident R91's weight record for February through June 2015, revealed that this resident experienced an eighteen pound weight gain over six months: January 1, 2015 - 457 pounds, May 4, 2015 - 467 pounds and June 1, 2015 - 475 pounds. There was no documentation to indicate that the physician or consulting physician had been notified of the resident's weight gain. This was confirmed during an interview with Employee E7, at 11:00 a.m., on June 10, 2015. Review of Resident R128's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's MDS, dated [DATE], revealed that the resident was moderately impaired in decision making skills. A review of the physician's orders dated March 4, 2015, revealed an order for [REDACTED]. Observations of the activities of daily living sheets did not appear that the resident was receiving showers two times a week as the resident was supposed to be getting. A review of the Medication Administration Record [REDACTED]. No other entries were noted for March. A review of the MAR for April 2015 and May 2015, revealed that no [MEDICATION NAME] was given as ordered. A review of the June 2015, MAR indicated [REDACTED]. An interview with Employee E9, a Licensed Nurse, on June 11, 2015, at 1:00 p.m., confirmed that the facility did not follow the physician's order for [MEDICATION NAME]. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 10/1/13, 9/11/14, 12/9/14. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/1/13, 7/15/14, 9/11/14, 12/9/14, 1/27/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/27/13, 10/1/13, 10/24/13, 7/15/14, 9/11/14, 12/9/14, 1/27/15.

Based on clinical record review, staff interview and review of facility documentation, it was determined that the facility failed to maintain a safe environment and failed to provide adequate supervision and fall interventions to prevent accidents for one of 30 residents reviewed that resulted in actual harm (Resident R79). Findings include: Review of Resident R79's Minimum Data Set assessment (MDS - periodic assessment of care needs) dated May 15, 2015, revealed the [DIAGNOSES REDACTED]. The MDS also revealed that the resident does not ambulate, needs extensive assistance with care needs and was on hospice (end of life care) services. Observation of Resident R79 on June 11, 2015, revealed that the resident was in bed with side bolsters (a restraint free wedge device for a bed), a helmet, bilateral floor mats (thin mats placed on the floor on either side of the bed to help prevent serious injury from a fall) and a bed alarm (a sensor pad for detection of a resident getting out of bed). Review of the facility's documentation related to Resident R79's consecutive fall investigations, beginning on January 18, 2015, at 8:49 p.m., revealed that while in the dayroom, the resident fell out of the wheelchair to the floor. The resident hit the table, sustaining a head laceration (a deep cut to the skin). The resident was sent to the hospital with the [DIAGNOSES REDACTED]. Five days later, on January 23, 2015, at 11:20 p.m., the resident had another fall in the dining room while trying to get up and developed a large hematoma (bleeding under the skin) on the left side of the head and was sent to the hospital. Eight days later on January 31, 2015, at 4:00 a.m., clinical documentation revealed that the resident was found on the floor with bleeding from the right side of the head and was sent to the hospital with the [DIAGNOSES REDACTED]. Review of Resident R79's nursing progress notes, following this last fall with injury on January 31, 2015, revealed that the resident was to be on one-to-one supervision at all times and was to wear a helmet at all times. A nursing progress note dated February 2, 2015, revealed that the helmet was not available yet. Review of a PB22 (Provider Bulletin 22 - a report for investigation of alleged neglect which is reported to the state agency) dated February 11, 2015, for Resident R79, revealed that on February 10, 2015, at 11:31 p.m., ten days after the previous fall, the charge nurse heard a loud noise coming from the dayroom. Upon the nurse's arrival, Resident R79 was found on the floor with a hematoma on the right side of the head and was sent to the hospital. Further review of the PB22, revealed that the staff working the 3-11 shift stated that she had reported off and the 11 to 7 staff member was in the day room. The nurse aide on 11-7 shift stated that she left the dayroom and did not attempt to find coverage during that time. The action left the resident alone in the day room, without the one-to-one coverage. Review of a nursing progress note dated February 13, 2015, revealed that Resident R79 was readmitted to the facility with the [DIAGNOSES REDACTED]. The facility failed to provide the interventions of one-to-one supervision intended to help prevent a fall and use of a helmet that resulted in actual harm to the resident. Observation of the C Unit on June 10, 2015, at 11:00 a.m., revealed an unlocked, clean utility closet. Inside the closet there was one bottle of True Clean cleaning product and one bottle of True Clean Pinex deodorizing pine cleaner. The C Unit is a locked dementia unit with multiple residents who both have dementia and are ambulatory. Interview with Employee E9, a Licensed Nurse, on June 10, 2015, confirmed that the clean utility closet door should have been locked. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 10/1/13, 7/15/14, 9/11/14. 28 Pa. Code 201.14(a)Responsibility of licensee. Previously cited 9/11/14, 12/9/14, 1/27/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/1/13, 9/11/14, 12/9/14, 1/27/15. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/11/14, 12/9/14. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/11/14, 12/9/14. 28 Pa. Code 211.12(d)(1)(5)Nursing services. Previously cited 10/1/13, 7/15/14, 9/11/14, 12/9/14, 1/27/15.

Based on a clinical record review, observations, facility documentation and resident and staff interviews, it was determined that the facility failed to provide residents with sufficient fluid intake to maintain proper hydration and health for three of five residents reviewed (Residents CL1, R4 and R5), resulting in actual harm for one resident (Resident CL1). Findings include: Review of the clinical record for Resident CL1, revealed an admission physician's orders [REDACTED]. Further review of the clinical record revealed an Initial Nutrition Assessment, dated December 12, 2014, which indicated Resident CL1 weighed 134 pounds (lbs.) and was 68 inches tall and should receive 1830 milliliters (ml, a unit of fluid measurement) of fluids a day and a range of 1830 - 2135 calories a day in order to maintain ideal body weight and good health. Further review of the Initial Nutrition Assessment indicated that Resident CL1 was at high nutritional risk and therefore superfoods (foods with a high calorie count) would be added to all meals along with snacks between meals and indicated the resident would continue to be monitored for intake closely and re-evaluated as needed. Review of the Medication Administration Record [REDACTED]. Review of the facility document titled, "Meal and Snack Intake" (documentation of all fluid and food intake) for Resident CL1, indicated the following amounts of fluid intake from the time of admission (December 10, 2014) until discharge (December 25, 2014): December 10, 2014 - 390 ml of fluid out of the 1830 ml needed. December 11, 2014 - 1140 ml of fluid out of the 1830 ml needed. December 12, 2014 - 600 ml of fluid out of the 1830 ml needed. December 13, 2014 - 480 ml of fluid out of the 1830 ml needed. December 14, 2014 - 800 ml of fluid out of the 1830 ml needed. December 15, 2014 - 1360 ml of fluid out of the 1830 ml needed. December 16, 2014 - 320 ml of fluid out of the 1830 ml needed. December 17, 2014 - 175 ml of fluid out of the 1830 ml needed. December 18, 2014 - 340 ml of fluid out of the 1830 ml needed. December 19, 2014 - 140 ml of fluid out of the 1830 ml needed. December 20, 2014 - 300 ml of fluid out of the 1830 ml needed. December 21, 2014 - 600 ml of fluid out of the 1830 ml needed. December 22, 2014 - 50 ml of fluid out of the 1830 ml needed. December 23, 2014 - 0 ml of fluid out of the 1830 ml needed. December 24, 2014 - 0 ml of fluid out of the 1830 ml needed. December 25, 2014 - 0 ml of fluid out of the 1830 ml needed. An interview with Employee E3, a Registered Dietician, on January 26, 2015, at 1:05 p.m., confirmed that from December 10, 2014 to December 25, 2014, there was no evidence that the resident received the amount of fluid that was identified to sustain health/hydration, or that any new interventions were initiated to increase Resident CL1's fluid intake as identified in the nutrition assessment of December 12, 2014. Review of Resident CL1's nursing progress notes dated December 23, 2014, timed at 11:26 p.m., indicated that Resident CL1 was very confused. Further review of the progress notes indicated that no nursing measures were taken. Review of the nursing progress notes dated December 24, 2014, timed at 2:54 p.m., indicated that Resident CL1 had, "spit out" medication after several attempts, consumed no supplement and had consumed only a small amount of juice. Further review of the nursing progress notes indicated that no nursing measures were taken and that the physician was not notified. Review of the nursing progress notes written on December 25, 2014, at 2:38 a.m., indicated that Resident CL1 was, "observed to be unresponsive, no response to tactile stimulation" with a pulse ox (amount of oxygen in the blood stream) of 75% while receiving 2 liters of oxygen per minute. Resident CL1 was transported to the Emergency Department for evaluation and treatment. An interview with Employee E2, the Director of Nursing, on January 26, 2015, at 11:30 a.m., confirmed that Resident CL1 was showing a decline from December 23, 2014 to December 25, 2014, and that nursing measures were not implemented nor was the physician notified in a timely fashion. Review of the hospital discharge summary dated December 26, 2014, revealed that Resident CL1 presented to the hospital emergency department with severe dehydration, cachectic (not alert or oriented), malnourished, very dry mucous membranes, severely underperfused (a lack of fluid within the body system) and no urine output. Lab Results from the hospital emergency department at the time of admission revealed the following for Resident CL1: *BUN: (Blood Urea Nitrogen, shows kidney function) 228 mg/dl (milligrams/ deciliter)- High. Normal range is 7 - 18. *Sodium: (salt, an essential body mineral that helps retain water and prevents dehydration) 175 mmol/L (millimoles/liter), - Critical. Normal range is 136 -145 mmol/L. *Chloride: (an essential electrolyte (a mineral in your blood and other body fluids that carry an electric charge) that maintains kidney balance) 131 mmol/L Critical. Normal range is 98 - 107 mmol/L *Creatinine: (a test used to determine kidney function) 11.47 mg/dl Critical. Normal range is 0.60 -1.30 mg/dl Resident CL1 was given 6 liters (a unit of fluid measurement) of IV (intravenous fluid) and a broad spectrum antibiotic. The hospital documentation stated, "the pressure was still low despite fluid management." Review of the Certificate of Death for Resident CL1 dated December 26, 2014, with the time of death of 11:52 a.m., indicated the cause of death to be Multisystem Organ Failure. Observation of all the resident rooms on the "C" Nursing Unit where Resident CL1 had resided, on January 26, 2015, from 8:30 a.m. to 8:55 a.m., with Employee E4, Licensed Nurse, revealed that none of the 49 residents on the unit were provided with individual water cups. Further observation of the "C" Nursing Unit on January 26, 2015, at 10:35 a.m., again with Employee E4, revealed that water cups were still not provided to the residents on the unit. At the time of this observation, an interview was completed with Resident R4, who was identified by the nursing staff as alert and oriented. The surveyor asked Resident R4, "How do you get a drink of water?" Resident R4 told the surveyor, "Down the hall on the right." The surveyor asked Resident R4, to show the surveyor what that meant. Resident R4 walked from the resident's room to the nursing station and then said to surveyor, "I think cups are in there," pointing to a closet door that was locked, behind the nurses' station. Employee E4 took a 4 oz. plastic cup out of the medication cart and filled it with water from a canister that was labeled, "coffee." Employee E4 gave Resident R4 the plastic cup of water and then Resident R4 indicated to the nurse that the water was "cold." An interview with Resident R5, who was identified by the nursing staff as alert and oriented, was conducted on January 26, 2015, at 10:50 a.m. Again the surveyor asked the resident, "How do you get a cup of water?" Resident R5, in the presence of Employee E4, made a cup with his/her hands and said to the surveyor and Employee E4, "I put my hand under the sink." A further interview with Employees E4, Employee E6, a Licensed Nurse and Employee E7, a Nurse Aide, on January 26, 2015, at 10:55 a.m., revealed that a "Hydration Cart" arrived to the nursing unit at 10:00 a.m., with the snacks. Further observation of the Hydration Cart, revealed a container that was labeled, "Coffee" which actually contained water. Employee E4, Employee E6, and Employee E7 further indicated to the surveyor that the "Hydration Cart" is removed from the unit (with the dirty dishes from dinner) around 5:30 p.m., every evening and does not appear again until the next day at approximately 10:00 a.m. A further interview with Employee E4, on January 26, 2014, at 10:40 a.m., confirmed that all Residents on the "C" Nursing Unit were not provided with water cups. The facility failed to provide appropriate hydration, to identify that a resident was not receiving adequate fluids, to recognize the signs/symptoms of a lack of fluids or to notify the physician that a resident was refusing medications, fluids and nutrition for one resident resulting in actual harm to that resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 09/11/2014, 12/09/2014. 28 Pa. Code 201.18(b)(1) Management. Previously cited 09/11/2014, 10/01/2013, 12/09/2014. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 09/11/2014, 07/15/2014, 10/01/2013, 12/9/2014. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 09/11/2014, 07/15/2014, 10/24/2013, 10/01/2013, 12/09/2014. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 09/11/2014, 07/15/2014, 10/01/2013, 12/09/2014.

Based on review of clinical records, facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to establish a plan of care related to hospice services, failed to communicate the lack of hospice services to staff, and failed to provide adequate care to the resident when hospice services were not initiated for one of three residents reviewed (Resident R1), resulting in actual harm to that resident. Findings include: Review of the facility policy, "Hospice," dated as last revised May 1, 2011, revealed that for residents electing hospice care, an interdisciplinary plan of care would be communicated, established, and agreed upon, and the development of this plan would include the resident's family. Review of the clinical record for Resident R1 revealed admission physician's orders, dated April 16, 2014, and monthly thereafter, stating that the resident would require full resuscitation (full code-all medical life-sustaining interventions are to be administered). Review of a Medicare 14-Day Minimum Data Set assessment (MDS-periodic assessment of needs), dated April 29, 2014, indicated [DIAGNOSES REDACTED]. The MDS further revealed that the resident was moderately impaired with making decisions regarding tasks of daily life. Review of a neurology consultation report, dated August 6, 2014, indicated Resident R1 had a [DIAGNOSES REDACTED]. Review of clinical documentation revealed a speech therapist progress note dated September 1, 2014, indicating Resident R1 was exhibiting "severely" decreased range of motion (ROM-body joint movement) for mouth opening. Review of a nutrition progress note dated September 5, 2014, revealed Resident R1 was experiencing decreased oral intake and was consuming approximately 25 to 50 percent of meals, was unable to open mouth fully, and recommended a nutritional supplement of House Shake three times a day. Review of a physician's order dated September 7, 2014, instructed the staff to administer a House Shake for the resident daily at 10:00 a.m., 2:00 p.m., and at hour of sleep (HS-bedtime), and for nursing to record the amount that the resident consumes. Further review of the order did not clarify the prescribed quantity of the House Shake. An interview with Employee E1, Registered Dietitian, on December 9, 2014, at 3:30 p.m., revealed the facility's established House Shake supplement amount is 120 milliliters (ml). Review of a telephone verbal physician's order dated September 16, 2014, revealed that Resident R1 was to be placed on hospice care (end of life care to support the resident and the family). Review of the clinical record for Resident R1 revealed no documentation that the resident's responsible party (RP) was contacted regarding the initiation of hospice care. An interview with the Director of Social Services on December 9, 2014, at 2:30 p.m., confirmed that there was no documentation that the facility made any attempts to contact the resident's RP regarding the discussion of the initiation of hospice care. Review of a nursing progress note dated September 16, 2014, confirmed acknowledgement of the physician's order for hospice for Resident R1, and that the facility social services was aware. Review of a nutrition follow-up progress note dated September 17, 2014, revealed that due to Resident R1 being on hospice, the Dietitian had no further dietary recommendations for the resident. Review of a nursing progress note dated September 18, 2014, revealed that Resident R1 was placed on hospice. The nursing progress notes dated September 22, 2014, and September 24, 2014, indicated that Resident R1 continued on hospice care. However, another nursing progress note, dated September 29, 2014, at 9:21 p.m., revealed that as per the facility's Social Work Director, the resident was evaluated by two hospice providers, and the resident's RP refused to sign the forms to place the resident on hospice. Additionally, review of the "Referral Profile" completed by the Hospice RN, dated September 19, 2014, indicated that the Hospice RN met with the resident's RP and she refused hospice services at that time. The Hospice RN indicated on that same document that the facility MSW (social worker) and the nursing staff were informed of the refusal. Review of an admission Nutrition assessment dated [DATE], revealed that Resident R1's estimated daily fluid needs were 2040 ml per day. A review of a meal and snack intake report for September 2014 and a review of the resident's September 2014 Medication Administration Record [REDACTED]"30%" intake of 120 ml) for House Shake intake (total daily intake 516 ml); September 21, 2014, 360 ml for meal and snack intake, 48 ml (documented at "20%" of 120 ml for both 10:00 a.m. and 2:00 p.m.) for House Shake intake (total daily intake 408 ml); September 22, 2014, 240 ml for meal and snack intake, 0 ml for House Shake intake (total daily intake 240 ml); September 23, 2014, 440 ml for meal and snack intake, 120 ml for House Shake intake (total daily intake 560 ml); September 24, 2014, 340 ml for meal and snack intake, 60 ml for House Shake intake (total daily intake 400 ml); September 25, 2014, 222 ml for meal and snack intake, 240 ml for House Shake intake (total daily intake 462 ml); September 26, 2014, 390 ml for meal and snack intake, 0 ml for House Shake intake (total daily intake 390 ml); September 27, 2014, 270 ml for meal and snack intake, and 90 ml for House Shake intake (total daily intake 360 ml); September 28, 2014, 60 ml for meal and snack intake, and 30 ml for House Shake intake (total daily intake 90 ml); and September 29, 2014, 440 ml for meal and snack intake, 0 ml for House Shake intake (total daily intake 440 ml). Further review of the meal and snack intake report, and the September 2014 MAR, revealed that for the time period of September 16, 2014, the date of the hospice order, to September 29, 2014, the resident's daily fluid intake was below the resident's established fluid need requirement, as assessed and calculated by the Dietitian, of 2040 ml per day. An interview with the Registered Dietitian on December 9, 2014, at 4:30 p.m., confirmed the resident's oral intake was below the facility's established value from September 16 - 29, 2014. Review of a nursing progress note dated September 29, 2014, at 7:06 p.m., revealed Resident R1 was not eating or drinking, had a change in mental status, and a physician's order was received to send the resident to the hospital for evaluation. The progress note further stated that staff attempted to contact Resident R1's RP, but stated that the "phone is off," and that social services was made aware of the unsuccessful attempt to reach the resident's RP. A review of a hospital history and physical (H & P) report, dated September 30, 2014, revealed that the resident was diagnosed with [REDACTED]. The H & P further stated the resident's laboratory results on September 29, 2014, were as follows: blood urea nitrogen, (BUN-a test to determine kidney function), 82 milligrams (mg) per deciliter (dl), Creatinine (a test to determine kidney function), 1.73 mg/dl, and Sodium 152 milliequivalents per liter (mEq/L). A normal value for BUN is considered 7 to 20 mg/dl; a normal value for Creatinine is considered 0.6 to 1.2 mg/dl; and a normal value for Sodium is considered 136 to 145 mEq/L. The facility lab report dated July 25, 2014, indicated a BUN level as 16 mg/dl, a Creatinine level as 0.97 mg/dl and a Sodium level as 137 mEq/L. Review of a physician's admission note dated October 16, 2014, revealed that Resident R1 was readmitted to the facility from the hospital on October 15, 2014, with [DIAGNOSES REDACTED]. Further review of the clinical record on December 9, 2014, revealed no documentation that an interdisciplinary plan was developed for the initiation of hospice care from September 16 - 29, 2014, and there was no documentation that facility staff obtained consent and approval from the resident's designated responsible party to initiate end of life care. A review of the clinical record revealed no documentation that the resident's physician was made aware by staff that during the time period of September 16 - 29, 2014, the resident's daily oral intake of fluids was below the established value determined by the facility. At the time of the exit conference by the surveyor with the facility, conducted on December 9, 2014, at approximately 5:30 p.m., there was no documentation regarding evaluation of the resident by the hospice personnel. An interview with the Nursing Home Administrator on December 9, 2014, at 5:30 p.m., confirmed that Resident R1 was admitted to the hospital on September 29, 2014, with a [DIAGNOSES REDACTED]. The facility failed to ensure Resident R1 received the appropriate care and services necessary to maintain the resident's highest practicable physical, mental, and psychosocial well-being. This failure caused actual harm to the resident. 42 CFR 483.25 Quality of Care. Previously cited 09/11/2014, 10/01/2013. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 09/11/2014. 28 Pa. Code 201.18(b)(1) Management. Previously cited 09/11/2014, 10/01/2013. 28 Pa. Code 201.18(b)(3)(e)(1) Management. Previously cited 09/11/2014. 28 Pa. Code 211.5(f) Clinical records. Previously cited 10/01/2013. 28 Pa. Code 211.10(c) Resident care polices. Previously cited 10/01/2013. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 09/11/2014, 07/15/2014, and 10/01/2013. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/11/14. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 09/11/2014, 07/15/2014, 10/24/2013, and 10/01/2013. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 09/11/2014, 7/15/2014, and 10/01/2013. 28 Pa. Code 211.16(a) Social services.

web14i3z4n Based on review of the clinical records, facility documentation and staff interviews, it was determined that the facility failed to provide supervision for one resident with a history of multiple choking episodes that resulted in actual harm to the resident, for one resident with physically abusive behaviors and for one resident with a history of suicide ideation. (Residents Cl1, Cl2 and Cl3) Findings include: A review of Resident Cl1's clinical record revealed [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated [DATE], indicated that Resident Cl1 was moderately cognitively impaired and required extensive assistance of one person during mealtime. The physician's orders [REDACTED]. Review of the Speech Therapy documentation for [DATE], indicated that the resident had been identified as able to feed himself, presented with pocketing food in his mouth, required one to one supervision by nursing during meals and bread products were to have nectar thick liquids to reduce the risk of choking. Speech Therapy was completed on [DATE], with the instruction of 100% direct supervision during all meals. A Speech Therapy evaluation was completed again on [DATE], and identified that the resident had deficits in three aspects of swallow that included consuming food at an increased rate. On [DATE], the speech therapy documentation indicated that further evaluation was not required and that the resident was on the restorative program with nursing supervision for all meals. Review of the restorative dining documentation for [DATE] through [DATE], revealed that towards the end of the month the resident had become restless, disrobing at the table and trying to get up from the dining area due to the dementia diagnosis. Review of nursing documentation for [DATE], at 5:18 p.m., revealed that the resident had been observed coming out of the dining room, into the hallway with food coming out of his mouth and appeared to be choking. A late entry nursing note, dated for [DATE], noted that Resident Cl1 had choked on food that he picked up from another resident's tray, he did not respond to abdominal thrusts and CPR (Cardiopulmonary Resuscitation) and expired at 5:46 p.m. A written statement from Employee E6, a member of the nursing staff, dated [DATE], regarding the incident said that Employee E6 was at the food cart and observed the resident walk out of the dining room hitting his chest in distress. Employee E6 yelled that the resident was choking to the charge nurses at the station, and said that both of them rushed to his aid and began emergency care. 911 was alerted, CPR was initiated and continued by the EMTs when they arrived. Employee E4, a Registered Nurse, on [DATE], at 10:30 a.m., and Employee E3, a Registered Nurse at 1:00 p.m., stated in interviews that it was well known that Resident Cl1 would grab food off of trays and eat it if he had the chance and that he was to have a nurse with him. The facility failed to follow the Speech Therapy and the physician recommendations for direct supervision by the licensed staff for safety while eating, to prevent choking and to provide aspiration precautions for a resident with history of choking, causing actual harm to Resident Cl1. A review of Resident Cl2's clinical record revealed [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated [DATE], indicated that Resident Cl2 was moderately, cognitively impaired and exhibited wandering behavior. A review of the nursing documentation from [DATE], through [DATE], revealed the resident wandering throughout the facility and a series of physical assaults on both staff and residents. This included one incident on [DATE], when Resident Cl2 struck another resident in the back of the head and on [DATE], when Resident Cl2 pushed a charge nurse down onto the floor, requiring 4 staff members to remove him from the area. A psychiatric consultation by the Nurse Practioner dated [DATE], stated that the resident was non-compliant, refused medications and exhibited aggressive behaviors towards staff and other residents. Inpatient psychiatric care was recommended at that time. On [DATE], at 8:15 a.m., the nursing documentation reported a nurse assistant had screamed in the hallway that the resident had hit her. The nurse went out in the hall and witnessed the resident chasing the staff down the hallway. The nurse assistant held the ice cart between herself and the resident until the Assistant Director of Nursing came to the unit to assist. The resident then began to kick and hit the Assistant Director of Nursing, 911 was called and the resident was sent to the emergency room for evaluation. The resident was placed on one to one supervision until the resident left for the hospital. A note nursing note at 7:42 p.m., reported that the resident had returned from the emergency room with no new recommendations. The nursing documentation for [DATE], reported that at 4:20 a.m., a nurse assistant yelled for help and that the nurse ran to Resident Cl2's room and saw Resident Cl2 standing in the doorway holding a metal reacher in his hands. They found the resident's roommate in bed bleeding from the head and face. The supervisor was called to the nursing unit, who reported that she then observed the other resident being hit with the objects. The supervisor directed the staff to call 911. Resident Cl2 then attempted to hit the staff with the objects and the nurse removed the injured resident from the room for safety. The police arrived on the unit and Resident Cl2 was handcuffed and arrested. Resident Cl2's roommate was sent to the emergency room for treatment of [REDACTED]. The Director of Social Services stated in an interview on [DATE], at approximately 10:30 a.m., that Resident Cl2 had often wandered throughout the facility and that the facility had been unable to provide the resident with access to the appropriate psychiatric services to address his needs. There was no evidence available that between [DATE], and [DATE], the facility made plans for the resident's transfer to an appropriate in-patient psychiatric unit and failed to provide adequate supervision of a resident with a history of physically aggressive behavior. Review of policy titled, "Accidents and Incidents", revised [DATE], revealed that all unusual occurrences will be reported immediately to the manager/supervisor on call and that an incident report will be completed. Review of Resident Cl3's clinical record revealed that the resident was transferred to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. Review of the history and physical documentation from the hospital revealed that the resident had attempted suicide by jumping from bridges in October, 2013, and April, 2014, requiring the resident to be admitted to the critical care unit. The resident was admitted to the facility for rehabilitation. A plan of care was developed that included monitoring Resident Cl3 for suicidal ideation. Review of the nursing documentation for [DATE], revealed that the medication nurse was unable to locate the resident for medication pass at 5:00 p.m. At 10:10 p.m., the resident was reported missing. Employee E3, a Registered Nurse, stated in an interview on [DATE], at approximately 11:30 a.m., that the resident was not reported missing until 10:00 p.m., that evening. Employee E3 thought someone had seen him get into a car earlier in the shift but did not report it. The Director of Social Services stated in an interview on [DATE], at approximately 11:00 a.m., that Resident Cl3 was often seen playing the piano in the dining room or in his room and that it was unusual not to be able to find him. The facility learned the next day he was out of the country and in Switzerland. In an interview on [DATE], at approximately 3:00 p.m., the Nursing Home Administrator confirmed there was a delay in attempting to locate this missing resident. The facility failed to provide adequate supervision for a resident who was at high risk for self-injury. 28 Pa Code: 211.12 (d)(1)(3)(5) Nursing services

Based on a review of clinical documentation, observations and interviews with staff and residents, it was determined that the facility failed to monitor and assess 2 of 30 residents for the development of pressure ulcers resulting in actual harm to the two residents (Residents R101 and 184). Findings include: A review of Resident R184's physician's progress note dated September 13, 2011 revealed a [DIAGNOSES REDACTED]. A review of an annual MDS (Minimum Data Set - a periodic assessment of needs) dated 8/2/11, revealed that the resident is severely impaired cognitively in decision making, is totally dependent on staff for personal hygiene and dressing, requires extensive assistance from staff for transfers and is non-ambulatory. A review of physician's orders [REDACTED]. A review of nursing progress notes dated August 5, 2011 at 3:06 pm revealed that the CNA reported to the nurse that the resident's sock was stuck to the heel of the right foot and was unable to be removed without tearing the skin. The same nursing progress note indicated that the resident's foot was soaked in saline to remove the sock. The residents heel was then newly identified as a Stage 3 pressure ulcer (full thickness tissue loss) with slough (separation of dead tissue from living tissue) that measured 4.5 cm by 5.0 cm. Nursing documention indicated that the physician was notified and ordered for wound to be treated with santyl (a [MEDICATION NAME] agent) and [MEDICATION NAME] (an antibiotic) gel to be applied daily and to cover and wrap with kling. The resident was also given pain medication. A review of a wound care specialist consultation dated September 20, 2011 revealed that the wound was identified as unstageable necrosis (dead tissue) that measured 5 cm by 4 cm and had some drainage. The wound consultant performed a surgical debridement to remove the necrotic tissue. Observation of the wound on October 3, 2011 at 11:00 am revealed the wound that was approximately 4 cm by 3 cm with two open, draining areas. Staff treated the wound with the santyl/[MEDICATION NAME] ointment and wrapped with kling. Interview with Employee E2 on October 4, 2011 at 10:00 a.m. confirmed that staff had not monitored the foot as ordered and that the wound had been identified at an advanced stage. A review of Resident R101's current physician's orders [REDACTED]. Review of the resident's quarterly MDS (Minimum Data Set - a periodic assessment of needs) dated June 16, 2011 revealed that the resident was alert and oriented and was independent with ambulation. A review of nursing progress note dated August 24, 2011 revealed that the resident was identified in the therapy department with an open area on the left posterior calf that measured 1 cm by 3.4 cm. that had been caused by a brace. The physician was notified and ordered for the staff to apply santyl (a [MEDICATION NAME] agent) daily and cover the wound. Nursing documentation dated August 25, 2011 at 2:52 pm revealed that the resident had been fitted for a molded articulated ankle foot orthosis (MAFO brace - a hard, custom fitted plastic brace that goes from the underside of the foot, up the back of the calf, to below the knee) and that therapy had been working with the resident in fitting and teaching the resident how to take off and on the braces. The nursing note stated that the therapy department had a schedule but that it had not been communicated to nursing. The nursing progress note also stated that the resident was unable to feel the wound due to diabetes. A review of a podiatry progress note dated August 26, 2011 indicated that the resident was seen related to the wound on the resident's leg and the resident was experiencing pain. The consult recommended that the brace not be worn until the wound healed and that the brace should be checked for proper fitting. A review of Resident R101's clinical record revealed that there was no physician order [REDACTED]. Observation and interview with the resident on September 30, 2011 at 11:00 am revealed the wound healed, currently a small scar. Interview with the resident at this time revealed that the wound had been caused by the top of the hard brace rubbing on the back of the leg and it had been painful at the time. Interview with Employee E9 on October 4, 2011 at 11:30 am revealed that the therapy department had not communicated to nursing that braces had been supplied or that the resident was utilizing the braces. Interview with Employee E2 on October 4, 2011 at 1:00 pm confirmed that the wound was caused by the use of the brace and that orders from the physician were not in place prior to the use of the brace. 28 Pa. Code 201.18 (b)(1) Management Previously cited 8/16/11 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/2/10, 9/8/11