Every finding on record at Monumentalpostacutecare at Woodside Park

Based on observations, review of facility policies, facility documentation and interview with staff, it was determined that the facility failed to ensure that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. This failure placed residents on three of three nursing units at risk of serious injury from a burn and resulted in an Immediate Jeopardy situation. (First floor East, Second floor East and West) Findings include:Review of facility policy titled Physical Environment Common A, dated January 2, 2025, revealed the facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The facility will meet the applicable provisions of the 1985 edition of the life safety code of the National Fire Protection Association. Hot water outlets accessible to residents shall be controlled so that the water temperature at the outlets does not exceed 110 degrees Fahrenheit. Observations conducted of the shower room on unit one East with Maintenance Director Employee E6 on December 8, 2025, at 10:20 a.m. failed to reveal a thermometer in the shower room. The hot water temperature tested 117.3 degrees Fahrenheit. Further observations of shower room [ROOM NUMBER]nd floor East failed to reveal a thermometer in the shower room. The hot water at the hand sink in the shower room was turned on and felt excessively hot to the touch. Hot water temperatures were taken of the hand sink and the shower by Maintenance Director, Employee E6 on December 8, 2025, at 10:30 a.m. The hot water temperature in the sink registered 118.2 degrees Fahrenheit. The shower temperature was 117.8 degrees Fahrenheit. The Maintenance Director, E6 confirmed the temperatures of the hot water were too high. Observation conducted in the shower room on Second floor [NAME] on December 8, 2025, at 10:50 a.m. in the company of Director of Maintenance, Employee, E6 failed to reveal a thermometer located in the shower room. Hot water temperatures were taken of the shower as well as hand sink. The hand sink temperature was 120.7 degrees Fahrenheit, and the shower temperature was 115.7 degrees Fahrenheit. Observation of the boiler room on December 8, 2025, at 11:15a.m. with Maintenance Director, Employee E6 revealed two domestic water storage tanks. Observation of boiler #1 revealed it was set at 125 degrees Fahrenheit.Observation conducted of boiler #2 which revealed the boiler was at 125 degrees Fahrenheit. Interview with Director of Maintenance at the time of the observation confirmed the incoming water temperature of the boilers was high and should be set at 110 degrees Fahrenheit. Observations conducted of hand sinks in resident rooms by the Maintenance Director, Employee E6 on all nursing units as follows: December 8, 2028 between 10:30 a.m. and 11:30 a.m. of First floor East and [NAME] and Second floor East and [NAME] revealed the following high hot water temperatures: room [ROOM NUMBER] registered a temperature of 118.2 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 117.5 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 119.6 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 120 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 115.3 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 118.7 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 120.7 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 116.6 degrees Fahrenheit Review of the water temperature logs was completed for the months of November and December 3, 2025. revealed that there was no temperatures out of ranges, all documented to be under the temperature of 110 degrees Fahrenheit. Interview with Maintenance Director, Employee E6 on December 8, 2025, at 11:20 a.m. revealed he was aware the temperatures are supposed to be under 110 degrees Fahrenheit but had turned up the temperatures on the boilers to accommodate the complaints of residents of water temperatures are too cold. Maintenance Director, Employee E6 revealed he adjusted the temperature approximately one month prior to observations. On December 8, 2025, at 11:20 a.m., an interview conducted with Nursing aide, Employee E5 revealed, Employee E5 uses his hand to test the water temperature and confirmed that he has not used water thermometers as they are not available in the showers. On December 8, 2025, at 11:24 a.m., an interview conducted with Unit manager, Employee E4 revealed the nursing station did not have water thermometers available to test the water temperatures when providing showers. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administer and assistant Nursing Home Administrator on December 8, 2025, at 2:31 p.m. for failure to ensure safe hot water temperatures were maintained on the first and seconds floors nursing units. The Nursing Home Administrator, Employee E1 was provided with the Immediate Jeopardy template, and an immediate action plan was requested. On December 8, 2024, at 5:31 p.m. the facility developed and submitted the following corrective action plan.-The policy will be updated to include safe processes for monitoring hot water. -The facility shall maintain what are delivered to residents use area including bathrooms, showers, and sinks at 110 degrees Fahrenheit (43 degrees Celsius) or below. This standard complies with safety regulations for long-term care environments and promotes resident safety. -If temperature of water temperature exceeds 110-degree Fahrenheit, staff must immediately notify maintenance supervisor and charge nurse. -Post a Do Not Use Hot Water sign until the temperature issue is corrected. -Document the corrective steps taken and recheck the temperature before returning the fixture to service. -Thermometers will be available on each unit for staff use. -Hot water systems were calibrated to deliver water not to exceed 110 degrees Fahrenheit at all resonant use fixtures. -The maintenance department shall ensure thermostatic mixing valves are installed and function properly in all areas where residents have access to hot water. -All water in resident rooms and showers were checked, and all were below 110 degrees Fahrenheit. -Temperatures shall be recorded on the water temperature log, including location, date, time, and staff initials. -Temperature logs will be kept on file at the facility for review by regulatory agencies. -Nursing staff will be in-serviced by Nurses, Managers, or designee, on the importance of checking water temperatures prior to assisting residents with bathing or other hygiene care. (90% of the staff will be in service by December 9, 2025, 100% by December 11, 2025) -All water in resident rooms and showers will be checked by maintenance daily for 5 days to ensure compliance to be completed by December 13, 2025. -Water temperatures shall be checked weekly in representative sample of resident areas (minimum three per wing/unit). All water log checks will be reported in monthly QAPI (Quality Assurance Improvement Plan) -Maintenance department was educated on importance of maintenance water system temperatures below 110 degrees. Education was completed December 8, 2025. The facility's action plan was submitted and accepted on December 8, 2025, at 5:31 p.m. Staff interviews were conducted on December 9, 2025, between the hours of 8:00 a.m. and 3:30 p.m. with nursing staff to verify the implementation of the immediate action plan. Nursing staff was able to verbalize the facilities updated policy, including that with their temperatures should not exceed 110 degrees Fahrenheit, what to do if temperatures were found to be too high and how often temperatures should be checked, nursing staff were able to demonstrate proper use of checking water temperatures and they have had sufficient thermometers available for use. Maintenance staff and supervisory staff were observed checking water temperatures and completing audit logs. The hot water at hand sinks throughout the facility were tested and verified and did not exceed 110 degrees Fahrenheit. Water temperature logs were reviewed and revealed appropriate water temperatures. Staff education documentation was received, and it was confirmed the facility in-service their staff on proper hot water temperatures. Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation the immediate jeopardy was lifted on December 10, 2025, at 11:05 a.m. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(a) Management28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(d)(3) Nursing Services

Based on observations, review facility policies and staff interview, it was determined that the facility failed to maintain a safe, clean and homelike environment in resident care areas for two of three nursing units observed (1st floor East and 2nd floor [NAME] Nursing units). Findings Include:Review of facility policy Physical Environment: Common Areas dated January 2025, revealed, the facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. On December 8, 2025, at 1:25 p.m. unit manager, Employee E8 confirmed that room [ROOM NUMBER]B had no grid on the heating unit and the cover of the heating unit was coming off. On December 9, 2025, at 12:45 p.m. the Maintenance Director, Employee E6, confirmed that room [ROOM NUMBER]B bedside dresser was broken on the sides of the dresser, there was a large amount of woodchip inside of the first drawer. room [ROOM NUMBER]B dresser had 3 broken shelves as the railing were dispatched and were not closing appropriately. The trashcan also had no liner. Observations during an initial tour of the 2-West nursing unit on December 8, 2025, at 10:30 a.m. revealed: In room [ROOM NUMBER], bed A, the mattress had a large rip along the right side, and the privacy curtain was soiled. In room [ROOM NUMBER], the blinds were observed to be broken and bent. Observations inside the 2-West utility closet revealed the faucet was leaking. Observations in room [ROOM NUMBER], the B-bed dresser had a front panel missing on a drawer. Observations made during follow-up visits to 2-West nursing unit on December 9, 2025, revealed: At 11:06 a.m. observations in room [ROOM NUMBER] revealed Resident R127 was on a tracheostomy and feeding tube. The bedside nightstand, with all the tracheostomy equipment on top, had significant build up of dirt and debris. Further, Resident R127's bed frame was visibly soiled with debris and tube feeding formula. Further observations in room [ROOM NUMBER] revealed the floor surrounding Resident R127's tube feeding pole had significant dust/debris build up. Interview on December 9, 2025, at 11:06 a.m. with Registered Nurse, Employee E10, confirmed the dirty environment of Resident R127's room. At 12:34 p.m. observations in room [ROOM NUMBER] revealed Resident R62 had no dresser or table to support his/her lamp (the lamp was placed directly on the floor). Further, Resident R62's dresser drawers were broken. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to safeguard medications tor one of 29 residents reviewed (Resident R7). Findings Include: Review of Resident R7's Annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 30, 2025, revealed the resident had a diagnosis of chronic obstructive pulmonary disease (COPD - progressive lung disease that makes it hard to breathe). Continued review of Resident R7's MDS dated [DATE], revealed the resident was cognitively intact. Review of Resident R7's comprehensive care plan revised February 15, 2025, revealed the resident had the potential for inadequate respiratory function. Intervention dated July 26, 2022, indicated to provide medication as ordered. Review of Resident R7's physician order summary revealed an order dated January 5, 2025, to administer Breztri Aerosphere Inhalation Aerosol (prescription inhaler), two times per day. During an interview on December 9, 2025, at 2:10 p.m. with Resident R7, the resident reported he/she has not received his/her inhaler in weeks. Per Resident R7, the nursing staff lost the inhaler. Review of Resident R7's medication administration record revealed the inhaler was first documented as not available on November 18, 2025, by Licensed nurse, Employee E13. Continued review of Resident R7's medication administration record revealed licensed nurse, Employee E13, consistently documented the inhaler as not available from November 18, 2025, through December 9, 2025. Review of Resident R7's entire clinical record revealed no documented evidence that the physician was notified of the unavailable and subsequently missed medication. Interview on December 9, 2025, at 2:15 p.m. with Licensed Nurse, Employee E13, confirmed Resident R7's inhaler was not available. Licensed Nurse, Employee E13, reported that pharmacy will not refill the inhaler because insurance will not cover the cost of a new one until December 11, 2025. Interview on December 10, 2025, at 12:10 p.m. with the Director of Nursing, Employee E2, revealed Resident R7's inhaler was last dispended by the pharmacy on November 18, 2025, for a 30-day supply. Director of Nursing, Employee E2, confirmed that Resident R7's inhaler was misplaced. Continued interview on December 10, 2025, at 12:10 p.m. with the Director of Nursing, Employee E2, revealed nursing staff should have notified the Director of Nursing about Resident R7's misplaced inhaler so that the facility could replace it. Further interview with Licensed Nurse, Employee E13, on December 10, 2025, at 12:45 p.m. confirmed Resident R7's inhaler had been missing since November 18, 2025. 28 Pa. Code 211.9 (a)(1) Pharmacy services.

Based on record review and staff interviews, the facility failed to ensure that PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medications for one of five residents reviewed. (Resident R10).Findings Include:Review of FDA (Food and Drug Administration) (The United States Food and Drug Administration (FDA), a federal agency within the Department of Health and Human Services, protects public health through the regulation of foods, drugs, cosmetics, and medical devices) guidance for Haldol revealed that, HALDOL (haloperidol) is indicated for use in the treatment of schizophrenia. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.Review of Resident R10's October 2025 through December 2025 physician orders revealed multiple PRN orders for Haldol injection (a prescription first-generation antipsychotic medication used to treat conditions such as schizophrenia) 5 mg/ml, to be given by intramuscular every six hours as needed for, each entered for a 14-day period as follows:Order started on October 31, 2025 (October 31, 2025 - November 14, 2025)Order started on November 14, 2025 (November 14, 2025- November 28, 2025)Order active on December 1, 2025 (December 1, 2025 - December 15, 2025)Further review revealed no documentation from the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for continued use as required by S483.45(e)(5).Interview with Director of Nursing, Employee E2 on December 10, 2025, at 2:00 p.m. confirmed that the medication order was renewed for Resident R10 after 14 days of the order multiple times. Employee E2 confirmed that there was no documentation from the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for continued use.28 Pa. Code 211.12(d)(1)(3) (5) Nursing services

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 discharge which occurred Against Medical Advise (AMA), attempts to provide discharge instruction, assess resident's capacity to make decision, attempts to contact the resident's representative, and notify the physician, for 1 of 2 residents reviewed (Residents R166).Findings include:Review of facility policy Admission, Transfer and Discharge,' undated policy, indicated Transfer and discharge include movement of resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge dos does not refer to movement of a resident to a bed within the same certified facility.On December 11, 2025, at 10:12 a.m., the Social Services Director, Employee E9, confirmed that Resident R166 was admitted to the facility on [DATE], and discharged on September 27, 2025, with an AMA status. The reviewed clinical record did not contain documentation that the facility attempted to provide discharge summaries, notify the physician, assess the resident's capacity to make decisions, or notify the family representative. In addition, there was no documentation showing that the Office of the State Long-Term Care Ombudsman was notified.28 Pa Code 201.29(a)(c.3)(2) resident rights

Based on a review of facility documents, observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure the resident's care plan was updated and revised to address a resident's diagnosis of legal blindness and required assistance with eating for one of 29 residents reviewed. (Resident R143) Findings include:Review of the Resident R 143's quarterly Minimum Data Set (MDS-a federally mandated assessment tool for all residents), dated November 25, 2025, revealed the resident was admitted to the facility on [DATE], with diagnoses including legal blindness and cerebrovascular accident (CVA)with left hemiplegia(a stroke that caused one sided paralysis to the left side of his body). The MDS assessment indicated the resident was dependent for most functional abilities. The resident was assessed as requiring total assistance with eating, which was defined as the helper performing all of the effort with the resident performing none of the effort, or requiring the assistance of two or more helpers to complete the activity. Review of the resident's care plan dated June 21, 2024, revealed the resident was identified as having a self-care deficit requiring assistance with activities of daily living (ADLs) related to contractures, decreased mobility, decreased vision, and weakness. Continued review of the resident's care plan did not address the resident's need for assistance related to the resident's legal blindness, specifically with eating. Observation on December 10, 2025, at 12:30 PM revealed Resident 143 was in his room with a lunch tray set up over the bed. The resident requested assistance with his meal. The resident was observed with food in his hands and on the tray, indicating the resident was not receiving the required assistance with eating. Interview with Licensed Nurse Employee E12 December 10, 2025, at approximately 12:35 PM revealed the nurse stated the resident is typically fed his meals and confirmed there was no staff assisting the resident at the time of the observation. 28 Pa Code 211.10(a)(b) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of clinical records, and staff and resident interviews it was determined that the facility failed to implement physician orders related to high blood sugars for one of 29 residents reviewed (Resident R7).Findings include: Review of facility policy Diabetic Management revised August 2013 revealed hyperglycemia (high blood sugar) is defined as a blood glucose level greater than 300. Per the facility policy, the glucose parameter levels indicate if a blood sugar is greater than 300 than the physician should be notified. Documentation of the event, along with the outcome, should be included in the nurse's progress note. Review of Resident R7's Annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 30, 2025, revealed the resident had a diagnosis of diabetes mellitus. Continued review of Resident R7's MDS dated [DATE], revealed the resident was cognitively intact. Review of Resident R7's physician order summary revealed an order dated February 3, 2023, for Accu Checks (refers to the process of measuring blood glucose levels) before meals and at bedtime. The directions specify to call the physician if glucose is less than 60 or greater than 350. During an interview on December 9, 2025, at 2:10 p.m. with Resident R7, the resident reported a history of elevated blood sugars, especially in the morning. Review of Resident R7's medication administration revealed the resident had a documented blood sugar of greater than 350 on the following dates and times: 11/3/2025 at 7:30 a.m. blood glucose level of 439 11/6/2025 at 7:30 a.m. blood glucose level of 386 11/6/2025 11:30 a.m. blood glucose level of 423 11/10/2025 21:00 p.m. blood glucose level of 379 11/15/2025 7:30 a.m. blood glucose level of 469 12/1/2025 at 7:30 a.m. blood glucose level 434 12/5/2025 at 7:30 a.m. blood glucose level 383 12/5/2025 at 11:30 a.m. blood glucose level of 422 12/7/2025 at 7:30 a.m. blood glucose level of 400 Review of Resident R7's entire clinical record revealed no documented evidence that the physician was made aware of elevated blood sugars. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(10(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure that tracheostomy equipment was properly maintained for one of one resident receiving tracheostomy care. (Resident R127)Findings include:Findings Include:Observation of Resident R127 on December 9, 2025, at 10:01 a.m. revealed that the resident was on a tracheostomy. It was revealed that the tracheostomy tube was not dated to indicate the date it was last changed. Further observation revealed that the oxygen tubing was not dated. It was also revealed that the tracheostomy tube was placed in a container, and the container was dirty. Continued observation revealed that the trach collar and the dressing around the stoma were not dated to indicate the date of the dressing change. Observation of the tracheostomy equipment and the humidifier revealed that the last inspection date for the humidifier was February 14, 2020, and the next inspection due date was February 14, 2021. Continued observation revealed that the suction machine was inspected on July 29, 2025, and the inspection due date was also July 29, 2025, indicating that both pieces of respiratory equipment were past their inspection due dates. Interview with the unit manager, Employee E10, on December 9, 2025, at 10:30 a.m. confirmed that the staff should change the tracheostomy tubing and date it to indicate the date it was changed. The employee also confirmed that the tracheostomy dressing should be dated to indicate the change date. The employee further confirmed that the tracheostomy equipment was past the quality inspection due date. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed receiving hemodialysis. (Residents R82).Findings Include:Review of facility policy titled Hemodialysis, undated, states, Dialysis pre and post treatment summaries will be communicated to facility. A review of Resident R82's record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease. On December 9, 2025, at 2:37 p.m., an interview with the Director of Nursing, Employee E2, confirmed that dialysis communication for Resident R82 was requested by the facility. A binder containing communication sheets with residents' information and documentation of communication between the facility and the dialysis team was provided. Further review of the dialysis communication binder revealed that on several days the communication sheets were not fully completed. There was missing documentation specific to nursing signatures, missing date, and absent dialysis pre- and post-treatment summaries. The section titled Communication from Dialysis Center was not completed for the following dates: December 3, 2025; November 28, 2025; November 19, 2025; November 17, 2025; and November 12, 2025. 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of clinical records it was determined that the facility failed to timely implement behavioral health interventions for one of five residents reviewed for behavioral/emotional health (Resident R4).Findings:Review of Resident R4's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 30, 2025, revealed the resident had diagnoses of 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 thing), and bipolar disease (extreme swings in mood and thought). Review of Resident R4's clinical record revealed a psychiatry note dated November 4, 2025, by Psychiatric Mental Health Nurse Practitioner, Employee E14, that revealed the resident was being seen for evaluation and management of bipolar disease and dementia. Per the psychiatry note, Resident R4 reported mood is all right, no sadness, and no anxiety. Resident R4 was noted to be getting out of bed more and taking walks. Further review of psychiatry note dated November 4, 2025, revealed Nurse Practitioner, Employee E14, indicated Resident R4 was tolerating a dose reduction of Risperidone (antipsychotic medication). Per Nurse Practitioner, Employee E14, risperidone can help stabilize mood and with a dose reduction could lead to a failed dose reduction in the absence of a mood stabilizer. Nurse Practitioner, Employee E14, subsequently recommended to start Depakote DR 125 milligrams (mg) by mouth (PO) two times (BID) per day for bipolar disorder and mood stabilizer. Further review of Resident R4's clinical record revealed the resident was seen for a follow-up by Nurse Practitioner, Employee E14, on November 18, 2025. Review of psychiatry note dated November 18, 2025, by Nurse Practitioner, Employee E14, revealed Previous visit recommended to start Depakote DR 125 mg PO BID for bipolar disorder mood stability in the context of reduction of Risperidone, which has not been started. Further review of psychiatry note dated November 18, 2025, revealed Resident R4 reported feeling depressed and felt like it got worse over the last couple weeks. Resident R4 reported feeling down at least daily. Continued review of psychiatry note dated November 18, 2025, by Nurse Practitioner, Employee E14, revealed recommendations again to start Depakote DR 125 mg PO BID for mood stability. Nurse Practitioner, Employee E14, also recommended to increase Mirtazapine dosage every night for depression. Review of Resident R4's clinical record revealed the resident was seen for follow up by the Psychiatric Mental Health Nurse Practitioner, Employee E14, on December 2, 2025. Review of psychiatry note dated December 2, 2025, by Nurse Practitioner, Employee E14, revealed Previous visit recommended to start Depakote DR 125 mg PO BID for Bipolar Disorder mood stability in the context of reduction of Risperidone, and to increase Mirtazapine for depression . Psychotropic regimen is unchanged from previous visit. Review of Resident R2's clinical record revealed the behavioral health interventions were subsequently implemented on December 2, 2025, about one month after the initial recommendation on November 4, 2025. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for 1 of 29 residents. (R45).Findings Include:Review of Facility Policy: Resident Representative/Family Provided Food undated, states Food items provided and considered perishable are to be brought into the dietary department and food will be stored in the designated area which shall be temperature controlled. 3. No food will be held for more than 2 days from the provided date. 4. Food provided will be dated and labeled including use by date not to exceed 2 days. On December 8, 2025, at 1:30 p.m., an interview was conducted with Resident R45, who had a small refrigerator next to his bed. Resident R45 was observed not to have a refrigerator thermometer inside the refrigerator or a thermometer log to monitor the refrigerator temperature. The resident also had two personal food containers inside the refrigerator that were not labeled, one food container on top of the refrigerator, and cheese in a Ziplock bag that was not labeled. Resident R45 reported that the facility did not educate him on how to maintain food items at safe temperatures when he obtained the refrigerator. On December 9, 2025, at 12:47 p.m., the Maintenance Director, Employee E6, confirmed that Resident 45's personal refrigerator did not have a thermometer. On December 9, 2025, at 12:56 p.m., an observation was conducted with the Director of Nursing, Employee E2, who confirmed the above findings: Resident R45 had a small bedside refrigerator with no thermometer and personal food containers that were unlabeled. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to ensuring that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. This failure placed residents on three of three nursing units at risk of serious injury from a burn and resulted in an Immediate Jeopardy situation. (First floor East, Second floor East and West) Findings include: Review of the Nursing Home Administers (NHA) job description revealed that the NHA is responsible for the overall management and operation of the facility, ensuring that high-quality healthcare services are delivered in a safe, compliant, and resident-centered environment. The Administrator enforces all regulations related to the level of healthcare provided, resident safety, and the protection of residents' personal property and individual rights. The Administrator ensures that a sanitary, safe, and comfortable environment is maintained for all residents through effective housekeeping practices and proper maintenance of the building and grounds. The role includes providing and implementing systems and standards for both resident and employee safety, including accident-prevention programs. The NHA plans, organizes, directs, reviews, and evaluates the functions of each department using appropriate delegation and clear lines of accountability. This position assures full compliance with all federal, state, and local regulations and maintains responsibility for the overall management, safety, and integrity of the facility and makes regular rounds throughout the building to verify that appropriate care, environmental conditions, and regulatory standards are consistently being met. Review of the Director of Nursing (DON) job description revealed it is the DON is responsible for administering and overseeing all nursing programs to ensure that high standards of patient care are consistently maintained. The DON advises medical staff, department heads, and facility administrators on all matters related to nursing services. The Director of Nursing is responsible for planning, organizing, staffing, coordinating, directing, and reporting the activities of the nursing department. This includes ensuring appropriate staffing levels, maintaining quality assurance standards, implementing nursing policies and procedures, and promoting compliance with all federal, state, and local regulations. Observations conducted of the shower room on unit one East with Maintenance Director Employee E6 on December 8, 2025, at 10:20 a.m. failed to reveal a thermometer in the shower room. The hot water temperature tested 117.3 degrees Fahrenheit. Further observations of shower room [ROOM NUMBER]nd floor East failed to reveal a thermometer in the shower room. The hot water at the hand sink in the shower room was turned on and felt excessively hot to the touch. Hot water temperatures were taken of the hand sink and the shower by Maintenance Director, Employee E6 on December 8, 2025, at 10:30 a.m. The hot water temperature in the sink registered 118.2 degrees Fahrenheit. The shower temperature was 117.8 degrees Fahrenheit. The Maintenance Director, E6 confirmed the temperatures of the hot water were too high. Observation conducted in the shower room on Second floor [NAME] on December 8, 2025, at 10:50 a.m. in the company of Director of Maintenance, Employee, E6 failed to reveal a thermometer located in the shower room. Hot water temperatures were taken of the shower as well as hand sink. The hand sink temperature was 120.7 degrees Fahrenheit, and the shower temperature was 115.7 degrees Fahrenheit. Observation of the boiler room on December 8, 2025, at 11:15a.m. with Maintenance Director, Employee E6 revealed two domestic water storage tanks. Observation of boiler #1 revealed it was set at 125 degrees Fahrenheit. Observation conducted of boiler #2 which revealed the boiler was at 125 degrees Fahrenheit. Interview with Director of Maintenance at the time of the observation confirmed the incoming water temperature of the boilers was high and should be set at 110 degrees Fahrenheit. Observations conducted of hand sinks in resident rooms by the Maintenance Director, Employee E6 on all nursing units as follows: December 8, 2028 between 10:30 a.m. and 11:30 a.m. of First floor East and [NAME] and Second floor East and [NAME] revealed the following high hot water temperatures: room [ROOM NUMBER] registered a temperature of 118.2 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 117.5 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 119.6 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 120 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 115.3 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 118.7 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 120.7 degrees Fahrenheitroom [ROOM NUMBER] registered a temperature of 116.6 degrees Fahrenheit Review of the water temperature logs was completed for the months of November and December 3, 2025. revealed that there were no temperatures out of ranges, all documented to be under the temperature of 110 degrees Fahrenheit. Interview with Maintenance Director, Employee E6 on December 8, 2025, at 11:20 a.m. revealed he was aware the temperatures are supposed to be under 110 degrees Fahrenheit but had turned up the temperatures on the boilers to accommodate the complaints of residents of water temperatures are too cold. Maintenance Director, Employee E6 revealed he adjusted the temperature approximately one month prior to observations. On December 8, 2025, at 11:20 a.m., an interview conducted with Nursing aide, Employee E5 revealed, Employee E5 uses his hand to test the water temperature and confirmed that he has not used water thermometers as they are not available in the showers. On December 8, 2025, at 11:24 a.m., an interview conducted with Unit manager, Employee E4 revealed the nursing station did not have water thermometers available to test the water temperatures when providing showers. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation. Refer to F689 28 PA Code 201.14 (a) Responsibility of licensee 28 Pa Code 201.18(a) Management

Based on observations, staff interviews, and clinical record reviews, the facility failed to ensure staff followed infection control practices by not wearing a gown during tracheostomy care and incontinence care for one of 29 residents reviewed for tracheostomy care and incontinence care (Resident R127).Findings Include: Review of the facility policy titled Enhanced Barrier Precaution revealed that Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident care activities include:DressingBathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Indwelling medical devices include, but are not limited to, central vascular lines (including hemodialysis catheters), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The policy further states that Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds who do not otherwise meet criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether other residents in the facility are known to have MDRO colonization. Devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring an MDRO, and many residents colonized with an MDRO are asymptomatic or not known to be colonized. Observation of Resident R127's room on December 11, 2025, at 9:30 a.m. revealed a sign outside the resident's room indicating EBP (Enhanced Barrier Precautions). Observation of Resident R127's room on December 11, 2025, at 9:30 a.m. revealed that Employee E11, Nurse Aide, was providing incontinence care. The employee was not wearing a gown, and it was observed that the employee's scrub top was touching the resident's bed. Observation of Resident R127's tracheostomy care on December 11, 2025, at 9:40 a.m. with Employee E12, Licensed Practical Nurse, and Employee E11 revealed that both employees, who were providing direct contact with the resident during tracheostomy care, were not wearing gowns as required by the facility's Enhanced Barrier Precautions policy. 28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, facility policies and facility documentation, and interview with staff, it was determined the facility failed to ensure Resident R1 was free of neglect which resulted in actual harm to Resident R1 who was transferred from chair to bed without the use of a mechanical lift and sustained a left humeral fracture for one of five residents reviewed. (Resident R1) Findings include: Review of an undated facility policy titled, Abuse Policy, revealed It is the policy of the facility to protect its residents from mistreatment, neglect, abuse, misappropriation of resident property and exploitation, and that all reports of abuse will be reported to the appropriate agencies and thoroughly investigated. The policy further defined neglect as the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm. Review of the clinical record for Resident R1 revealed the resident had been admitted to the facility on [DATE], with diagnoses including muscle weakness and difficulty walking. Further review of Resident R1's clinical record revealed a care plan initiated on September 14, 2018, indicating the resident required the assistance of two staff for incontinent care, toileting, turning, moving up in bed and transfers with 2-persons transfer using a mechanical lift. Review of Resident R1's October 7, 2025, quarterly MDS (Minimum Data Set- comprehensive resident assessment) revealed the resident was totally dependent on the assistance of two or more staff for a chair to bed transfer. The resident was assessed with a BIMS (Brief Interview of Mental Status) of 14 which indicated the resident was cognitively intact. Review of information submitted to the State Survey Agency on October 24, 2025, revealed, on Sunday, October 19, 2025, at 1:52 p.m. it was reported Resident R1 was observed with swelling and bruising to (her/his) left upper arm and left lateral breast area. When asked about the bruises Resident R1 reported it happened sometime Friday, October 17, 2025, during a one-person transfer by male staff later identified as Licensed nurse, Employee E4, who worked on the unit that day. Resident R1 went on to say that during the transfer (she/he) felt a pop in (her/his) shoulder but felt ok once (she/he) was lying in bed. Two days later, on Sunday the swelling and bruising was noted to the left side of the resident's body and the physician was notified and ordered an in-house x-ray of the left side which was inconclusive. Resident R1 was sent out to the emergency room (ER) for detailed radiologic studies which showed the resident sustained a comminuted fracture (broken bone with multiple pieces, usually caused by severe trauma) of the proximal left humerus (proximal humerus fracture is when the top part of the upper arm bone, which is shaped like a ball, is broken. It may also be referred to as a shoulder fracture). The report further revealed Licensed nurse, Employee E4 did not follow Resident R1's plan of care for transfers which was for two-person transfer using a mechanical lift. Review of facility documentation, revealed statement from nurse aide, Employee E5, which indicated, she was on duty on the second floor on October 17, 2025, and caring for Resident R1 on the evening shift. She and another nurse aide were preparing to put Resident R1 to bed and had tried two mechanical full body lifts, which were not working, and asked the Licensed nurse, Employee E4, for help. Review of Licensed nurse, Employee E4's statement revealed that he was the charge nurse on duty on the second floor on October 17, 2025, when around 8:00 p.m. the nurse aide, Employee E5, asked him for assistance putting Resident R1 back to bed. The statement indicated when I entered [Resident R1's] room I saw that [she/he] was sitting on the lift pad in [his/her] wheelchair next to the bed with the lift next to [her/him], but the lift was not working. The space between the wheelchair and the bed was small, so I decided to quickly transfer [him/her] to the bed using a one-person lift. Review of Licensed nurse, Employee E7's written statement indicated she was on duty on the 11:00 p.m. to 7:00 a.m. shift on October 17, 2025, on the second floor. Licensed nurse, Employee E7 indicated Resident R1's son had come out of the resident's room and requested more pain medication. She told Resident R1 that (she/he) had to wait six hours until [he/she] could have more medication and that Resident R1 indicated that [she/he] did have pain in [her/his] left arm when touched but that it was not bruised at the time. Review of nurse aide, Employee E8's written statement indicated that he was caring for Resident R1 in resident's room on the morning of October 19, 2025, when he noticed that the resident's left arm was swollen when he was washing the resident. Resident R1 told him that the injury happened when a male caregiver had picked [her/him] up under [his/her] arms and put [her/him] in bed because the lift was not working. Nurse aide, Employee E8 reported the swelling to the charge nurse. Review of Licensed nurse, Employee E9, written statement revealed that she was the charge nurse on the 7:00 a.m. to 3:00 p.m. shift on October 19, 2025, when nurse aide, Employee E8 reported to her that Resident R1 had swelling on [her/his] left upper arm. Licensed nurse, Employee E9's assessment of Resident R1 revealed the resident complained of pain from [her/his] left upper arm to [her/his] shoulder, and there was visible bruising to [her/his] bicep and left lateral breast. The statement also indicated that Resident R1 stated that it had happened during a transfer. Review of written statement of Nurse Supervisor, Employee E10, on duty on October 19, 2025, when the charge nurse called her to assess Resident R1. She noted redness, swelling and pain and asked the charge nurse to call the physician to obtain an x-ray. She further noted that the order was obtained for the x-ray and to continue current pain management that was in place. Review of the statement from Unit Manager, Employee E11, on October 20, 2025, revealed that she interviewed and assessed Resident R1 noting swelling and discoloration under the resident's left armpit and under (his/her) left arm. Resident R1 told her that a male caregiver was transferring (her/him) by lifting (her/his) into (her/his) bed because he said that the mechanical lift was not working. Unit Manager, Employee E11 notified maintenance about the lift and Resident R1 was sent out to the emergency room for evaluation. Review of the Social Work Director, Employee E6, interview of Resident R1 on October 20, 2025, revealed that Resident R1 remembered a male caregiver wrapping his arms around (her/him) and lifting (her/him). Resident R1 stated that is when the resident heard a crack and pain to the left side from (her/him) arm to (her/his) shoulder. Social Work Director, Employee E6 observed resident's left arm appeared to be swollen from above elbow to (her/his) shoulder. Review of Resident R1's CT (computed tomography scan- medical image use to create detail cross sectional images of the inside of the body) scan of the left shoulder dated October 20, 2025, revealed an acute comminuted left proximal humeral fracture. Interview with Licensed nurse, Employee E12, revealed that there were two mechanical lifts on each floor, one on each unit, and that the extra batteries were kept in the med-room on the charger. She further stated that the 11:00 p.m. to 7:00 a.m. staff switch the batteries each morning before the day shift comes on duty. Interview with Employee E1, Nursing Home Administrator (NHA), on November 3, 2025, at approximately 1:15 p.m. confirmed that when she interviewed Licensed nurse, Employee E4 he admitted that he performed a one-person transfer of Resident R1 on October 17, 2025, at around 8:00 p.m. And that he was upset and tearful, stating that during the transfer he felt it did not feel right. Telephone interview with Licensed nurse, Employee E4, at 7:45 p.m. on November 4, 2025, confirmed that he was asked for help by nurse aide, Employee E5, to put Resident R1 back to bed because the mechanical lift was not working, and that he decided to perform a one-person lift because the resident's wheelchair was close to the bed, and that he understood that this usually calls for at least two-person lift. Licensed nurse, Employee E4 further stated that Resident R1 was not his resident but he was just trying to help, and that the lift was not working due to the battery not being charged, and that he did not look for another battery. The facility failed to ensure that Resident R1 was free of neglect which resulted in actual harm to Resident R1 who was transfer from chair to bed without the use of a mechanical lift as care plan and sustained a left humeral fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) 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

Based on staff interview and facility documentation, it was determined that the facility failed to report to the State Survey Agency and conduct an investigation related to an allegation of neglect for one of 9 residents reviewed. (Resident R2) Findings include:A review of the Incident and Accidents Documentation policy, which was undated, revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.On September 4, 2025, at 2:45 p.m., an interview was conducted with the Administrator, Employee E1, who reported that the facility was not aware of any incontinence neglect, with respect to Resident R2. Employee E1 further reported that the Human Resources Director, Employee E11, was out sick, and the facility was unable to provide the nurse aide personnel file for Employee E14, who had been terminated on August 29, 2025. Employee E1 stated that Employee E14's file would be forwarded to the surveyor via email on September 5, 2025.On September 5, 2025, at 2:00 p.m., a review of nurse aide, Employee E14's, personnel file contained an email from Employee E14 to the Nursing Home Administrator, dated August 23, 2025, at 5:53 p.m. In the email, Employee E14 reported: Resident R2, at approximately 3:00 p.m., at the start of my second shift, I found the resident seated in a Geri chair. The resident's clothing and the Hoyer pad were saturated with urine. The urine had soaked through all layers of clothing and the pad, and the chair was also wet. The Hoyer pad in use was observed to be a size not recommended for the resident's weight per the care plan. There was no indication or documentation that the resident had been toileted or changed prior to my shift.The same day an email was sent to the facility at 2:29 p.m. and again at 4:01 p.m. requesting the investigation of the above allegation of neglect. No response was received from the Administration. There was no documented evidence that the allegation of neglect was reported to the State Agency as required and that the facility conducted an investigation upon becoming aware of the allegation of neglect related to delivering timely incontinence care to Resident R2. 28 Pa. Code 201.14(a)(b) Responsibility of licensee28 Pa. Code 201.18(b)(1)(2)(3) Management28 Pa. Code 201.29(a) Resident rights

Based on review of facility documentation, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall and to ensure that an air mattress was properly fastened to the bed for two out of nine residents reviewed. (Residents R1 and R8).Findings include:A review of the undated facility policy title Incident and Accidents Documentation revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of cerebral infarction, falls, pain, acute kidney failure, encephalopathy (disease of the brain), muscle weakness, cognitive communication deficit, mixed receptive-expressive language disorder, and obesity.Review of Resident R1's Minimum Data Set (MDS-an assessment of a resident's abilities and care needs), dated August 7, 2025, revealed that Resident R1 did not have a Brief Interview for Mental Status (BIMS) score recorded, indicating that the resident was unable to participate in the assessment due to severe cognitive impairment.Review of Resident R1's care plan, initiated on March 14, 2022, revealed that the resident had a self-care deficit, requiring assistance with activities of daily living (ADLs) related to decreased cognition and generalized muscle weakness. Interventions included: two-person assistance with transfers and turning, mechanical lift with two or more persons, two-person assistance for incontinent care, repositioning in bed, and transfers with a Hoyer (mechanical) lift.A comprehensive care plan, dated August 27, 2025, further revealed that Resident R1 was at risk for falls due to decreased cognition and decreased mobility. Interventions included: Have maintenance check the mattress to ensure it is well fastened to the bed.Review of facility documentation, dated August 28, 2025, revealed an investigation was initiated on August 26, 2025 related to Resident R1's had a witnessed fall in her bedroom during routine care. At about 11:45 a.m. 2 staff members, a certified nursing aide, [Employee E4] and charge nurse were providing routine a.m./incontinence care for [Resident R1] in her bed. While turning the resident onto her right side towards the [Nurse Aide, Employee E4] suddenly the mattress shifted causing the [Resident R1] to accidentally roll out of bed to the floor mat resulting in a small hematoma to the left side of her forehead.An interview was conducted with nurse aide, Employee E4. E4 on September 4, 2025, at 11:22 a.m., revealed that on August 26, 2025, while providing incontinence care to Resident R1, I was standing approximately two feet away from Resident R1 bed and turned her towards myself. The mattress shifted, and Resident R1 fell into the two-foot gap between myself and the bed. Employee E4 further explained that he had been trained to use his body to close the gap between himself and the bed to prevent accidental falls. He acknowledged, I was too far from the bed, which allowed the resident to fall.An interview was conducted with the Maintenance Director, Employee E7 on September 4, 2025, at 12:03 p.m. who confirmed that he had placed an air mattress for Resident R1 a month ago before the fall and the mattress was secured with six straps before resident's fall on August 26, 2025.Observation conducted of Resident R8, who was also ordered to have an air mattress in room [ROOM NUMBER]B. Resident R8's mattress was not fastened to the bed with the six straps. Maintenance Director, Employee E7 confirmed this observation and reported that it is common practice in the facility for evening or night staff, when changing an air mattress for a resident, to not fasten the mattress to the bed. He acknowledged that this practice could result in the air mattress shifting. Employee E7 immediately fastened the six straps securing Resident R8's mattress to the bed.On September 4, 2025, at 2:45 p.m., an interview was conducted with the Nursing Home Administrator, Employee E1. who confirmed that Nurse aide, Employee E4, was standing approximately two feet away from Resident R1 during incontinence care, which resulted in the resident's fall. Employee E1 further confirmed that Resident R8's air mattress should have been secured to the bed with six straps.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records and staff interview, it was determined that the facility failed to maintain complete documentation of resident's clinical records for one of 9 resident records reviewed (Resident R9).Findings include:A review of the Incident and Accidents Documentation policy, which was undated, revealed The facility will document unusual occurrences and events. Guidelines q. The following occurrences warrant an incident report a. Actual, alleged, or suspected abuse, including verbal abuse, oral, written or gestured, sexual abuse, harassment, coercion, assault, physical abuse, hitting, slapping, pinching, kicking, pushing, pulling, rough hanging, etc.On September 4, 2025, at 2:35 p.m., an interview was conducted with the Administrator, Employee E1, and the weekend supervisor, Employee E13. They reported that on August 24, 2025, at 6:00 p.m., an incident occurred in the front lobby involving Resident R9 during a visit with the resident's family. Employee E13, who responded to the situation, confirmed that there was no documentation in Resident R9's clinical record regarding the incident. 28 Pa. Code 201.14(a)(b) Responsibility of licensee28 Pa. Code 201.18(b)(1)(2)(3) Management28 Pa. Code 201.29(a) Resident rights

Based on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to provide adequate supervision and failed to maintain an environment free of potential hazards for one resident with elopement risk (Resident R14). One of four residents reviewed. (Resident R1) Findings include: Review of undated facility policy Resident Elopement Follow-Up Procedure, revealed that Guidelines: After an elopement,. The following actions will be initiated: 1) A photograph will be taken and placed at the reception desk identifying the resident as an elopement risk. 2) The receptionist will be familiarized with the resident. 3) Elopement Risk will be added to resident's Care Plan. 4) An elopement assessment will be conducted for residents on incident and at least quarterly thereafter. 5) If a president is no longer an elopement risk, he/she will be reassessed and care [plan will be updated as appropriate. The facility strives to prevent resident/patient elopement. The facility also recognizes mobility as a strength to be supported and promoted. Review of facility documentation dated May 01, 2025, revealed that during routine rounds, it was discovered that resident was not in his room. His room was located on the first floor, the resident had broken the window block, kicked out the screen and squeezed through the window. Resident was able to walk off without injury due to the room window being on the first floor and close to the ground. Resident R1 was found at his family home by police, and the police returned the resident to the facility. Resident R1 was placed on one-on-one supervision immediately. Review of care plan for Resident R1 dated May 1, 2025, revealed that the resident was at risk for elopement related to eloping from facility. Interventions included staff to check on resident's whereabouts throughout the shift and place picture at receptionist desk. Observation of the facility reception desk on May 15, 2025, revealed that there was a picture folder with residents at risk for elopement. It was revealed that there was no picture of Resident R1 at the reception area. Interview with Administrator, Employee E1, on May 15, 2025, at 1:30 p.m. stated placing picture at the reception area was one of the intervention facilities implemented following Resident R1's elopement on May 1, 2025. Administrator confirmed that Resident R1's picture was not available at the reception area according to his plan of care and facility corrective action. . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, and interview with staff and residents, it was determined that facility failed to ensure that resident were assisted out of bed as per resident's preference for nine of 69 residents observed (Resident R10, R11, R12, R13, R14, R15, R16, R17, R18) Findings include: Review of facility policy 'Quality of Care: Activities of Daily Living - Prevent Deterioration,' indicates that based on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. Interview with licensed nurse, employee E4, on April 9, 2025 at 10:50 am, revealed that residents are to be assisted out of bed by 11:00 am. Interview with Resident R11, on April 9, 2025, at 11:15 am, revealed that he is paralyzed on right side of body and requires assistance with transfer from bed to chair. Interview with Resident R11 revealed that the resident prefers to be placed in wheelchair during day shift (7-3 shift). Further observations of residents on unit 2-West, revealed Residents R10, R11, R12, R13, R14, R15, R16, R17, and R18 in beds at 11:15 am. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and interview with residents, it was determined that facility did not provide a clean, comfortable, homelike environment for four of 20 rooms observed (common shower room, Resident R8's room, room#225-B, room [ROOM NUMBER]-A) Findings include: Review of facility policy related to 'Physical environment: common areas,' states that the facility will be maintained to protect the health and safety of residents, personnel and the public. Observations of common shower room on unit 2-West, on April 9, 2025, at 10:30 am, revealed used towels on floor and used paper towels on floor in toilet stall. Further observations revealed shower gel/shampoo bottles on floor in shower stall. Further observations revealed used hygiene products on shower bed; shower bed appeared unclean. Findings confirmed with facility's director of nursing. Observations in room [ROOM NUMBER] revealed stained ceiling tile near bed B; upon interview with resident R7 it was revealed that during rainy weather water leaks through the ceiling tile, down the wall and from the bottom of HVAC. A towel was observed under HVAC (air conditioning system). Further observations on 2-West unit revealed Resident R8, sitting on bed stained with feces, urine-soaked linen on top of bed, foul odor noted and trash laying on the floor. Resident R8 was attempting to pick up soiled brief from floor. Further observations on unit 2-West, room#228, bed A, revealed used urinal attached to trash bin, briefs on floor, washbasin on floor, used washcloth on bedside table, toilet paper on bedside table. Review of facility provided grievance reports revealed a concern reported by resident's family member on March 4, 2025, which states the following : On Sunday, March 2, 2025, I came into my mom's room at 10:30 am. There were used latex gloves on the dresser, used tissues on the floor, a wet washcloth laying on the side of the bed. I cleaned the room. Today (March 4, 2025) I come in her room and her dentures are sitting on the edge of the bedside table and could have easily broken. I would like the aides to clean up after themselves and not leave discarded supplies lying around the room. Also, when not in her mouth, please put her dentures in the blue cup provided. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 205.63(b) Plumbing and piping systems required for existing and new construction.

Based on a review of facility documentation, review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to ensure for two out of three residents reviewed were free from physical abuse (Resident R1 and Resident R3) from another resident (Resident CL1) which resulted in a [CONDITION(S)] and actual harm to Resident R1. Findings include: A review of the facility's abuse policy titled Freedom from Abuse, Neglect and Exploitation dated November 28, 2016, revealed that, It is the policy of [NAME] Nursing Center [facility previous name] to protect its residents from mistreatment, neglect, abuse, misappropriation of resident property and exploitation, and that all reports of abuse will be reported to the appropriate agencies and thoroughly investigated. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or any other individual. Further review of the policy revealed that physical abuse includes but not limited to hitting, slapping, pinching, kicking, etc. It also includes control of the resident behavior through corporal punishment. Prevention of abuse will include: identify, correct, and intervene in situations in which abuse, neglect, and/ or misappropriation of a resident property is more likely to occur. Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. This includes resident to resident abuse. The Administrator or his/her designee will report the allegations to the appropriate agencies as required by law. The following reporting procedures will be observed: The local police will be contacted as necessary. A review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R1's annual MDS (minimum data set- a periodic review of the residents needs) dated July 26, 2022, revealed that the resident was independent in decision making skills and was independent in ambulating in her room. A review of Resident CL1's closed clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident CL1's MDS (minimum data set-a periodic review of the residents needs) dated June 30, 2022, revealed the resident was severly impaired in decision making skills and was able to ambulate by pushing her wheelchair. Review of Resident CL1's clinical record revealed a care plan initiated on June 25, 2022, and revised on August 8, 2022, that revealed the resident has the potential to be physically aggressive related to Dementia, Poor impulse control and actual history of aggression. The goals for the resident included not to harm self or others and for the resident to verbalize of need to control physically aggressive behavior. The interventions for the resident included: to administer medications as ordered; and to monitor / document for side effects and effectiveness; Assess and address for contributing sensory deficits; Assess and anticipate resident 's needs, food, thirst, toileting needs, comfort level, body positioning and pain; Give the resident as many choices as possible about care and activities; Psych Consult PRN; When the resident becomes agitated intervene before agitation escalates; guide away from source distress, engage calmly in conversation, If response is aggressive staff to walk calmly away and approach later. A review of facility documentation dated August 14, 2022, revealed that Resident R1 and CL1 were found on the floor near the doorway of Resident R1's room after an altercation. Resident R1 stated that Resident CL1 pulled on her wrist and flung her to the floor. Resident R1 was found lying on her right side and Resident CL1 was found sitting on the floor. Resident R1 was assessed and found to have one leg shorter than the other. The resident did complain of right wrist and right hip pain. Emergency medical personnel were called, responded and transported Resident R1 to the hospital. Resident CL1 remained on the floor yelling and stating I'm not getting up. Staff assisted Resident CL1 off the floor and she attempted to hit and bite the staff. Resident CL1 was put on one to one for observation. The hospital called the facility and stated that Resident R1 had a fractured right hip. Resident CL1 was admitted to a behavior health facility for 15 days. An interview with Resident R1 on August 19, 2022, at 10:30 a.m. revealed that Resident CL1 would come into Resident R1's room and take items. Resident R1 stated that she didn't mind if [CL1] wanted food [Resident R1] would share it but [CL1] would take items like clothes or perfume. On August 14, 2022, Resident R1 stated that [Resident CL1] was in her room and blocking the doorway for [Resident R1] to get out. Resident R1 asked the resident to move and that's when [CL1] grab my wrist and flung me onto the floor. Resident R1 stated that my hip hurt and the staff sent me to the hospital and the hospital told me my right hip was fractured. An interview with Employee E18, RN-staff development, on August 19, 2022, at 10:45 a.m. revealed that she was working as the supervisor on August 14, 2022, the day of the incident. She stated I received a call from the 2nd floor that two residents had an altercation and were on the floor. I responded and assessed [Resident R1] and found the right leg shorter than the left leg. I called for an ambulance and the resident was taken to the hospital. I found out later that [Resident R1] had a right [CONDITION(S)]. When asked if Resident CL1 had ever hit or attacked another resident Employee E18 stated not to the best of my knowledge. Employee E18 stated Resident CL1 was combative while staff was trying to get her off the floor. An interview with Employee E16, social worker, on August 19, 2022, at 11:50 a.m. revealed that he worked as a manager on duty on August 14, 2022. He stated he was called to the 2nd floor to help with Resident CL1. He stated that [Resident CL1] was agitated and kicking and trying to bite staff. She was placed in a chair and started to fall asleep. When asked if he had ever observed Resident CL1 hit or attack another resident he stated no and he stated per staff she does threaten staff. An interview with Employee E19, a nursing assistant on August 19, 2022, at 11:30 a.m. revealed that she worked as a nursing assistant on August 14, 2022. She stated I heard my co-worker yell for help I ran to the resident room and observed Resident R1 lying on her side and Resident CL1 sitting on the floor. Other staff were taking care of Resident R1 and Resident CL1 was shouting don't touch me. Additional staff came and assisted CL1 off the floor. When asked if she had ever observed Resident CL1 hit another resident or staff she responded no. Further review of resident CL1's clinical record revealed a nurse's note dated July 27, 2022, the resident was physically and verbally aggressive to staff and to roommates, tried to push them out of the room. Nurse's note dated August 1, 2022, revealed the resident yelling get out of my room. The facility failed to ensure that Resident R1 remained free from physical abuse from another resident resulting in actual harm to include a [CONDITION(S)]. An interview with the Director of Nursing on August 19, 2022 at 1:00 p.m. revealed that Resident CL1 had pushed a resident out of bed several days prior to grabbing Resident R1's wrist and flinging her onto the floor causing Resident R1 to sustain a right [CONDITION(S)]. A review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R3's quarterly MDS (minimum data set- a periodic review of the residents needs) dated June 14, 2022, which revealed that the resident was severely cognitively impaired in decision making skills. The resident is on hospice since September 25, 2021. A review of a nurse's note dated August 7, 2022, revealed that Resident CL1 was sleeping in her roommate's bed (Resident R3), when asked why she stated that's my bed. Asked why did you push her out of bed, she just stared at me.'' Further review of nurse's note dated August 7, 2022, revealed the resident pushed her roommate out of bed and layed in her bed. A review of Resident R3's nurse's note dated August 7, 2022, revealed that the resident was lying on floor and Resident CL1 was in her bed. Some redness noted to face and right inner knee [Resident R3]. Neurological checks initiated. Review of the facility's investigation for the event occurring on August 7, 2022, revealed: interventions implemented to prevent another occurrence: UA/C & S (Urinalysis culture and sensitivity); Psychiatric Consult; Q (every) 30 minute checks; Room Change; medication Change. The facility failed to ensure for two out of three residents reviewed were free from physical abuse (Resident R1 and Resident R3) from another resident (Resident CL1) which resulted in a [CONDITION(S)] and actual harm to Resident R1. 483.13 Resident behavior and facility practices 10-1-1998 edition 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

Based on observation, interviews with a resident and staff and review of clinical records, facility documentation, and review of facility policies and procedures, it was determined that the facility failed to ensure that each resident environment residents remained free of accident hazards by failing to test the temperature of hot coffee prior to being served to residents. This failure resulted in an Immediate Jeopardy situation to Resident R1 who spilled hot coffee on the left lateral thigh and developed a second degree burn for one of five residents reviewed. (Resident R1) Findings include: Review of the facility policy titled, Dietary Services, last reviewed January 2020 indicated that the Coffee Machine is programmed at 160 degrees. The coffee temperature is checked prior to serving to ensure palatable temperature range (120-140 degrees). Review of Resident R1's admission Minimum Data Set (MDS is a periodic assessment of the resident's needs) dated July 15, 2020, revealed a BIMS (Brief Interview of Mental Status- a brief screening tool that aids in detecting cognitive impairment ) score of 15, which indicated that the resident was cognitively intact. Further review of the resident's MDS revealed that the resident was assessed as requiring limited assistance for eating of one person, no upper extremities limitation and no swallowing disorder. The resident's diagnoses listed in the MDS assessment included [CONDITION(S)] (a progressive lung disease that makes it hard to breath), depression, [CONDITION(S)] (low iron) and Von Willebrand's Disease (a bleeding disorder). Review of facility documentation dated September 25, 2020, stated that, Resident R1 knocked over a coffee cup spilling it on her. The documentation continued to state, Resident had received cup of coffee from activity prior to incident. In-service provided to activity department to check temperature of coffee before serving. Review of the Resident R1 nursing progress notes dated September 25, 2020, at 11:30 a.m. indicated the resident called for a nurse and stated she had Spilled some liquid on herself. When the nurse removed the wet clothing, Redness was noted to her left side. The nurse applied a cool compress and once removed, Noted blister to left hip 2x1. Review of Resident R1's physician's orders dated September 26, 2020 revealed that a treatment was obtained for the left upper thigh to topically apply [MEDICATION(S)] Cream 1% (a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound [CONDITION(S)] in patients with second- and third-degree [CONDITION(S)]), every day shift, for skin care. Cleanse area with normal saline and pat dry, and cover with 4x4 (size bandage). Review of Resident R1's wound progress report dated, October 1, 2020, described the wound as, blister/second degree, partial thickness (the first and some second layers of skin are burned), 100% slough (yellowish-white dead skin) measuring 2. X 3. centimeters. Review of Resident R1's October 1, 2020, surgical note described a subcutaneous tissue debridement (damaged tissue was removed in the lower most layer of skin) was performed on the resident's left thigh. The wound area measured 2 centimeters (cm) x 3 cm x 0.1 cm. The surgical note stated, There was an indication of tissue degradation entailing continuing supervision and will probably need future debridement. Healing of these wounds can not be guaranteed given the patient's risk factors/diagnoses. The same note states, I feel the prognosis for the patient's left thigh to be poor. During an interview with Resident R1 on October 5, 2020, at 11:00 a.m. the resident stated that when she went to reach for the cup I knocked the coffee all over me. The coffee went down my leg and it was hot! The resident pointed to her left upper thigh revealing the bandaged wound. The resident described the pain as 8/10 (on a scale of 0-10, 10 being the most painful) and stated, It was painful. Observation of the wound on October 5, 2020, at 1:30 p.m. with the Registered Nurse (RN) One East, Unit Manager, Employee E6 indicated the wound measured 3cm. x 2cm. x <0.1 cm. The wound was 100% slough. During an interview on October 5, 2020, at approximately 12:00 p.m. with the Director of Physical Therapist, Employee E4 and Occupational Therapist, Employee E5 both employees indicated that Resident R1 was evaluated on July 1, 2020 during admission and again in August 2020. Both assessments revealed no adaptive equipment were needed for eating. Since the coffee spill, a safety lid is now required with coffee. Interview with the Activity Director, Employee E2 on October 5, 2020, at 1:00 p.m. revealed We have an activity called the Traveling Coffee Klatch on Mondays, Wednesdays and Fridays. The Activity department would make the coffee, put it in an urn and place the coffee on a cart. We'd wheel the carts to the residents' rooms and offer them coffee and cookies. I'm the one that gave Resident R1 the coffee, then left to finish serving the coffee. The next time I saw her it was after the coffee spill. During that time, the Activity department got their own coffee ready for the activity, not the kitchen. We (Activity Department's staff) never tested the temperature of the coffee before it was served to the residents. During an interview on October 5, 2020. at 2:15 p.m. the Nursing Home Administrator (NHA) stated, During an Activity program, the Activity department offers coffee to the residents. The Activity department was not checking the temperature of the coffee prior to serving the coffee to the residents. The Activity Director offered Resident R1 the coffee and the resident spilled it on herself. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on October 5, 2020, at 7:25 p.m. The Nursing Home Administrator failed to ensure that hot beverages were served at a safe temperature, resulting in actual harm to Resident R1 spilling hot coffee on the left lateral thigh on September 25, 2020, and developing a second degree burn. The facility's corrective action plan included the following interventions: -All residents are evaluated for dexterity/fine motor skills on admission, readmissions, significant change and quarterly. -All residents have been reevaluated for dexterity/fine motor skills. -Therapy and nursing will keep a list of residents who require adaptive equipment which is available in the dietary department. -Prior to serving hot beverages, the activities personnel will obtain a list of residents who require adaptive equipment from the dietary department, therapy department or nursing supervisor. -Hot beverages will be obtained from the dietary department. -The cook or designee will prepare hot beverages for the activity and check temperature with thermometer to ensure that it is within the range of (120-140 degrees). -Activities personnel will re-check temperature with thermometer prior to delivering to residents to ensure temperature is within the range of (120 to 140 degrees). -Dietary department will recheck temperatures prior to delivery on food trays for each meal to ensure temperature is within the range of (120 to 140 degrees). -Temperatures will be recorded in a log and kept on file at facility. -Hot beverages will be served with a lid as precautionary measure. -In servicing has begun on this protocol and continue until all dietary and activities staff have been reeducated. -Staff will be in- serviced prior to the start of their shift. All in-servicing will be completed by Thursday 10/8/20. Monitoring visits were conducted on October 6, 2020, and October 7, 2020, to verify the implementation of the corrective action plan and review staff education documentation. The Activity and Dietary staff were inserviced prior to the start of their shift. Observation conducted of the activity and dietary department and review of the temperature assessment of the hot liquids served to the residents on October 7, 2020 at approximately 10:00 a.m. confirmed the activity department obtained the prepared hot beverages from the dietary department. The dietary department tested the hot beverages with a thermometer to ensure the temperature range of 120-140 degrees Fahrenheit. The activity department re-checked the temperature of the hot beverage prior to delivering to residents to ensure the temperature was within the degree range. The activity department obtained a list of residents needing adaptive equipment with their hot beverage. All residents were served hot beverages with either adaptive equipment or with mug and lid. Activity and Dietary documented and maintained a temperature log of all tested hot beverages. Interviews conducted with the activity and dietary department on October 6, 2020, between 1:00 p.m. - 2:30 p.m. and on October 7, 2020, between the hours of 10:00 a.m. -11:00 a.m. confirmed that the dietary and activity staff had been in-serviced and the facility's plan of action had been implemented. The Immediate Jeopardy was lifted On October 7, 2020, at 1:28 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)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, facility documentation and policy, and interviews with staff, it was determined that the facility failed to ensure the alarms on the main entrance door were functioning properly on weekends, including Saturday (MONTH) 10, (YEAR). This failure resulted in one resident (Resident R2) eloping from the facility, placed the health and safety of 21 other residents assessed at risk of eloping from the facility, and continued to pose a threat to the health and safety of 17 residents in the facility who were assessed at risk of eloping as of (MONTH) 7, 2019 because weekend door checks were not being completed. These conditions resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Resident Elopement, dated last revised (MONTH) 2010, revealed that It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. The policy defines elopement as when a resident leaves the facility premises for any period of time that the staff does not know his/her whereabouts. Clinical record review for Resident R2 revealed an admission Minimum Data Set assessment (MDS - a mandatory periodic resident assessment tool) dated (MONTH) 11, (YEAR), indicating that the resident was admitted to the facility on (MONTH) 4, (YEAR), and was severely cognitively impaired. Review of the resident's elopement assessment dated (MONTH) 11, (YEAR), revealed that the resident was at risk for elopement and had a Wanderguard (a system to assist monitoring residents and maintain safety) device on his right wrist. Review of progress notes revealed a nurse's note dated (MONTH) 10, (YEAR), at 12:16 p.m. which indicated that Resident R2 was observed aggressively talking to staff, persistently walking the halls, that he had placed all his belongings including his TV outside of his room and stated that he wanted to go home. Continued review of progress notes revealed a nurse's note dated (MONTH) 10, (YEAR), at 5:00 p.m. stating that she was notified by another nurse that Resident R2 had left the building and was found at the deli. Review of facility documentation submitted on (MONTH) 12, (YEAR), at 6:54 a.m. revealed that Resident R2 was observed by a staff member outside of the building on (MONTH) 10, (YEAR), at 4:20 p.m. Review of facility documentation related to the incident revealed a witness statement from a nurse aide stating that she was in a deli, a block away from the facility, when Resident R2 walked into the store unaccompanied. Witness statements from other staff members on duty on (MONTH) 10, (YEAR), revealed that they were unaware that the resident had left the facility. Continued review of facility documentation related to the incident revealed pictures from camera footage dated (MONTH) 10, (YEAR), showing Resident R2 walking out the main entrance of the building. There were no staff members present in the pictures by the entrance or at the reception desk. Further review of the facility documentation revealed that the Wanderguard door was not wired properly. Interview on (MONTH) 30, 2019, at 12:10 p.m. with the Nursing Home Administrator, revealed that she was unaware that the Wanderguard system was not working properly until after the elopement occurred. Review of maintenance logs for (MONTH) (YEAR), revealed that the Wanderguard system was not checked on (MONTH) 10, (YEAR). Interview on (MONTH) 30, 2019, at 1:15 p.m. with the Maintenance Director, confirmed that the Wanderguard system was not checked on (MONTH) 10, (YEAR), the day of the elopement. Interview on (MONTH) 7, 2019, at 5:40 p.m. with the Maintenance Director revealed that the Maintenance Technician has, for at least the last 12 months, conducted the Monday to Friday checks of doors and that no staff were assigned to conduct weekend checks of the doors through which residents, at risk of eloping, could leave the facility. Interview on (MONTH) 7, 2019, at 6:16 p.m. with the Nursing Home Administrator revealed that on (MONTH) 10, (YEAR), when Resident R2 eloped from the facility, there were another 21 residents at risk of eloping from the building. She also confirmed that it was not the policy of the facility to check door security on weekends. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on (MONTH) 7, 2019, at 6:28 p.m. related to Resident R2 having eloped on (MONTH) 10, (YEAR), the 21 other residents in the facility, who had the potential to elope, on (MONTH) 10, (YEAR), and the ongoing risk to 17 residents in the facility on (MONTH) 7, 2019, who all had been assessed at risk of eloping. These residents were at risk of eloping on the weekends since the functioning of the security doors were not assessed on the weekends and therefore the defect was not identified by the facility staff until Resident R2 had eloped from the facility. The corrective action plan included the following interventions: 1. Unit managers or designee will assess all residents for elopement on admission, readmission, quarterly and following a change in condition. 2. Elopement assessments will be recorded on the resident's medical record in the assessments section. 3. Unit managers or designee will ensure that all residents who are at risk for elopement will have an elopement care plan that is updated at least quarterly. 4. The Maintenance Director or designee will verify and check every door pertaining to the Access Control System on a daily basis Monday through Friday during the day shift to ensure proper functioning. 5. The administrative coverage staff will verify and check every door pertaining to the Access Control System on Saturday and Sundays during the day shift to ensure proper functioning. 6. All door checks will be recorded in a daily written log and made available upon request of regulatory officials. 7. In the event that a door is found to be not functioning properly, the person checking the door will immediately assign a staff person to monitor the door and call the Nursing Home Administrator and the Director of Maintenance. Malfunctioning doors will be monitored 24 hours a day until repaired. 8. In the event of a fire or electrical outage, the nursing supervisor will initiate door watch. Facility staff will be assigned to the lobby, employee's entrance and exit stair towers 24 hours a day until repaired. 9. In addition, the Access control System will be checked monthly on different days and different shifts by the facility fire drill inspector and recorded in the fire drill log. 10. The Nursing Home Administrator, Medical Director and Director of Nursing will review Access Control Policy annually and updated as needed. 11. In-servicing of facility staff will begin immediately to include the following: In the event that a door is found to be not functioning properly, the person checking the door will immediately assign a staff person to monitor the door and call the Nursing Home Administrator and the Director of Maintenance. Malfunctioning doors will be monitored 24 hours a day until repaired. In the event of a fire or electrical outage, the nursing supervisor will initiate door watch. Facility staff will be assigned to the lobby, employee's entrance and exit stair towers 24 hours a day until repaired. In-servicing will be completed by Tuesday, (MONTH) 12, 2019. Weekend and PRN staff will be brought in for in-servicing. Monitoring visits were conducted on (MONTH) 8, 2019 and (MONTH) 9, 2019, to verify the implementation of the immediate action plan and to review staff re-education documentation. All staff in the building at the time of the visit on (MONTH) 9, (YEAR), had been inserviced on the use and care of the new magnetic locking system, which the Nursing Home Administrator felt was 75 % of the entire staff. The staff that come into work will not be allowed to work until they have had the mandatory inservice training. Interviews with the staff working on the floor, including RN'S, LPN'S, NA's, and Dietary staff, reported they had all been inserviced on how to monitor and check that the magnetic log is functioning. The staff knew that if a door is found to not be working correctly they are to station someone at the door and alert the Nursing Home Administrator and the Director of Maintenance. Observation of the doors on the ground floor verified that they were working correctly. The Nursing Home Administrator is training all of the Department Heads regarding their responsibilities when they are assigned as the manager on duty during the weekends. The Immediate Jeopardy was lifted on (MONTH) 9, 2019, at 11:30 a.m. The facility failed to ensure that the alarms on the main entrance door were functioning properly resulting in an elopement and placing the health and safety of 21 other residents assessed at risk of eloping from the facility and continued to pose a threat to the health and safety of 17 residents in the facility who were assessed at risk of eloping as of (MONTH) 7, 2019. The facility failed to ensure that all of the doors through which residents could elope were checked for the functioning of the Wanderguards seven days per week. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 04/03/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/18/19, 05/23/18, 06/07/17, 04/03/17 28 Pa. Code 201.18(a) Management Previously cited 01/18/19, 06/07/17 28 Pa. Code 201.18(b)(1) Management Previously cited 05/23/18, 04/03/17 28 Pa. Code 201.18(b)(3) Management Previously cited 01/18/19, 05/23/18, 06/07/17, 04/03/17 28 Pa. Code 201.18(e)(1) Management Previously cited 04/03/17 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 01/18/19, 05/23/18, 06/07/17, 04/03/17 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/23/18, 04/03/17

Based review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide the necessary assistance to safely transfer and provide care for one resident, which resulted in actual harm of a fractured leg for one of eight residents reviewed (Resident R1). Findings include: Review of facility policy titled, Freedom from abuse, neglect, and exploitation, dated (MONTH) 28, (YEAR), revealed the definitions of abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting physical pain or mental anguish. Abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental and social well-being. Review of Resident R1's clinical record revealed the resident was admitted to the facility on (MONTH) 30, 2013, with a [DIAGNOSES REDACTED]. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident's needs) dated (MONTH) 21, (YEAR), revealed for bed mobility and transfers that the resident required a two-person physical assist. Review of facility document titled, Resident Status Sheet, (utilized by staff as a plan of care for residents) revealed that Resident R1 was a two-person assist for care. Review of Resident R1's clinical record revealed a nurse progress note dated (MONTH) 4, 2019, which revealed Called to resident's room to assess bruising and swelling to resident right lower extremities, on entering room, resident observed in bed lying on her right side, right knee assessed and was noted to be bruised and swollen, noticeable sign of pain upon palpation, temp hot to the touch, x-ray ordered (STAT) awaiting technician arrival. Resident medicated for pain. resident representative was in the facility. Review of Resident R1's clinical record revealed a nurse progress note dated (MONTH) 4, 2019, which revealed resident noted with bruise and swelling to right lower leg outer calf area, resident noted with pain upon touching area, call placed to certified nurse practitioner on call, notified of area and of bruising and swelling. Orders were to get a two view x-ray of right leg, Tylenol given for pain, daughter in today and is aware. Review of Resident R1's clinical record revealed a nurse progress note dated (MONTH) 4, 2019, which revealed a radiology report received with the conclusion of a non-displaced spiral fracture involving the tibia and fibula (lower leg bones), certified nurse practitioner made aware and also gave order for resident to be sent to emergency room for evaluation. Review of Resident R1's clinical record revealed a nurse progress note dated (MONTH) 5, 2019, which revealed the resident was admitted to an acute care hospital with spiral [MEDICAL CONDITION] of the right tibia. Review of the facility's investigation revealed a witness statement signed by Employee E3, nurse aide, and dated (MONTH) 10, 2019, which revealed I provided care for the resident that morning did my morning rounds she was checked at 8 a.m. and she was dry at that time she was happy singing along with me as I checked her. She did not show any signs of pain or discomfort. I then came back it was around 11:45 - 12:00 when I went and started to get her washed and dressed I did not see any kind of bruising or swelling as I was getting her dress. We had did our usual routine we do every day which is singing while getting her ready for the day she did not show any signs of pain she usually kicks her legs up when putting her socks on cause of the touching of the feet and she did that when I put her lotion and socks on. After she was dressed I had left her in bed cause it was lunch time and was going back to get her up after lunch. When I went back to get her up she was sleep and that was at 2:00 (a.m.) after my lounge duty so I just checked to make sure she was not soiled I was done my shift a 3 p.m. as I was walking past her room she was asleep listening to her music. Review of the facility's investigation revealed a witness statement signed by Employee E7, nurse aide, and dated (MONTH) 10, 2019, which revealed I have help (sic) in the past to help but on the (MONTH) 2, 2019, I didn't help her (Employee E3, nurse aide) with any care nor transfer. She approach me to lie for her (Employee E3, nurse aide) and I apologize. Review of a facility in-service document titled, Resident Status Sheets, dated (MONTH) 31, (YEAR), revealed Employee E3, nurse aide, signed the sheet which revealed all nurse aides must check the resident status sheet prior to providing care to the resident. Resident status sheets are there to provide you with pertinent information regarding your resident so that you will be able to provide appropriate care. If there are any missing status sheets for your residents, you must notify your manager or supervisor immediately so that the sheet can be replaced prior to the start of your care. Employee (Employee E3, nurse aide) was in-serviced on the protocol for checking the status sheet on 3/31/17. When the NHA asked the employee if she was aware that she was supposed to look (sic) at the status sheet at the beginning of her shift, she admitted that she was aware but that she did not look at them. During an interview with the NHA on (MONTH) 30, 2019, at approximately 11:30 a.m. she confirmed that Employee E3, nurse aide, admitted providing care and transferring the resident by herself and not with the assistance of another staff member as ordered on (MONTH) 3 and 4, 2019. The facility failed to provide the necessary assistance to safely transfer and provide care for one resident, which resulted in actual harm of a spiral [MEDICAL CONDITION] leg. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/18/19, 05/23/18, 06/07/17, 04/03/17 28 Pa. Code 201.18(b)(1) Management Previously cited 05/23/18, 04/03/17 28 Pa. Code 201.18(b)(3) Management Previously cited 01/18/19, 05/23/18, 06/07/17, 04/03/17 28 Pa. Code 201.18(e)(1) Management Previously cited 04/03/17 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/23/18, 04/03/17

Based on review of clinical records, and interviews with staff, it was determined that the facility failed to ensure adequate supervision during care, which resulted in injury, when the resident fell from the bed and suffered a subarachnoid hemorrhage, for one of 26 residents reviewed (Resident R61). Findings include: A review of Resident R61's physcian's orders dated March 2017, revealed [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set assessment (MDS - periodic assessments of needs) dated January 4, 2017, revealed that Resident R61 was cognitively intact and had a BIMS (Brief Interview for Mental Status - a tool used to assess a resident's congitive status) score of 13 (scores of 13 to 15 indicate that the resident is cognitively intact). An incident note dated June 6, 2016, at 10:30 a.m. revealed that the resident was on the floor and needed help stat (quickly). She was noted lying on the floor, at the left side of the bed and was face down. Upon assessment the resident was noted to have a huge hematoma (localized collection of blood outside a blood vessel due to trauma), to the right side of her forehead. Physcian's orders were obtained to send the resident to the emergency room . The hospital consultation records dated June 6, 2016, revealed that the resident was diagnosed with [REDACTED]. Review of the facility's incident/investigation report dated June 8, 2016, revealed a witness statement from the Nurse Assistant (NA) that gave care to Resident R61 during the time of the fall. The NA stated, I was giving care to the resident this morning. I had to turn her to her, to her left side, to clean her bottom. I was holding her with my left hand and tucking her brief with my right. I couldn't fully tuck the brief with one hand so I let go of her body to use both hands. As I continued to tuck, she began to slightly move. I tried to grab her but it was too late and she fell and hit the floor. I went into the hallway and called for help. The facility's investigation report further revealed a fall risk assessment dated [DATE]. The assessment revealed that the resident required the assist of two persons to help with ADLs (the activities of daily living). The facility's Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated June 8, 2016, revealed that the NA was providing care to the resident that resulted in harm to the resident. The resident required a two person assist with her care, not one person. An interview with the Second Floor Unit Manager, Registered Nurse, Employee E9, on March 31, 2016, at 12:00 p.m. indicated that in the beginning of every shift, it is necessary that the NAs review the individual care status sheet for each resident. The individual care status sheet indicates how many care nurses are involved with incontinent care, baths, transfers, ect. Review of Resident R 61's care status sheet indicated that, at all times must have two care nurses. Employee E9 stated, she should always be a two person assist with care because of her large size (resident was morbidly obese), all the NA know this. An interview with the Director of Nursing, Employee E2, on March 31, 2017, at 1:20 p.m. confirmed that Resident R61 should have been a two person assist with all care at the time of the fall. The facility failed to provide adequate supervision for one resident which resulted in harm when the resident fell and sustained a subarachnoid hemorrhage. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 07/22/16 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 04/23/15, 05/05/16 28 Pa. Code 201.18(b)(1) Management Previously cited 04/23/15, 11/04/15 28 Pa. Code 201.18(b)(3) Management Previously cited 04/23/15, 05/05/16 28 Pa. Code 201.18(e)(1) Management Previously cited 04/23/15 28 Pa. Code 211.12(c) Nursing services Previously cited 07/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 04/23/15, 06/14/16, 07/22/16

Based on clinical record review, facility and hospital documentation and staff interviews it was determined that the facility failed to identify, treat and monitor one of three residents reviewed with the [DIAGNOSES REDACTED]. Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Nursing progress notes dated October 10, 2010 revealed that the resident complained that she was not feeling well and was very tired, the resident's temperature was 94 degrees Fahrenheit, normal is 98.6 degrees Fahrenheit, the physician was notified and ordered the resident to be sent to the hospital. Further review of Resident R1's clinical record revealed that blood sugars (normal is 70-99 mg/dl.), were done monthly in 2010 that revealed elevations as follows; March 9, 162 mg/dl., June 10, 148 mg/dl., July 12, 173 mg/dl., August 10, 184 mg/dl. and September 10, 278 mg/dl. Review of the resident's physician's progress notes and physician's orders [REDACTED]. that was recorded in September 2010 that included a [DIAGNOSES REDACTED]. Review of Resident R1's hospital record "Emergency Physician Clinical Report" dated October 10, 2010 revealed that the resident was admitted to the hospital with [REDACTED].(deciliter), hypothermia (low body temperature) temperature recorded at the nursing home was 94.0 degrees Fahrenheit and dehydration with elevated BUN (blood urea nitrogen) 40 mg/dl. and [MEDICATION NAME] 1.7 mg/dl. (elevation indicates dehydration related to body metabolism). Lack of monitoring and treatment of [REDACTED]. and required intravenous (via vein) fluid therapy and insulin (hormone to utilize blood sugar) therapy. An interview with the resident's physician on October 19, 2010 at 1:45 p.m. confirmed the lack of [DIAGNOSES REDACTED]. 483.25 Quality of Care. Previously cited 4/27/2010 and 6/1/2010. 28 Pa. Code: 201.18(b)(1)Management. Previously cited 4/27/2010 and 6/1/2010. 28 Pa. Code: 211.1(a)Physician services. 28 Pa. Code: 211.12(d)(1)(5)Nursing services. Previously cited 4/27/2010 and 6/1/2010.