Every finding on record at Mountain City Nursing & Rehabilitation Center

Based on select facility policy, observations, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications and failed to ensure that medications were stored in accordance with expiration date guidelines in three out of five medication storage rooms and in two out of ten medication carts (Blue third-floor west medication cart and storage room, Blue second-floor east medication cart and storage room, and Blue first-floor medication storage room). Findings include: A review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, last reviewed by the facility on January 20, 2026, revealed that it is the policy of the facility to ensure medications that have an expired date on the label that have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy. Once any medication or package is opened, the facility should follow manufacturer guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. Medications with a manufacturer's expiration date expressed in months and years will expire on the last day of the month, and if a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded in twenty-eight days unless the manufacturer specifies a different date for the opened vial. Observation of the Blue third-floor west medication cart on August 27, 2026, at 8:28 AM, in the presence of Employee 1 (Licensed Practical Nurse), revealed one multi-dose insulin pen of Novolog Insulin (a short-acting insulin medication used to lower blood sugar) that had been opened and was available for resident use but not dated when initially opened. According to manufacturer guidance, Novolog insulin pens are for single-patient use and should be discarded within 28 days after first use, even if insulin remains in the pen. When the date of opening is not documented, the facility cannot ensure insulin is being administered within the manufacturer's recommended timeframe for potency and sterility, posing a risk of decreased medication effectiveness and possible infection from compromised medication. Observations of the Blue third-floor medication storage room on August 27, 2026, at 8:31 AM, in the presence of Employee 1 (Licensed Practical Nurse), revealed a bottle of dairy aid (lactase enzyme supplement) that was expired with an expiration date of February 2026. During an interview with Employee 1 during the time of observation, the staff member confirmed the presence of the expired medications/supplements in the blue third-floor medication storage room. Observation of the Blue second-floor east medication cart on August 27, 2026, at 8:48 AM, in the presence of Employee 2 (Licensed Practical Nurse), revealed one multi-dose insulin pen of Tresiba Insulin (an ultra-long-acting insulin medication used to lower blood sugar) that had been opened and was available for resident use but not dated when initially opened and a medication bottle of aspirin 325 milligrams that was expired with an expiration date of May 2026. According to manufacturer guidance, Tresiba insulin pens are for single-patient use and should be discarded within 56 days after first use, even if insulin remains in the pen. When the date of opening is not documented, the facility cannot ensure insulin is being administered within the manufacturer's recommended timeframe for potency and sterility, posing a risk of decreased medication effectiveness and possible infection from compromised medication. Observations of the Blue second-floor medication storage room on August 27, 2026, at 8:53 AM, in the presence of Employee 2 (Licensed Practical Nurse), revealed one multi-dose vial of Fiasp insulin (a fast-acting insulin medication used to lower blood sugar) that had been opened and was available for resident use but not dated when initially opened. According to manufacturer guidance, Fiasp insulin vials are for single-patient use and should be discarded within 28 days after first use, even if insulin remains in the pen. When the date of opening is not documented, the facility cannot ensure insulin is being administered within the manufacturer's recommended timeframe for potency and sterility, posing a risk of decreased medication effectiveness and possible infection from compromised medication. During an interview with Employee 2, on August 27, 2026, at 8:55 AM, the staff member confirmed the presence of the expired medication in the Blue second-floor east medication cart and the undated when opened medication in the Blue second-floor medication storage room fridge and east cart. Observations of the Blue first-floor medication storage room on August 27, 2026, at 9:16 AM, in the presence of Employee 3 (Licensed Practical Nurse), revealed one opened multi-dose vial of Tuberculin Purified Protein Derivative Diluted Aplisol (solution used during tuberculosis (TB) skin testing to determine exposure to TB bacteria) dated with a 7 and 24. Interview at the time of observation with Employee 3 indicated that she is unsure when the bottle was opened. A review of the manufacturer's dosage and administration recommendation for Aplisol revealed that vials in use for more than 30 days should be discarded. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on August 27, 2026, at 10:08 AM revealed that if staff are to open a medication, they should indicate a month, day, and year when labeling and dating when medications are opened and confirmed there was no definite way of knowing when the Tuberculin bottle would have been opened without complete labeling and dating present. An interview with the DON and NHA on August 27, 2026, at 10:10 AM confirmed that the facility failed to ensure the timely removal of expired medications and supplements and failed to ensure acceptable storage and adherence to use-by dates for multi-dose medications, as required by facility policy and manufacturer recommendations. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain a clean, safe, functional and sanitary environment in the facility's laundry area.Findings include: Observation of the entry into the clean area of the laundry department on August 28, 2026, at 11:00 AM, in the presence of the director of nursing, revealed two open bags of resident laundry on the floor. It was unknown if the items in the open bag were dirty or had recently been washed. Observation beside the washing machine area revealed six brand new bagged comforters, eight boxes of isolation gowns, an open jar of paste like material, a box of exam gloves, an open bag of various clothing items (sneakers, pullovers), a box of solid oxy detergent and a white paste like material on the floor, in contact with the box of isolation gowns on the floor. Observation of the area behind and on top of the washing machines revealed dust, debris, dusty pipes, exam gloves and wash clothes on the floor and in need of cleaning.The area on the ceiling beside the laundry machines had visible spider webs and the screening to the open window was covered with debris. Observation of the dryers revealed a posted lint log trap with hourly cleaning/observation. At the time of observation (August 28, 2026, at 11:00 AM), there was no signage to indicate the 5 dryers being utilized had the lint traps inspected or cleaned on an hourly basis between the hours of 6:00 AM and 11:00 AM. Observation of the lint trap to dryer #1 revealed a large amount of lint inside the dryer and was in need of cleaning. An interview with the Director of Nursing on August 28, 2026, at the time of observations was unable to provide evidence that the laundry area was being maintained in a clean, safe, functional and sanitary manner. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(e)(2.1) Management

Based on select facility policy, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain the resident's right to retain and use personal possessions for one of 36 residents reviewed (Resident 14).Findings include: Review of facility policy titled Resident Rights and Facility Responsibilities last reviewed January 20, 2026, indicated the facility will comply with all Residents' Rights and communicate these rights to residents and their designated representatives. The policy stated the residents would receive a listing of Resident Rights upon admission and when requested, and that staff would receive education on Resident Rights upon hire and annually thereafter. Review of the Resident Rights included in the facility admission packet indicated that Section (e)(2) Respect and dignity, includes the resident's right to retain and use personal possessions, including furnishings and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. Review of the facility policy titled Resident Personal Belongings last reviewed January 20, 2026, indicated the facility will ensure each resident has the right to retain and to use personal possessions while residing in the facility, as space permits. The policy stated staff will inventory items and document in the clinical record upon admission and when the resident and/or family alerts staff that they have acquired new items during his/her stay. Review of the clinical record revealed Resident 14 was admitted to the facility on [DATE], with diagnosis to include Type 2 diabetes (a chronic condition where the body cannot use insulin properly or make enough of it, causing sugar to build up in the blood) and hypertension (high blood pressure). A review of Resident 14's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 16, 2026, revealed that Resident 14 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). During an interview on August 24, 2026, at 11:23 AM, Resident 14 expressed frustration that he does not have footwear and was only provided slipper socks (non-skid socks with rubber grips). He stated he had been admitted with two pairs of Crocs (lightweight, slip-on foam shoes), a black pair and a white pair. He reported, About a month ago, they got rid of my Crocs. They said they're discontinuing them in the building, and they threw them away. I have zero footwear and I feel like I'm being singled out. He expressed concern about the upcoming fall and winter season stating, What if I have to outside in the wheelchair for an appointment and it's raining or snowing? I can't go outside in socks, it's just not right, I can't go out without footwear. Review of the resident's inventory sheet (a formal document used to record and track all personal belongings upon admission and throughout a resident's stay), which lacked a date, showed the resident had one green t-shirt, one grey zip-up hoodie, one black pair of Nike sneakers, and a set of upper and lower dentures. The inventory sheet lacked a resident signature certifying accuracy and lacked an employee signature confirming completion. Observation of the resident's closet and dresser on August 27, 2026, at 10:35 AM, in the presence of Employee 4 (nurse aide) revealed the resident had 2 polo shirts, 2 long sleeve shirts, 5 t-shirts, 1 lightweight jacket, 1 winter coat, 11 pants, 6 shorts, 6 underwear, one unopened packed of 5 t-shirts, one unopened package of 5 flannel pajama bottoms, and 1 unworn pair of black sneakers (not Nike).During an interview at the time of the observation, Employee 4 stated that Resident 14 previously had a pair of white Crocs. She searched the room but was unable to locate them and stated she did not know why the resident no longer had them. During an interview on August 27, 2026, at 12:07 PM the Director of Nursing (DON) stated the Interdisciplinary Team (IDT) identified Crocs as a safety hazard related to another resident's fall (Resident 76) on July 27, 2026. The IDT determined Crocs were a safety risk and conducted a facility-wide sweep, removing Crocs from all residents who owned them. Review of the facility's fall investigation report for Resident 76 dated July 27, 2026, revealed the resident slipped and fell. The resident's Crocs had worn-out soles which were determined to be the root cause of the fall. The facility was unable to provide documented evidence that Resident 14 had experienced any fall related to footwear, or that an individualized assessment had been performed to justify removing the resident's Crocs. There was no documented evidence that the facility provided alternative footwear or obtained consent prior to removing his personal shoes. Failure to assess the resident individually, failure to obtain consent, and removal of the resident's personal possessions without justification represent noncompliance with Resident 14's right to dignity and personal property. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.10 (c)(d) Resident Care Policies.

Based on select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to ensure a residents medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 103).Findings included: A review of the facility policy titled Psychotropic Gradual Dose Reduction, last reviewed by the facility on January 20, 2026, revealed it is the facility's policy that the facility will use psychotropic medications only when beneficial and necessary, ensuring appropriate use, evaluation, and monitoring. A clinical record review revealed Resident 103 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 103's progress notes beginning May 2026 through July 2026 showed an increase in behaviors including resident being more physically aggressive and refusing medications.A progress note dated May 27, 2026, revealed the resident was wandering, exit seeking, and yelling.A progress note dated June 3, 2026, revealed the resident became aggressive with a lab worker and staff in the facility.A progress note dated June 4, 2026, revealed the resident was yelling loudly and singing loudly.A progress noted dated June 8, 2026, revealed the resident was throwing folders from the nurses' station down the hallway.A progress note dated June 13, 2026, revealed the resident was agitated and screaming loudly.A progress note dated June 14, 2026, revealed the resident was aggressive with staff. A psychiatric consultation note dated June 10, 2026, revealed Resident 103 presented for a four-week follow-up related to previous treatment of dementia. The note documented to continue current medications, monitor mood and behavior, and continue to attempt nonpharmacological interventions. A progress note dated June 15, 2026, revealed Resident 103 primary care physician ordered Secuado (an antipsychotic medication) patch 3.8 milligrams once daily with no diagnoses given to justify use of medication. The medication Secuado is approved for the use of treatment of Schizophrenia. A review of the FDA black box warning (the FDA's strongest safety alert, placed at the top of a drug's label to warn about risks that may cause serious injury or death. It appears inside a bold black border and is used only when substantial clinical evidence shows severe or life threatening dangers associated with a medication) for this medication revealed that increased risk of death in elderly patients with dementia-related psychosis, and it is not approved for treating this condition. A review of Resident 103's clinical record revealed the resident does not have a diagnosis of Schizophrenia and/or Schizoaffective Disorder. Review of Resident 103's clinical record revealed during this period of increased behaviors May 2006 through June 2026 no other medications were attempted prior to the initiation of an antipsychotic specifically targeted to treat Schizophrenia. Review of residents documented behaviors in this time period showed no behaviors to indicate the resident had the criteria to meet the DSM-5 criteria to diagnosis Schizophrenia. A progress note dated June 24, 2026, revealed social services consulted with the outside psychiatric contractor and was advised that Resident 103 does not meet the criteria for Schizoaffective Disorder and/or Schizophrenia and was given a list of alternative medications to be attempted. As of the survey ending August 28, 2026, the resident continued on Secuado without attempts at other medications as indicated by psychiatric services. During an interview on August 28, 2026, at 9:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide documentation of the rationale for the initiation of an antipsychotic medication. The facility failed to ensure Resident 103 was free from unnecessary use of a psychotropic medication, resulting in the resident receiving an antipsychotic medication without documented evidence that it was required to treat a specific medical symptom. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.2(d)(3) Medical director. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.10(c) Resident care policies.

Based on select facility policy, observations, clinical record review, and staff interviews, it was determined the facility failed to ensure enteral feeding syringes in use were labeled and dated and failed to ensure tube feed solution was properly labeled, dated, and discarded for one resident out of 36 residents reviewed (Resident 120).Findings include: A review of the facility policy titled Enteral Feeding Tube Policy, last reviewed by the facility on January 20, 2026, indicated when irrigation sets/syringes are used with feeding tubes, they should be rinsed with warm water after each use and replaced every twenty-four hours. Failure to ensure syringes used for enteral nutrition were labeled, dated, and discarded within an appropriate timeframe created the potential for syringes to be reused beyond their safe period, increasing the risk of bacterial contamination, gastrointestinal infection, or other complications related to compromised enteral administration. A review of the facility policy titled Dietary Enteral Nutrition Care, last reviewed by the facility on January 20, 2026, indicated enteral formula will be administered at room temperature and the formula will be discarded according to the manufacturer's recommendations. According to manufacturer guidance, once opened, Isosource (a liquid high-calorie enteral feeding formula) should be consumed within twenty-four hours. Clinical record review revealed Resident 120 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Resident 120's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated June 21, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A clinical record review revealed a physician order dated March 31, 2024, directed staff to change feeding syringes daily and label them with the resident name and date. Further Resident 120 had a physician order, dated June 15, 2026, for enteral feeding with Isosource 1.5 at 80 ml/hour from 8:00 PM to 6:00 AM. Observation of Resident 120 on August 27, 2026, at 9:10 AM revealed a 60 mL enteral syringe (a syringe used to deliver medications, flushes, or feedings directly into the gastrointestinal tract via the PEG tube) hanging on a pole in a plastic bag and an Isosource tube feed solution bag connected to tubing hanging freely and disconnected from the resident. Neither the tube feed solution, tubing, syringe, nor the bag was labeled or dated. A second observation of Resident 120 on August 27, 2026, at 11:48 AM revealed a 60 mL enteral syringe hanging on a pole in a plastic bag and an Isosource tube feed bag connected to tubing hanging freely and disconnected from the resident. Neither the tube feed solution, tubing, syringe, nor the bag was labeled or dated. A review of Resident 120's Medication Administration Record for August 2026 revealed that on August 27, 2026, it was signed off that the tube feed was taken down at 6:00 AM and that the syringe was changed, labeled, and dated. During an interview with the Director of Nursing (DON) on August 28, 2026, at 11:45 AM, the above findings were confirmed, and the DON revealed it was the expectation that supplies used for enteral feeding, flushes, and medications be labeled and dated upon opening and that the tube feed solution should have been discarded.28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of the facility's abuse prohibition policy, clinical records, facility submitted documentation, select investigative reports, and resident and staff interviews, it was determined the facility failed to assure that one resident (Resident 2) out of 15 reviewed was free from physical abuse perpetrated by another resident (Resident 1). This deficiency is cited as past non compliance. Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, last reviewed by the facility on January 20, 2026, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and major depressive disorder (a mental health disorder characterized by a persistently low mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 1's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 19, 2026, revealed that Resident 1 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and paraplegia (loss of movement or feeling in the lower half of the body). A review of Resident 2's quarterly MDS dated [DATE], revealed Resident 2 was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates cognition is intact). Review of Resident 1's care plan last revised August 8, 2026, identified behavioral concerns related to being verbally and physically abusive to staff and to peers, agitation, screaming and yelling at staff, aggressiveness with staff members, and throwing objects at staff. Interventions included approaching the resident calmly, educating the resident on appropriate behavior, redirecting him to a room or private area, and offering to play music on his radio. A continued review of Resident 1's plan of care identified a mood related problem area. The resident had a documented history of depression and was noted to become easily annoyed, angered, and agitated, with a past pattern of aggressive behaviors. The behavioral symptoms outlined in the care plan indicated that the resident exhibited disruptive verbal outbursts and physical aggression toward staff and others. In response to these behaviors, a behavioral contract was issued to the resident. A review of a behavioral contract for inappropriate behaviors dated and signed by the resident on June 9, 2026, indicated Resident 1 was not allowed to enter other residents' rooms, not permitted to ask others to purchase items for him or ask them for food, drink, or tobacco products, not permitted to touch residents in any way, and not permitted to yell or curse or treat staff with disrespect. A review of a nurse progress note dated June 16, 2026, at 2:41 PM, revealed the resident was observed with multiple verbal outbursts and was demanding to go outside to smoke during non-smoking times. A review of a progress note from the social worker dated July 17, 2024, at 2:00 PM, revealed the resident had increased behaviors, including loud disruptive outbursts in the lobby related to smoking times at the facility. Nursing documentation dated July 24, 2026, at 9:35 PM, revealed that Resident 1 was involved in a physical altercation with Resident 2 in the hallway near the elevators in the front on the main floor. Resident 1 had struck Resident 2 in the back of the head twice with a closed fist. Resident 1 stated he punched Resident 2 in the head due to him bumping into this wheelchair. When asked why he did not alert nursing staff about the wheelchair bumping, Resident 1 stated that Resident 2 deserved it. A review of the facility's investigation documentation dated July 24, 2026, at 8:00 PM indicated that Resident 2 was identified as the victim and Resident 1 as the perpetrator. The report stated that Resident 2 was waiting to access the elevator, and Resident 1 was positioned in the way. Resident 2 attempted to go around him and, in doing so, bumped Resident 1's wheelchair. Resident 1 then struck Resident 2 in the back of the head. Facility interventions included the immediate separation of both residents, revocation of independent off unit status for both residents, revocation of smoking privileges for Resident 1, and increased supervision with monitoring every fifteen minutes. A review of Resident 2's written statement dated July 24, 2026, indicated that while he was waiting to get on the elevator, Resident 1 was blocking the way. Resident 2 stated that he tried to go around Resident 1's wheelchair and bumped into the back of it. Resident 1 then cursed at Resident 2 and punched him twice in the back of the head. Resident 2 reported that he did not hit Resident 1 and added that Resident 1 is a bully and that nothing is done about his behavior. A review of a written statement from Resident 1 dated July 28, 2026, indicated that Resident 2 began moving backward and bumped into his wheelchair. Resident 1 stated that he asked Resident 2 what he was doing as Resident 2 was attempting to go around him to reach the elevator. Resident 1 reported that Resident 2 swung at him and missed, and that he then swung and hit Resident 2 in the head because Resident 2 was in his way. An interview with Resident 1 on August 19, 2026, at 1:00 PM, revealed on July 24, 2026, after the 8:00 PM smoke break, he was going to the vending machine to go get a soda and was in front of the elevator when Resident 2 slammed into his wheelchair multiple times and then proceeded to go around him. Resident 1 then indicated he punched Resident 2 in the back of the head. An interview with Resident 2 on August 19, 2026, at 1:30 PM, revealed that on July 24, 2026, after the 8:00 PM smoke break, he came inside toward the elevators, and Resident 1 was in the way, so he went around his wheelchair and bumped into Resident 1 during the process, and then Resident 1 punched him in the back of the head two times. These findings demonstrated the facility failed to ensure effective supervision and monitoring measures were implemented to address Resident 1's known history of aggression, resulting in physical abuse of Resident 2. This deficiency is cited as past noncompliance. The facility's corrective action plan was to identify other residents with the potential to be affected, and all residents who have independent off-unit status were assessed for any behavioral issues that could result in physical aggression. Residents were assessed and interviewed to ensure they felt safe at the facility and to ensure they were free from abuse. Resident 1 and Resident 2 lost their independent status immediately after the incident. Resident 2 was reassessed for any behaviors and received an order to be independent off the unit again. The facility also initiated for Resident 1 to go on smoke breaks thirty minutes prior to the other residents who smoke to avoid confrontation. To prevent this from recurring, the Nursing Home Administrator and interdisciplinary team provided re-education to facility staff regarding the facility's abuse policy and also educated to ensure residents return back to the unit after smoking regardless of independent status. To monitor and maintain ongoing compliance, the facility performed audits of the smoking breaks to ensure residents returned to the unit. The findings of the plan of correction were submitted to QAPI for review. The facility's immediate corrective action plan was completed on July 30, 2026. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)(c) Resident Rights28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records, physician orders, facility documentation, and interviews with staff and the resident's family, it was determined the facility failed to honor and implement the resident representative's end-of-life treatment decisions by failing to facilitate and implement requested hospice services after the resident representative authorized hospice care and requested a change in the resident's Pennsylvania Orders for Life-Sustaining Treatment (POLST) order, for one of three residents reviewed (Resident CR1).Findings include:A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, muscle stiffness. slowness of movement, and poor balance and coordination) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the arms or legs). The resident expired at the facility on [DATE]. Social Services documentation dated [DATE], at 4:04 PM, revealed the facility received notification from a hospice agency that the resident's son contacted the agency requesting hospice services for Resident CR1. Hospice is a coordinated program of end-of-life care that focuses on comfort, symptom management, and emotional and spiritual support for individuals with a terminal illness. The Social Services employee contacted the resident's son to discuss comfort measures (care focused on relieving pain and other symptoms without attempting to cure the underlying illness) and hospice services. The son remained adamant that hospice services be initiated and stated he had already contacted a hospice provider. Social Services documented that the resident's POLST (Physician Orders for Life-Sustaining Treatment form is a medical order that allows seriously ill patients to specify the types of medical care they want or do not want in emergencies) would need to be updated and confirmed by the resident representative before hospice services could proceed. The facility forwarded the resident's clinical information to the hospice agency and contacted the resident representative regarding hospice services and the resident's code status. Social Services documentation dated [DATE], at 4:33 PM, revealed the resident representative initially declined hospice services, stating she was not yet ready to proceed and planned to discuss the matter with the physician.A review of the social services progress note dated [DATE], at 5:21 PM, revealed the resident's code status (the level of medical treatment a resident has chosen to receive during a medical emergency) was documented as Do Not Resuscitate (DNR), meaning that if the resident's heart stopped beating or the resident stopped breathing, cardiopulmonary resuscitation (CPR) (an emergency procedure that uses chest compressions and, when appropriate, assisted breathing to attempt to restore a heartbeat and breathing) would not be initiated. Documentation indicated the resident representative had spoken with the physician, who reportedly did not recommend hospice at that time but planned to evaluate the resident on [DATE]. Social Services documented that a physician's order would be required before hospice services could be initiated.Nursing documentation dated [DATE], at 6:49 PM, revealed the resident's POLST was updated from Full Code to Do Not Resuscitate (DNR) based on the resident representative's verbal consent, witnessed by two licensed nurses. Nursing documentation dated [DATE], revealed the resident representative came to the facility and signed the updated POLST. The documentation further indicated the resident representative asked whether the physician agreed with her decision and staff documented that the physician was OK with family wishes.A subsequent review of the clinical record failed to identify documentation that the physician evaluated the resident on [DATE], as planned. The record also failed to identify a physician order initiating hospice services, documentation that a hospice referral was completed following the resident representative's request, documentation that hospice services were initiated, or evidence that the facility informed the resident representative that hospice services had not been implemented. A review of the physician orders, care plan, and nursing documentation failed to identify evidence that the resident received hospice services before the resident expired on [DATE]. During an interview on [DATE], at 1:15 PM, the Nursing Home Administrator and Employee 2, Social Services, confirmed Resident CR1 was not receiving hospice services at the time of death despite the resident representative's request for hospice care.During an interview on [DATE], at 1:48 PM, conducted by three-way telephone call with the resident representative and the resident's son, the resident representative stated the resident had been declining since the middle of [DATE]. She explained that she initially delayed hospice because she wanted the resident to attend a scheduled medical appointment and was informed that the appointment would not occur if hospice services were initiated. She stated that after the appointment she contacted the facility and requested hospice services. She further stated she spoke with the physician, who planned to evaluate the resident the following day, and later came to the facility to sign the updated POLST. The resident representative stated that when she asked whether the physician agreed with her decision, she was informed that he did. She stated, My wish was for my dad to be put on hospice. That is what I was waiting for. She further stated, When they told me the physician agreed with our decision, I believed my dad was being placed on hospice. A review of the resident's physician orders, care plan, and nursing notes failed to identify evidence that hospice services were initiated or provided following the resident representative's request. The clinical record contained no evidence that the physician evaluated the resident regarding hospice despite the documented plan to do so. The clinical record also contained no evidence that the facility informed the resident representative that hospice services had not been initiated or took additional steps to implement the resident representative's expressed end-of-life goals and preferences. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, dental consultation records, documentation from the dental provider, and staff and resident representative interviews, it was determined the facility failed to assist a resident in obtaining timely medically necessary dental services after a fractured tooth requiring extraction was identified, for one of 13 residents reviewed (Resident CR1) for dental services.Findings included:A review of the facility policy titled Dental Services, last reviewed [DATE], revealed the facility would assist residents in obtaining routine and emergency dental care and services to meet each resident's needs. The policy indicated nursing staff were responsible for notifying Social Services of a resident's need for dental services. Social Services personnel would assist the resident and resident representative in making dental appointments and transportation arrangements to and from the dental service location. A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, muscle stiffness. slowness of movement, and poor balance and coordination) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the arms or legs). The resident expired at the facility on [DATE]. Clinical record review revealed nursing documentation dated [DATE], at 1:49 PM indicating the resident representative requested the resident be evaluated by the facility's in-house dentist. Nursing documentation dated [DATE], at 11:07 AM revealed a mobile dental provider evaluated the resident and documented a fractured tooth requiring evaluation by the dentist. A Dental Consult Sheet dated [DATE], revealed the in-house dentist evaluated the resident. The resident reported pain involving tooth number 4. A dental x-ray (an imaging study used to evaluate the teeth and surrounding bone) was obtained. The dentist recommended extraction (removal of the tooth), prescribed an antibiotic (a medication used to treat bacterial infection), and prescribed pain medication for 20 days. Continued review of the clinical record failed to identify evidence the recommended extraction was completed.A Dental Consult Sheet dated [DATE], revealed the resident continued to report discomfort involving tooth number 4, and the dentist again recommended extraction. Nursing documentation dated February 4, 2026, at 7:10 PM revealed the mobile dental provider evaluated the resident and documented it was awaiting physician approval and resident representative consent. The February 4, 2026, Dental Consult Sheet revealed the fractured tooth remained present and recommended extraction by an oral surgeon (a dentist specially trained to perform surgical procedures involving the mouth, jaw, and facial structures). The dentist again prescribed an antibiotic for 20 days. Nursing documentation dated February 6, 2026, at 4:48 AM revealed the physician approved the recommended extraction. Nursing documentation dated February 7, 2026, documented the resident representative consented to the procedure and the mobile dental provider was notified. Despite physician approval and resident representative consent, the facility failed to ensure the recommended extraction was obtained. Social Services documentation dated February 17, 2026, at 9:12 AM revealed the resident's son requested that his father receive the tooth extraction as soon as possible. Documentation indicated several local oral surgeons had been contacted but did not accept the resident's Medicaid insurance coverage. Social Services documented the family was advised either to change Medicaid plans or pay privately for the procedure and declined both options. Documentation indicated Social Services would continue to monitor. Nursing documentation dated February 24, 2026, at 7:35 AM revealed that nursing staff spoke with the physician and the resident's antibiotic was discontinued because the procedure had been cancelled. The clinical record failed to identify documentation the facility developed or implemented an alternative plan to obtain the recommended extraction after cancellation of the procedure. Social Services documentation dated [DATE], at 3:36 PM revealed nursing notified Social Services the resident continued to complain of tooth pain. Social Services documented that the in-house dentist was unable to perform the extraction and that multiple local oral surgeons had been contacted but would not accept the resident's Medical Assistance coverage. Documentation indicated the resident representative was advised the extraction could be completed if the family paid privately and that the family preferred to have the procedure covered by insurance. The clinical record failed to identify documentation the facility coordinated treatment with the mobile dental office located approximately 92 miles away in a different city, arranged transportation, communicated available transportation services to the family, or documented additional efforts to overcome identified barriers after physician approval and family consent had been obtained. During an interview on [DATE], at 1:15 PM, Employee 2 (Social Services) stated the in-house dentist could not perform the extraction and that mobile dental company maintained an office near Philadelphia where the extraction could be completed. Employee 2 stated the resident's son did not want the resident to travel to Philadelphia because of the distance. Employee 2 further stated several local oral surgeons had been contacted but none accepted Medicaid and the family was advised they could pay privately for the extraction. During an interview, the Nursing Home Administrator stated the facility would have transported the resident to the mobile dental office near Philadelphia at no cost to the resident. However, during a three-way telephone interview conducted on [DATE], at 1:48 PM, the resident representative and the resident's son expressed frustration that the resident had experienced pain from a fractured tooth since [DATE]. They stated they were never informed the facility would provide transportation to the appointment. They reported they believed transportation was their responsibility and, because the resident was non-ambulatory (unable to walk independently), they did not believe they had an appropriate vehicle or could safely transport him to an appointment located approximately 92 miles from the facility. The resident representative stated, Transportation was never offered. We were led to believe it was our responsibility to get him there. Had we known they would drive him there, it wouldn't have been an issue. Documentation provided by the mobile dental provider, dated [DATE], indicated the provider maintains an office located approximately 92 miles from the facility in another city where dental extractions that cannot be performed in the mobile setting are completed. The documentation further stated, According to the facility, the family of (Resident CR1) declined to transport the resident to our office for treatment. Per our notes, the extraction was initially recommended on [DATE], and the treatment plan was signed on [DATE]. However, the extraction consent form was not received. During the same telephone interview, the resident representative stated she completed and returned all consent forms mailed to her and was never informed additional documentation was required. She further stated neither the dental provider nor the facility notified her that any required paperwork remained outstanding or advised that the facility would provide transportation for the appointment. During an interview on [DATE], at 3:30 PM, the Nursing Home Administrator was unable to provide documentation demonstrating the facility informed the resident representative that transportation would be provided, notified the family that additional consent documentation was needed, or documented ongoing efforts to coordinate and facilitate the recommended extraction after it had been ordered. The facility failed to implement its Dental Services policy by failing to coordinate, facilitate, and document the actions necessary to obtain timely recommended dental treatment after the need for extraction had been identified, approved by the physician, and consented to by the resident representative. The facility failed to address identified barriers related to provider availability, transportation, insurance coverage, and required documentation to obtain the medically necessary dental service. As a result, Resident CR1 remained without receiving the recommended extraction for 8 months before his death. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa Code 211.12 (c) Resident care policies.

Based on review of clinical records, facility policy, observations, facility-provided investigative documentation, security camera evidence, and resident and staff interviews, it was determined that the facility failed to ensure appropriate supervision and implementation of safety interventions to protect a resident from accident hazards (medications) and elopement from the facility. This failure resulted in actual physical harm for one out of 10 residents sampled (Resident 1). Findings include: A review of the facility policy titled Elopement/Unauthorized Absence, last reviewed by the facility on August 15, 2025, revealed that it is the policy of the facility to identify residents with potential or actual risk factors for elopement and protect the residents through development and implementation of safety interventions. Further review revealed that in the event of a resident elopement, the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Elopement occurs when a resident leaves the premises or a safe area without authorization or necessary supervision to do so, and residents identified at risk will have interventions promptly implemented to reduce the risk of elopement. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include insomnia (a sleep disorder causing difficulty falling asleep, staying asleep, or waking up too early) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). A review of an annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 16, 2025, revealed that Resident 1 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13 to 15 indicates cognition is intact). A review of physician orders dated November 4, 2025, at 10:12 AM, revealed that Resident 1 was ordered to ambulate independently in the room and on the unit without a device and independently off the unit and on facility grounds with a rollator walker (a wheeled walking aid). A nurse's progress note dated November 29, 2025, at 7:20 PM documented that the resident fell in the blue building after losing balance and falling backward onto her buttocks. A clinical record review of a physician's order dated December 2, 2025, at 4:47 PM revealed the resident was independent with ambulation in the room and on the unit without an assistive device. The previous order allowing the resident to ambulate independently in the room and on the unit without a device and independently off the unit and on facility grounds with a rollator walker was discontinued. A review of the elopement risk assessment dated [DATE], revealed that Resident 1 was assessed as not being at risk for elopement. A clinical record review of a physician's order dated December 3, 2025, at 9:01 AM revealed the resident was independent with ambulation in the room and on the unit without an assistive device and independent off the unit within the building with a rollator walker. A review of a nurse's progress note dated December 15, 2025, at 11:56 PM revealed that the resident activated her call bell and self-reported that she had fallen by the sink. The note further documented that the resident scooted herself to the bed in order to get up. A review of Resident 1's clinical record revealed a nursing progress note dated December 29, 2025, at 3:13 AM, which documented that the resident was observed walking back from the bathroom with an unsteady gait (difficulty maintaining balance while walking). The note revealed the resident's oxygen saturation (the percentage of oxygen carried in the blood, measured by a pulse oximeter clipped to the finger to assess how well the lungs are oxygenating the blood) was 84 percent, below the normal range of 95 to 100 percent. The progress note documented that Resident 1 told staff that she had taken pills. When asked what type of pills she had taken, the resident was unable to respond. The record indicated that the resident was transferred to the emergency department for further evaluation.A review of outside emergency department records dated December 29, 2025, revealed that the resident was evaluated for a possible medication overdose. The hospital documentation revealed that Resident 1 was administered two doses of Narcan (a life-saving medication that rapidly reverses opioid effects by blocking opioid receptors in the brain), after which the resident became more responsive. A review of a nurse's progress note dated December 29, 2025, at 4:32 PM revealed that the resident returned to the facility with new physician orders to discontinue trazodone (a medication commonly used to treat depression and insomnia). The note documented that both the physician and the resident were made aware of the medication change. An interview with Resident 1 conducted on January 12, 2026, at 11:20 AM revealed that during medication administration she sometimes drops pills onto the floor or onto her bed. The resident stated that she sometimes keeps dropped pills in her drawer and takes them later if she chooses to do so. She further stated that she was unsure which medications she had taken on December 29, 2025, and reported that the pills were found on the floor of her room. She stated she did not know what they were, but that there were around four of them.An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) conducted on January 12, 2026, at 12:00 PM revealed the facility did not complete an internal investigation related to the potential medication overdose involving Resident 1. The Director of Nursing stated that because the emergency department did not confirm that an overdose had occurred, the facility did not investigate the incident further, despite documentation and resident statements indicating the resident consumed unknown pills. A review of a nurse's progress note dated December 30, 2025, at 4:42 AM revealed the resident activated her call bell. Upon entering the room, the nurse found the resident sitting on the floor next to the bed. The nurse's note documented that the resident stated she had fallen out of bed while reaching for her call bell. A clinical record review of a physician's order dated December 30, 2025, the resident was to transfer with assistance from one person and to ambulate using a rollator walker. The order allowing the resident to be independent off the unit within the building was discontinued. A review of a nurse's progress note dated December 30, 2025, at 3:30 PM revealed that nursing staff were called to the social services office located on the ground floor (resident resided on the first floor) after the resident was found on the floor. Upon assessment, the resident was observed sitting in a chair. The nurse's note documented that the resident stated she did not fall and reported that she had been lying on the floor to hide from social services in order to scare them. The note further documented that the resident's ambulation status had changed to requiring assistance from one person with a rollator walker and that independence off the unit within the building was discontinued pending evaluation by physical therapy. A review of a written witness statement dated December 30, 2025, from Employee 1 (Social Services) revealed that a walker was positioned in front of the office door and that upon entering the office, the employee observed the resident lying on the floor with her eyes closed. The statement further documented that when the employee called out to the resident, the resident sat up. When asked whether she had laid down or fallen, the resident stated that she had laid down. The statement noted that the resident stated that she was not being given her medications. Clinical record review revealed that following the events on December 30, 2025, when the resident was found on the floor in the social services area and her ambulation status was changed to require assistance from one person with a rollator walker, and independence off the unit within the building was discontinued, the facility did not complete a new elopement risk assessment or revise supervision and safety interventions to reflect the resident's increased need for monitoring and the restriction of off-unit mobility. A review of a nurse's progress note dated December 31, 2025, at 4:35 AM revealed that the resident activated her call bell requesting trazodone (a medication commonly used to treat depression and insomnia). The nurse documented that trazodone had been discontinued following the resident's recent hospital return and that the resident was informed the physician would be contacted regarding the request. A review of written witness statements dated December 31, 2025, from Employee 4 (Nurse Aide) revealed that at 4:30 AM the resident rang her call bell and asked for her medication. The employee documented that she did not see the resident after this interaction. A review of written witness statements dated December 31, 2025, from Employee 3 (Nurse Aide) revealed that the resident was last observed at 4:30 AM lying in bed after ringing her call bell. The employee documented that the resident did not request to go outside. The statement further revealed that the employee was later notified that the resident had been found outside near the gazebo on the ground and observed emergency medical services at that location. A review of written witness statements dated December 31, 2025, from Employee 2 (Nurse Aide) revealed that the resident was last seen in bed at 4:30 AM and was later found outside near the gazebo. A review of a written witness statement dated December 31, 2025, from Employee 5 (Licensed Practical Nurse) revealed that at 5:07 AM the employee was notified that a resident had called 911 reporting a fall in the gazebo. Upon arrival, emergency medical services were present. The resident was observed sitting on the floor in the gazebo wearing winter clothing and was assisted to a stretcher by emergency medical services. A review of facility-provided investigative documentation from the Nursing Home Administrator dated December 31, 2025, revealed that security camera footage showed the resident exiting the white building through the front doors at 4:36 AM dressed in winter clothing. At 4:39 AM the resident was observed walking through the blue building parking lot (a review of facility layout information revealed that the facility consists of two separate buildings, commonly referred to as the white building and the blue building, which are located adjacent to one another and separated by a parking lot. Resident 1 resided in the white building. Access between the two buildings requires travel across the parking lot and outdoor grounds) and at 4:41 AM she was seen walking toward the gazebo area (660 feet from the front door of white building). The gazebo was not visible on camera. The documentation noted that the resident avoided the paved walkway due to snowy conditions. The outside temperature at that time was 25 degrees Fahrenheit, (per weather history documentation) indicating cold weather exposure while the resident was outside without staff supervision. Emergency medical services arrived at 5:06 AM as observed on camera. A review of a nurse's progress note dated December 31, 2025, at 7:46 AM revealed that a 911 dispatcher contacted the facility at 5:07 AM reporting that a resident had fallen outside near the gazebo and had called for an ambulance. Staff immediately checked the resident's room, which was empty, and then proceeded outside to assist the resident as EMS was arriving. The nurse documented that the resident reported leg pain, feeling cold, and stated that she went outside to go for a walk. The nurse further documented that the resident stated she was upset that her doctor would not give her medication to help her sleep. Emergency medical services transferred the resident to the hospital before a full head-to-toe assessment could be completed. The resident was noted to be wearing a black coat, pants, and sneakers. Resident 1 was admitted to the hospital from [DATE], through January 6, 2026. A review of outside hospital diagnostic imaging dated December 31, 2025, revealed that the resident sustained a left femoral neck fracture (a break in the upper portion of the thigh bone near the hip joint), which required surgical intervention, and a left pelvic hematoma with active extravasation (a collection of blood caused by ongoing bleeding from damaged blood vessels). A review of the resident's care plan revealed that a problem area related to elopement and wandering was initiated on December 31, 2025, after the elopement event occurred. The care plan identified the resident as being at risk for injury related to elopement and wandering and documented noncompliance with transfer status, self-ambulation, and signing in and out of the unit. A goal was identified for the resident to wander safely within her environment and not elope from the facility. The care plan did not reflect the elopement event of December 31, 2025, or include updated, specific interventions addressing the incident during the survey period ending January 12, 2026. A review of an elopement risk assessment dated [DATE], revealed that Resident 1 was assessed as being at potential risk for elopement and required additional interventions to address identified risk factors. Increased supervision, including 15-minute checks, was initiated after the elopement event. An interview with Employee 6 (Maintenance Director) conducted on January 12, 2026, at 10:00 AM revealed that the doors in the white building always remain unlocked. The employee explained that residents exiting the white building must use the elevator to access the main lobby in order to leave the building. The employee further explained that elevator alarms activate and the elevator locks only when a resident wearing a wander guard bracelet attempts to exit. An interview with Resident 1 on January 12, 2026, at 11:20 AM revealed that in the early morning hours of December 31, 2025, she was upset because trazodone had been discontinued and she felt she was not aware of the change at the time. The resident stated she then felt like she wanted to blow off some steam and go for a walk. She reported that she put on her winter coat, gloves, and an extra sweatshirt and walked down to the elevators with her walker, went into the elevators down to the main floor, and left through the front doors of the white building. She stated she wanted to go to the gazebo because she felt like it would be less windy. The resident stated that she fell when she arrived near the gazebo, was unable to get up because she could not grab anything to lift herself up due to leg pain and called 911 using her personal cell phone. She stated she remained outside for 30 minutes. The resident further stated that on the evening of January 11, 2026, time unknown, she walked to the nurse's station and did not observe staff present. She stated that this led her to believe she could leave the facility without staff awareness. The resident further stated that she later informed staff that she could have left again and was told that she could not because she was wearing a wander guard bracelet, despite not having a wander guard bracelet applied at that time. The resident acknowledged that she should not have left the facility unattended on December 31, 2025, and stated she understood she should not do so again. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 12, 2026, at 1:30 PM revealed the facility had not utilized a wander guard system for Resident 1, because the facility felt it was a restraint despite the resident's ability to consent or deny the use of the system. Following the interview, facility staff discussed the use of a wander guard system with Resident 1 who agreed to allow one to be applied. The security camera footage from December 31, 2025, was reviewed by the surveyor on January 12, 2026, at 11:40 AM. Following surveyor inquiry, a review of a physician's order dated January 12, 2026, at 1:56 PM revealed an order for application of a wander guard bracelet and monitoring for proper placement and function. During an interview with the Nursing Home Administrator and Director of Nursing conducted on January 12, 2026, at 2:00 PM the above findings for Resident 1 were confirmed. The facility failed to ensure appropriate supervision and timely implementation of safety interventions to protect a resident from accident hazards and elopement from the facility. Specifically, the facility failed to investigate and address a reported accident hazard after Resident 1 indicated she had consumed unknown pills on December 29, 2025, and failed to reassess supervision needs and elopement risk following significant changes in the resident's condition and functional status. As a result, the resident exited the facility unsupervised on December 31, 2025, and sustained serious physical injuries, including a left femoral neck fracture requiring surgical intervention and a pelvic hematoma, constituting actual harm. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that one resident (Resident 2) out of 15 sampled were free from physical abuse perpetrated by another resident (Resident 1). Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation last reviewed by the facility on November 12, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). and malignant neoplasm of the prostate (cancerous tumor in the prostate gland). A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 14, 2025, indicated the resident was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status - a tool to assess cognition, a score of 8-12 indicates moderate cognitive impairment), and was independent for ambulation. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), and parkinsonism (a broad term for various neurodegenerative diseases that cause motor symptoms with symptoms similar to Parkinson's disease). A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 0 (a score of 0-7 indicates severe cognitive impairment), and was independent for ambulation. Review of Resident 1's plan of care dated July 11, 2024, identified issues related to wandering into other residents' rooms and various aggressive behaviors, including physical aggression toward staff and other residents. Interventions included offering activities of interest, involving family, utilizing Spanish-speaking staff for redirection, and psychiatric referrals as needed. Continued review of Resident 1's plan of care revealed a problem area identified related to restlessness, aggression, depressed mood and exhibits the following behaviors related to the same: wandering, agitation, combativeness, tearfulness, verbal outbursts, history of resident-to-resident altercations, verbal aggression directed to staff, talks loudly, physical behaviors and physical aggression directed at staff, threatening staff, machining sexually inappropriate statements, urinating on floor in hallway, inappropriate touching, bowel movements in trash can in hallway, spitting on floor, using other resident bathrooms, refusing care, activities and showers. Interventions included: administration of medications as ordered, encourage activities of interest, provide Spanish TV and music, attend activities that he enjoys, engage in simple, structured activities that avoid overly demanding tasks, and refer to psych as needed. A review of nursing documentation from January 2025 through March 2025, revealed that Resident 1 exhibited behaviors such as pacing, wandering into other residents' rooms, yelling, agitation, aggression, verbal and physical abuse toward staff, urinating in hallways, and attempted elopement. It was documented that constant redirection was provided, but the resident was difficult to redirect and would become aggressive and abusive toward staff. Nursing documentation dated March 4, 2025, at 9:08 PM revealed that Resident 1 was involved in a physical altercation with Resident 3 in the doorway of Resident 3's room, involving pushing and shoving. A Review of the Mandatory Abuse Report dated March 4, 2025, at 7:15 PM documented that Resident 1 wandered into Resident 3's room via a closed door. Resident 3 pushed Resident 1 out of his room with his hand on Resident 1's back. Resident 1 turned around and grabbed Resident 3 by the neck. Staff immediately separated the residents. Both residents were placed on every 15-minute checks. Continued review of nursing documentation dated March 12, 2025, at 10:46 AM displayed increased behaviors, including wandering without pants/briefs, urinating on the floor, aggression, and attempting to punch staff. Nursing documentation dated March 13, 2025, at 3:41 AM revealed Resident 1 stood in front of the elevators blocked elevator access, yelled, swung at staff, and wandered into peers' rooms while talking loudly that he is the boss and refused to move away from the elevator. Nursing documentation dated March 13, 2025, at 9:27 AM revealed the resident wandered into other residents' rooms, was difficult to redirect, got on the elevator triggering alarms, refused to get off, and threatened to punch staff. Nursing documentation dated March 13, 2025, at 7:00 PM (recorded as a late entry note on March 14, 2025, at 2:02 AM) staff found Resident 1 and Resident 2 lying on the floor outside Resident 2's room. A Review of the Mandatory Abuse Report dated March 13, 2025, at 6:25 PM documented that Resident 2 was the victim, and that Resident 1 was the perpetrator. The report indicated that the RN was called to the floor by staff to evaluate Resident 1 and Resident 2 noted to be lying in the hallway on the floor outside Resident 2's room. Residents were immediately separated. Both residents were evaluated, and treatment was provided. Upon interview, Resident 2 stated We got into a fight. He came into my room and was doing something with the curtain. Resident 2 stated that he punched Resident 1, and that Resident 1 punched him. Facility interventions included placing Resident 1 on one-to-one supervision, relocating Resident 2 to another wing, initiating staff education, notifying physicians and responsible parties, and reporting the incident to law enforcement. Despite documented patterns of aggressive and intrusive behaviors by Resident 1 prior to the incident, the facility failed to implement adequate supervision and monitoring measures to prevent the physical abuse of Resident 2. An interview with Nursing Home Administrator on March 27, 2025, at approximately 2:30 PM confirmed the facility failed to prevent the physical abuse of Resident 2 perpetrated by Resident 1, which resulted in a punch to the face. The facility failed to implement sufficient supervision and monitoring measures to address Resident 1's known history of aggression, resulting in physical abuse of another resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of the facility's Plan of Correction from the survey ending February 7, 2025, the results of the revisit survey conducted on March 27, 2025, clinical record review, facility-submitted documentation, and staff interview, it was determined that the facility failed to implement and sustain corrective actions through its Quality Assurance and Performance Improvement (QAPI) program to prevent the recurrence of deficiencies related to abuse prevention for one resident out of 15 residents reviewed. (Resident 1) Findings include: As a result of the deficiencies cited under the requirements related to abuse prevention during the survey of February 7, 2025, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure solutions were sustained. The corrective plan was to be completed and functional by March 11, 2025. However, during the survey ending March 27, 2025, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited on February 7, 2025, relating to implementation and adherence to procedures to ensure abuse prevention and to ensure deficient practice was corrected included update activity assessments to assess possible diversional activity interest, identify other residents that have the potential to be affected, residents that exhibit aggressive behaviors will be reviewed by the IDT. Care plans will be updated, as necessary, to prevent this from reoccurring, re-education of the abuse policy and behavior interventions will be completed with facility staff by the staff educator/designee, and monitor and maintain compliance, the DON/designee will review 10 residents that exhibit aggressive behaviors to ensure that behaviors are addressed, and care plan interventions are appropriate for behaviors exhibited. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations. The results of the revisit survey conducted on March 27, 2025, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to prevent abuse and to ensure residents in the facility are protected from residents with aggressive behaviors. The facility's QAPI monitoring process, which was intended to ensure sustainability of solutions, did not detect ongoing risk to residents nor prevent further similar deficient practice as cited during the survey ending February 7, 2025. Refer F600 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of select facility policy, facility grievance forms, and resident, family and staff interviews, it was determined the facility failed to make ongoing efforts to resolve grievances and the provision of timely follow-up with residents and/or their representative regarding the status update on the resolution progress of a grievance for three of seven residents reviewed (Residents 107, 15 and 4). Findings include: A review of the facility's policy titled Resident Grievances and Concerns Policy last reviewed by the facility on November 12, 2024, indicated that upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated. The grievance review will be completed in a reasonable time frame consistent with the type of grievance, but in no event will the review exceed thirty (30) days. If the Grievance Committee/Grievance Official determines that a resident rights violation has occurred, then violation must be corrected within ten (10) days. Upon completion of the review, the Grievance Official will complete a written grievance decision. The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved. A copy of the written grievance decision will be provided to the resident, upon request. The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued. During a group interview conducted on February 5, 2025, at 10:00 AM with six alert and oriented residents, two of the six residents in attendance reported they filed grievances but never received a response from the facility. Resident 107 stated she had filed three grievances within the last 2 months and never received a response from the facility. She reported that an aide filled out the concern forms for me because I can't write so good. I saw her put it in the box(grievance box) Resident 15 stated that she filed a written grievance about six months ago and never received a response. An interview conducted on February 6, 2025, at 8:13 AM with Resident 4's family member revealed that, We have 30-40 concern forms filed since admission to the facility in April (2024). Maybe 2-3 have been addressed, otherwise we have received no response, nothing has been resolved and no appropriate steps have been taken. The family member continued to report that Assistant Director of Nursing, RN Supervisor, nurses, Social Services and/or kitchen manager are the staff members who have taken he and his mother's verbal concerns and complaints. He indicated that many of the grievances centered around dietary issues, lack of receiving fresh water daily, staff treatment of his mother, wandering residents, and other care and service concerns. He reported that They come in and fill out the paperwork and say they'll take care of it and then I don't hear from them again. No resolution, no response. The lack of follow-up is concerning. Review of the grievance log for Resident 4 revealed three (3) grievances on file since admission to the facility in April 2024. The results of the three grievances indicated that they were resolved. There was no documented evidence the resident's additional complaint/grievances were investigated. There was no documented evidence of a summary of findings or conclusion regarding the resident's concerns as a result of the grievances. During an interview on January 7, 2025, at 9:30 AM the Nursing Home Administrator (NHA) confirmed the facility only had three grievances on file for Resident 4. The NHA was unable to provide evidence of prompt efforts to resolve a grievance and to keep the resident/family appropriately apprised of progress toward resolution. 28 Pa. Code 201.18(e)(1) Management

Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that two residents (Residents 366 and 52) out of 35 sampled were free from physical abuse perpetrated by another resident (Resident 180). Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation last reviewed by the facility on November 12, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 366's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and diabetes mellitus (body has trouble controlling blood sugar and using it for energy). A review of the resident's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 6, 2024, indicated that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool to assess cognition) score of 15 (13-15 represents intact cognitive responses). A review of Resident 180's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included vascular dementia, severe with behavioral disturbances (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients) and metabolic encephalopathy (chemical imbalance in the blood that affects the brain which can cause loss of memory and difficulty coordinating motor tasks). A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 2. A review of nursing documentation from June 2024 through December 2024, revealed that Resident 180 displayed behaviors of pacing, wandering the halls, wandering into other residents' rooms, yelling, agitation, aggressive behavior, verbally abusive with staff and other residents, physically abusive to staff, cursing, walking the hallway with no pants on, and attempting to elope from the facility. It was further noted that the resident would kick and hit staff while walking past him in the hall. It was documented that constant redirection was given, but the resident does not consistently follow redirection. A review of nursing documentation dated December 10, 2024, at 3:33 AM revealed that Resident 180 was found in Resident 366's room. Staff noted that Resident 180 was standing next to Resident 366's bed. When redirection was attempted, resident 180 became agitated and was directed back to his room. Resident 366 reported Resident 180 initiated physical aggression towards her. One-to-one support provided and assessed for injuries. No injuries were noted. A review of the Mandatory Abuse Report dated December 10, 2024, at 4:26 AM documented that Employee 8 (nurse aide) responded to Resident 366's call light and observed Resident 180 in her room. Resident 366 reported that Resident 180 poked her right thigh forcefully, causing pain. Employee 11 (registered nurse) assessed Resident 366, who stated that Resident 180 entered her room and punched her leg multiple times with full force. Resident 366 described feeling shocked and noted that Resident 180 was significantly larger than her. Facility interventions included redirecting Resident 180 to his room, administering PRN lorazepam, offering Resident 366 a room change, relocating her to another hall, providing one-to-one emotional support, offering Tylenol for pain, and reporting the incident to law enforcement. Facility documentation indicated a pattern of aggressive behaviors and intrusive wandering behaviors by Resident 180 prior to the reported incident involving Resident 366. The facility failed to demonstrate proactive measures to prevent the incident. A review of Resident 52's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures) and cerebral infarction (brain damage that results from a lack of blood). A review of the resident's Quarterly Minimum Data Set Assessment (dated December 17, 2024, indicated that the resident was severely cognitively impaired with a BIMS score of 4. On December 27, 2024, at 8:46 AM, Resident 180 approached Resident 52 in the hallway and slapped him on the right cheek. A review of the Mandatory Abuse Report dated December 27, 2024, at 8:47 AM indicated that Resident 52 was seated in the hallway, singing and talking to himself, when Resident 180 approached him, raised both fists, and struck Resident 52 on the right cheek with one hand. A physical assessment revealed no noted injuries, redness, or marks. Facility interventions included the immediate separation of the residents, initiation of safety checks for Resident 52 every 15 minutes, implementation of one-to-one supervision for Resident 180, completion of body assessments, and notification of the physician and responsible party. A review of a witness statement submitted by Employee 10 (Physical Therapist) on December 27, 2024, with an additional statement signed on December 31, 2024, indicated that Employee 10 observed Resident 180 walking up and down the [NAME] Hall several times. While documenting at the nurse's desk, Employee 10 heard Resident 52 singing and repeating a phrase from a kitchen aide's t-shirt. Employee 10 observed Resident 52 seated in a wheelchair at the start of East Hall across from the desk. Resident 180 was seen walking from [NAME] Hall past the desk, stopping in front of Resident 52, raising his fists, and striking Resident 52 on the right cheek. Employee 10 immediately intervened, escorting Resident 180 away and redirecting him to his room. A nurse aide approached Resident 52, and the LPN was notified. The LPN then informed the RN Supervisor. The facility failed to ensure that Residents 366 and 52 were free from physical abuse perpetrated by Resident 180. An interview with Nursing Home Administrator on February 7, 2025, at approximately 9:35 AM confirmed the facility failed to prevent the physical abuse of Residents 366 and 52 perpetrated by Resident 180, which resulted in a punch to the thigh and a slap to the face. The facility failed to implement sufficient supervision and monitoring measures to address Resident 180's known history of aggression, resulting in physical abuse of other residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 35 sampled (Resident 179 and Resident 159). Findings include: A review of the clinical record revealed that Resident 179 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders and personality changes). A review of Resident 179's quarterly MDS assessment dated [DATE], revealed that Section E-Behavior, item E0900, was coded as 0-Behavior not exhibited, indicating the resident did not exhibit wandering behaviors. However, a review of the clinical record revealed documentation of wandering behavior. A progress note dated November 6, 2024, at 9:49 PM indicated that the resident had multiple incidents of wandering into and out of other residents' rooms. An interview with the Nursing Home Administrator on February 7, 2025, at 11:27 AM confirmed that Resident 179's quarterly MDS dated [DATE], was coded inaccurately in Section E-Behavior, item E0900, as it did not reflect the resident's documented wandering behavior. A review of the clinical record revealed that Resident 159 was admitted to the facility on [DATE], with diagnoses that included psychosis (mental disorder characterized by a disconnection from reality). A review of Resident 159's quarterly MDS dated [DATE], indicated the following in Section N: N0415 High-Risk Drug Classes was coded to indicate the resident was receiving a hypnotic medication (a psychoactive medication prescribed to treat sleeplessness); however, a review of the clinical record revealed no documented evidence that the resident was receiving a hypnotic medication. N0450 Antipsychotic Medication Review was coded in: N0450A to indicate the resident was receiving antipsychotic medication on a routine basis. N0450B to indicate that a Gradual Dose Reduction (GDR, a stepwise tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose) had not been attempted. N0450E did not indicate a date that the physician determined a GDR was clinically contraindicated. Further review of the clinical record revealed a physician order dated November 17, 2024, to discontinue Secuado (an antipsychotic) 0.8 mg/24 hours one patch applied transdermally (administer a drug through the skin) one time daily for psychosis and removed per schedule. A nurse's note dated December 13, 2024, at 12:48 PM, documented that the resident was scratching their face during the shift and required redirection with one-on-one intervention. The note also indicated the resident had recently undergone a GDR of the Secuado patch and that the resident's representative and physician were aware, with orders pending. A subsequent nurse's note dated December 13, 2024, at 6:28 PM documented that the resident was exhibiting behaviors including restlessness, agitation, and repetitive movements. A new physician's order was received to restart Secuado 0.8 mg/24 hours, one patch applied transdermally once daily for psychosis and removed per schedule. A physician's order dated December 13, 2024, documented the reinstatement of Secuado 0.8 mg/24 hours, one patch applied transdermally once daily for psychosis and removed per schedule. A social services note dated December 16, 2024, indicated that an interdisciplinary review had determined that the GDR had failed. An interview with the Director of Nursing on February 6, 2025, at approximately 2:00 PM confirmed that Resident 159's quarterly MDS assessment dated [DATE], was inaccurate. The facility failed to ensure that MDS assessments accurately reflected the clinical status of Residents 179 and 159, resulting in incomplete or inaccurate assessments used for care planning. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, select facility investigative reports, and resident and staff interviews, it was determined the facility failed to implement effective safety measures to prevent an injury during transfer for one out of the 35 sampled residents (Resident 157). Findings include: A clinical record review revealed Resident 157 was admitted to the facility on [DATE], with diagnoses to include but not limited to arthritis (a disease that causes swelling and tenderness in one or more joints) and morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 3, 2024, revealed that Resident 157 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 157's plan of care dated August 28, 2024, indicated that the resident had a self-care deficit related to decreased mobility requiring extensive-to-total assistance with mobility and transfers. Interventions implemented included assisting the resident during all transfers with the assistance of two staff members via mechanical lift with a black sling (a lift that uses hydraulic power to transfer a person while cradled in a sling). A care plan indicating Resident 157 has a self-care deficiency requiring extensive-to-total assistance with mobility and transfers related to decreased mobility initiated on August 28, 2024. Interventions implemented include assisting the resident during all transfers with the assistance of two staff members via mechanical lift with a black sling. A facility investigation report dated August 30, 2024, at 9:03 PM, revealed Resident 157 sustained a forehead laceration during a transfer from her bed to a bariatric bed with a new air mattress using a mechanical lift. The investigation report indicated the forehead laceration injury was new and bleeding. A wound report dated August 30, 2024, at 10:31 PM, revealed a forehead laceration measuring 5 cm x 0.5 cm. A witness statement dated August 30, 2024, no time indicated, provided by Employee 1 (nurse aide), revealed she was using the mechanical lift to transfer Resident 157 from her bed to a bariatric bed with new air mattress. Employee 1 indicated she was driving the lift and put her in the hallway to transfer the resident into the new bed. When lowering the bed, the leg of the lift got caught between the wheels of the bed, and Employee 2 (nurse aide), pushed Resident 157 and pulled himself toward her, and then he flipped over and hit Resident 157 in the head where the top part of the sling was, causing a small wound. An injury was identified, and Employee 1 immediately reported to the supervisor. A witness statement dated August 30, 2024, no time indicated, provided by Employee 2 revealed Resident 157 was transferred into a bariatric bed in the hallway next to her room in the mechanical lift and was positioned over the bariatric bed, and during lowering the resident, her weight became displaced, and the base of the lift tipped over. A progress note dated August 30, 2024, at 9:03 PM provided by Employee 3, Registered Nurse, revealed that Resident 157 was being transferred to a different bed in the hallway to allow the contractor to put a new air mattress on the resident's bed. Upon transfer, via mechanical lift, Resident 157 suddenly hit the bed and was heard screaming OW, OW, OW. Employee 3 was at the nurses' desk, looked up, and saw that Resident 157 was in the bed and the lift was tipped on top of her. Upon arrival, Employee 3 pulled the lift from the resident's forehead and assessed the laceration that was actively bleeding, and pressure was placed on the wound, and 911 was called. A progress note by Employee 3, RN, dated August 30, 2024, 9:03PM, revealed the cause of the injury was improper placement and use of the mechanical lift. A statement from Resident 157 dated September 3, 2024, no time indicated, revealed that her air mattress had popped, and Employee 1 and Employee 2 transferred her to a bariatric bed with a new mattress via mechanical lift in the hallway. Resident 157 stated that during the transfer, the lift was pulled and hit her in the head. Resident 157 stated, I am not in any pain, but they said I have a cut. A community emergency department report dated August 30, 2024, at 11:10 PM documented that Resident 157 was evaluated for a laceration after being struck in the head with the mechanical lift during transfer. A head CT scan (a noninvasive medical procedure that uses x-rays to create detailed images of the body), was performed and was negative. The resident was prescribed Tylenol for pain. A progress note dated August 30, 2024, at 2:55 AM, revealed the resident returned from the emergency department. During an interview on February 4, 2024, at 1:00 PM, Resident 157 confirmed that she was hit in the head during a transfer into a new bariatric bed and had to be transferred to an emergency department for evaluation of her bleeding wound. A review of the facility's investigation confirmed the injury occurred due to improper placement and use of the lift during the transfer. Competency evaluations revealed that both Employee 1 and Employee 2 had satisfactory transfer skills and knowledge. During an interview on February 7, 2025, at 9:15 AM, the Nursing Home Administrator (NHA) confirmed that it was the facility's responsibility to ensure effective safety measures were implemented to prevent accidents and injuries to residents. The NHA acknowledged that Resident 157 sustained a laceration during the transfer on August 30, 2024. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected; the Director of Nursing (DON)/designee completed a house-wide audit of proper lift technique and that air mattresses had proper inflation. To prevent this from recurring the unit manager provided education to nursing staff regarding proper transfer technique and lift competencies were completed, and mechanical lifts were inspected for safety. To monitor and maintain ongoing compliance, the DON/designee audits and assesses 5 residents weekly x 4 to ensure proper lift technique is used during transfers and air mattresses are inflated without issues. Any negative findings will be immediately corrected. Results of audits will be forwarded to facility QAPI for review and recommendation as indicated. The facility's immediate corrective action plan was completed on September 2, 2024. 28 Pa. Code 211.18 (e)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, select facility investigative reports, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, in accordance with professional standards of practice for one (1) of 35 sampled residents (Resident 266). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. Review of the clinical record revealed that Resident 266 was admitted to the facility on [DATE], with diagnoses to include diabetes and dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders and personality changes). A physician order dated [DATE], noted an order for a LCS (low concentrated sweets) regular texture diet. Review of an Occupational Therapy Evaluation dated [DATE], indicated the resident was independent for self-feeding. Review of a nurses note dated [DATE], at 6:45 PM written by Employee 7 (RN) revealed the resident was found unresponsive, was determined to be a full code (medical order that instructs healthcare team to perform all possible life-saving measures if the patient's heart or lungs stop working), and life-saving measures were immediately initiated, 911 was called immediately, EMS (Emergency Medical Services) arrived at the facility, continued life-saving measures, and the resident was transferred to the hospital. Physician and Resident Representative were made aware. A nurses note dated [DATE], at 11:11 PM written by Employee 7 (RN) revealed that the hospital notified the facility that the resident expired at the hospital on [DATE], approximately 7:30 PM. Review of the resident's SBAR Communication Form (situation, background, assessment recommendation used in healthcare to share information about a patient's condition) dated [DATE], completed by Employee 7 (RN) revealed that Resident 266 was found unresponsive at 6:45 PM, it was determined that resident was a full code and life saving measures were immediately initiated, 911 was called immediately with their arrival at 7:10 PM, EMT continued lifesaving measures and resident transported to the hospital emergency room . Resident representative and physician notified. Further review of the resident's SBAR Communication Form dated [DATE], revealed that Employee 7 (RN) electronically completed the form. However, Employee 7 (RN) indicated at the bottom of the SBAR Communication Form that Employee 5 (LPN) completed the form. Review of a facility investigative report dated [DATE], revealed that Resident 266 was noted to be choking on his dinner. The Heimlich Maneuver (first-aid technique that uses abdominal thrusts to help someone who is choking) was immediately performed without success. The resident then became unresponsive, and CPR (cardiopulmonary resuscitation-emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) was initiated. The resident was sent to the emergency room for further evaluation of the situation. A review of a witness statement from Employee 4 (nurse aide) dated [DATE], revealed on [DATE], at 6:45 PM Employee 4 (nurse aide) heard the resident choking. Employee 4 (nurse aide) went into the resident's room to assist while he was coughing. Employee 4 (nurse aide) performed the Heimlich Maneuver until the resident went completely unresponsive. By then the nurse had arrived and CPR was started. A review of a witness statement from Employee 6 (LPN) which was signed but not dated revealed that on [DATE], Employee 6 (LPN) was alerted by staff that Resident 266 was choking. Upon entering the resident's room, the resident was sitting at the side of the bed and color was cyanotic (bluish, grayish). Employee 4 (nurse aide) was behind the resident performing the Heimlich Maneuver, the resident was unresponsive, laid on bed, mouth sweep done unable to feel or see anything. Dentures were in resident's mouth. Resident suctioned, small pieces of food, resident with no respirations, no pulse, Code Blue called, CPR initiated. 911 called. AED (automated external defibrillator which is a medical device that delivers an electric shock to the heart to help restore a normal rhythm) pads placed, no call for shock. CPR continued. Emergency Medical Technician (EMT) arrived. LUCAS (mechanical chest compression system that helps healthcare providers perform CPR on patients in cardiac arrest) device placed on resident. IV (intravenous- giving medications or fluids through a needle or tube inserted into a vein) line started. Two doses of medication were administered. While EMT was attempting to intubate (medical procedure which involves inserting a tube into a patient's airway to help them breathe) resident, a full-size meatball was pulled out of the resident's throat. CPR continued. Pulse obtained. Resident was transferred to the hospital emergency department. A review of a witness statement from Employee 5 (LPN) dated [DATE], revealed that on [DATE], noted that Resident 266 was observed prior to the incident moving around the unit and talking with everybody without any problems or concerns. Upon returning from break, heard the Code Blue and ran to the scene. Employee 5 (LPN) started helping. Resident 266 was sent to the hospital via ambulance. Resident unresponsive. Family made aware of the transfer. The investigative report documented a choking episode, but the resident's clinical record lacked any documentation of the choking incident, the Heimlich Maneuver, or the removal of a full-size meatball from the resident's airway by EMT personnel. Review of facility documentation revealed inconsistencies between the nursing notes, SBAR Communication Form, witness statements, and the facility's investigative report. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 5, 2025, at approximately 11:30 AM confirmed the facility's nursing staff failed to accurately and consistently document the incident in the resident's clinical record. The NHA and DON confirmed there was no documented evidence of the resident's choking incident. The DON verified that the staff member listed at the bottom of the SBAR Communication Form should have accurately reflected the individual completing the form. The facility failed to ensure that the residents clinical record was accurate and complete. 28 Pa. Code 211.5 (f)(ii)(iii)(ix) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of the facility's plan of correction from the survey ending February 7, 2025, the results of the current revisit survey on March 27, 2025, review of clinical records, information submitted by the facility, and staff interview it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies related to abuse prevention and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: As a result of the deficiencies cited under the requirements related to abuse prevention during the survey of February 7, 2025, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure solutions were sustained. The corrective plan was to be completed and functional by March 11, 2025. However, during the survey ending March 27, 2025, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited on February 7, 2025, relating to implementation and adherence to procedures to ensure abuse prevention and to ensure deficient practice was corrected included (1) Resident 233 was discharged with no ill effects. Resident 180 plan of care was reviewed, and an updated activity assessment was completed to assess possible diversional activity interest, (2) To identify other residents that have the potential to be affected, residents that exhibit aggressive behaviors will be reviewed by the IDT. Care plan will be updated, as necessary, (3) To prevent this from reoccurring, re-education of the abuse policy and behavior interventions will be completed with facility staff by the staff educator/designee, and (4) To monitor and maintain compliance, the DON/designee will review 10 residents that exhibit aggressive behaviors to ensure that behaviors are addressed, and care plan interventions are appropriate for behaviors exhibited. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations. The results of the revisit survey conducted on March 27, 2025, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to prevent abuse and to ensure residents in the facility are protected from residents with aggressive behaviors. The facility's quality assurance monitoring plan, designed to ensure solutions were sustained, failed to identify the continuing deficient practice with this quality requirement and prevent recurrence of similar deficient practice as cited during the survey of February 7, 2025. Refer F600 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of select facility policy and clinical records and staff interviews, it was determined the facility failed to offer and/or provide the influenza immunization, unless the immunization was medically contraindicated or the resident had already been immunized, to one resident out of five residents reviewed for administration of the flu vaccine. (Resident 110). Findings include: A review of facility policy titled Resident Vaccination Policy, last reviewed November 12, 2024, revealed that each resident is to be offered an influenza immunization unless the immunization is medically contraindicated. Nursing staff will provide educational information to the resident/authorized representative prior to the administration of each vaccine. Once education has been completed, a signed consent form is to be obtained prior to the administration of the vaccine. A review of the clinical record revealed that Resident 110 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, fatigue, and feelings of worthlessness). Review of Resident 110's Informed Consent for Influenza, Pneumococcal, and Covid Vaccines signed by Resident 110's resident representative on August 26, 2024, confirmed authorization for the facility to administer the influenza vaccine., Covid vaccine, and pneumococcal vaccines. However, there was no documented evidence that the influenza vaccine was administered as per the signed consent. An interview with the Director of Nursing on February 7, 2025, at 12:24 PM confirmed the facility failed to provide the influenza immunization to Resident 110 despite having obtained the required valid signed consent. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.10(a)(d) Resident care policies . 28 Pa code 211.12 (c)(d)(1)(5) Nursing Services.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor and evaluate weight and hydration requirements of a resident to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of six sampled (Resident A1). Findings include: Review of the facility Resident Weight Policy last reviewed December 2024 indicated weights must be obtained routinely to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the Resident Hydration Policy last reviewed December 2024 indicated residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations. A dietitian will evaluate resident fluid status within 14 days of admission, quarterly, and as needed. This may include laboratory testing by the provider as ordered. Fluids include water, juices, coffee/tea, gelatin, ice cream, soups, popsicles, and any other substance which is essentially liquid in nature. Nursing staff will be primarily responsible for resident fluid intake during and between meals. Fluids may be provided by others determined by resident fluid and dietary orders (such as activities, dietary, visitors). Nursing, medical providers, and dietitians will monitor for signs of dehydration and monitor resident medications which may alter fluid balance. Fluids will be provided with meals, snacks, and at the bedside, unless otherwise ordered by the provider. If resident fluid status is identified as inadequate, the interdisciplinary team will discuss with the resident and provider and determine if alternative (non-oral) methods of hydration are desired/warranted. A review of the clinical record revealed Resident A1 was admitted to the facility on [DATE], with diagnoses which included dementia, congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), and chronic kidney disease (disease characterized by progressive damage and loss of function to the kidneys). A review of the resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 3, 2024, indicated the resident was severely cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 0 (a score of 0-7 indicates severe cognitive impairment). A physician order dated October 19, 2024, noted an order for Furosemide (a diuretic or water pill, used to treat a build- up of fluid in the body which increases urination and may increase risk for dehydration) 20 mg one tablet by mouth daily for a diagnosis of edema (buildup of fluid in the body's tissue). Review of a Medical Nutritional Therapy Observation and Admission Nutrition assessment dated [DATE], indicated the resident was prescribed a Regular diet and consumed 76-100% of food and fluids. The resident's calorie needs were 1375-1650 kcal per day and fluid needs were 1375 ml-1650 ml per day. The resident was noted to have non-blanchable areas (area of redness on the skin that does not turn white when pressure is applied) to the sacrum and right upper back. The resident's nutrition goals were stable weight, stable or improved skin, and adequate hydration. A nutrition intervention of 90 ml med pass (nutritional supplement) every day was recommended. A review of the resident's weights noted the resident experienced weight loss as follows: October 18, 2024- 114 pounds October 23, 2024- 107 pounds (which indicated a 7-pound significant weight loss (defined as 5% loss of body weight in one month interval) or 6.1% loss of body weight in one week. A dietary note dated October 25, 2024, noted current weight shows 7 pounds, 6.1 % weight loss in the first week of admission. No fluid changes noted. BMI (body mass index a screening tool based on height and weight to evaluate weight categories) indicates low body weight. Meal intake variable but greater than 50% intake of many meals. 90 ml med pass in place every day. Supplement accepted two of three offerings. Resident has impaired skin. Recommend Mighty Shake every day to promote weight stability and adequate oral intake for wound healing. Further review of the resident's weights noted the following: October 29, 2024- 106 pounds November 5, 2024- 104 pounds November 12, 2024- 104 pounds November 19, 2024- 98.6 pounds which indicated a 5.4-pound significant weight loss or 5.1% loss of body weight in one week. There was no documented evidence of a reweight to verify the weight loss or that the dietitian evaluated the resident following the significant weight changes. There was no documented evidence of physician or resident representative notification of the weight changes. Review of the resident's appetite record from December 1 through December 9, 2024, indicated the resident was consuming less than 75 % at most meals. Review of the resident's fluid intake from December 1 through December 9, 2024, indicated the following: December 1, 2024- 1140 cc fluids (with and between meals) and 76-100% supplements. December 2, 2024- 520 cc fluids (with and between meals) and 76-100% supplements. December 3, 2024- 760 cc fluids (with and between meals) and 76-100% supplements. December 4, 2024- 720 cc fluids (with and between meals) and 76-100% supplements. December 5, 2024- 320 cc fluids (with and between meals) and 76-100% supplements. December 6, 2024- 700 cc fluids (with and between meals) and 76-100% supplements. December 7, 2024- 720 cc fluids (with and between meals) and 26-50% supplements. December 8, 2024- 720 cc fluids (with and between meals) and 1-100% supplements. December 9, 2024- 720 cc fluids (with and between meals) and 76-100% supplements. From December 1 to December 9, 2024, the resident's fluid intake ranged from 320 cc to 1140 cc per day, consistently below the required range of 1375-1650 ml/day. There was no documented evidence based on the resident's weight loss, decreased appetite, decreased fluid intake, and diuretic use that the facility was timely monitoring and evaluating the resident's appetite and fluid intake to ensure the resident's caloric and fluid needs were met to the extent possible. A nurses note dated December 9, 2024, at 12:16 PM noted the resident was documented as lethargic with poor appetite. A nurse's note indicated the physician was notified, and labs were ordered along with a urinalysis with C&S (culture and sensitivity). The resident's diet was downgraded to a pureed texture. A nurses note dated December 10, 2024, at 3:02 PM noted lab results received. Physician called due to high abnormal lab results. Per physician resident is to be sent to emergency department for intravenous fluids and further evaluation. Review of the resident's lab results dated December 10, 2024, showed significantly elevated BUN 144 mg/dL (normal value 7-25 mg/dL, may be elevated with dehydration); Creatinine was elevated at 3.14 mg/dL (normal value 0.40-1.10 mg/dL, may be elevated with dehydration); Sodium elevated at 167 mmol/L (normal value 135-145 mmol/L, may be elevated with dehydration); and Chloride elevated at 127 mmol/L (normal value 100-109 mmol/L, may be elevated with dehydration). Review of the hospital discharge summary dated December 13, 2024, revealed the resident was admitted to the hospital for treatment of hypernatremia likely secondary to fluid deficit secondary to diuretic use, acute kidney injury superimposed on chronic kidney disease secondary to fluid deficit secondary to diuretic, and urinary tract infection. The resident was readmitted from the hospital to the facility on [DATE]. There was no documented evidence the facility identified or addressed the resident's significant weight loss and inadequate fluid intake. Interview with the director of nursing on January 3, 2024, at approximately 12:00 PM failed to provide documented evidence that the facility timely identified the resident's significant weight loss and decreased oral intake and, nor did they reassess nutritional, and hydration needs to ensure the resident's nutritional parameters were maintained and plan nutritional support as necessary. 28 Pa. Code 211.5 (f) (ii) (ix) Medical Records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents and resident representatives, it was determined that the facility failed to ensure that one resident was free from sexual abuse and resultant psychosocial harm (Resident 16) and that one resident (Resident 106) was free from physical abuse out of 11 residents sampled for abuse prohibition. Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property an injuries, of unknown source. The definition of sexual abuse incudes but is not limited to, non-consensual sexual contact of any type, sexual harassment. sexual coercion, or sexual assault. A review of Resident 16's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included mild cognitive impairment of uncertain or unknown etiology. A review of the resident's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 24, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview For Mental Status score of 7, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment). A review of Resident 91's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) affecting the left non dominant side due to history of a cerebral infarct (when a cluster of brain cells die due to lack of blood flow), depression and congestive heart failure (CHF occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs A review of Resident 91's admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14 (scores of 13-15 equate to intact cognition). A review of a facility investigation report dated July 6, 2024, at 6:00 PM revealed that Employee 1, a nurse aide, walked into Resident 16's room and observed Resident 16 and Resident 91 naked in Resident 16's bed. A review of Employee 1's witness statement dated July 6, 2024 revealed that she entered Resident 16's room to give her a dinner tray and found both residents lying naked in the resident's bed. When Resident 16 saw Employee 1 she quickly sat up. The nurse aide immediately notified the nurse. The residents were quickly separated and were placed in their own rooms. Nursing documentation dated July 6, 2024, at 10:13 PM from Employee 2 the Registered Nurse indicated Resident 91 reported that Resident 16, called him over into her room and they engaged in a sexual act. A review of the facility investigation dated July 9, 2024, revealed statements from both residents. Employee 2, RN, obtained a statement from Resident 16, which indicated that this female resident did not remember a guy being in her room. She stated if a guy was in her room it would be her boyfriend. Resident 16 continued to state that all she did all was stay in her room and change her clothing twice. Employee 2 stated the resident had no recollection of the sexual encounter with Resident 91. A statement was obtained from Resident 91, whose primary language is not English, and may require a translator as requested, and was translated and written by Employee 3, Licensed Practical Nurse (LPN) on July 6, 2024. According to Resident 91's statement, he observed Resident 16 in her room across the hall. Resident 91 stated that Resident 16 was naked and gestured to him to come to her room. He walked over to Resident 16's room and he climbed on top of her and had sexual intercourse with Resident 16. He stated a girl walked in while he was still engaged in sexual intercourse with Resident 16. He then stopped the sexual act, pulled his pants up and left the room and went back to his room. Resident 91 also stated Resident 16 was provoking him the prior day by talking and conversing with him. A telephone interview conducted on July 9, 2024, at 1:26 AM with Employee 1. the nurse aide, revealed that she found both residents naked in bed in Resident 16's room on the evening of July 6, 2024, and immediately told a nurse. She stated she was very surprised because Resident 91 usually stays to himself in his room and he barely comes out. She stated he rings his call bell when he needs something. She stated she usually didn't see him conversing with Resident 16. Employee 1 stated that Resident 91 does speak to her because she is able to converse with him in his primary language. She stated on the evening of this sexual encounter Resident 91 was taken to the dayroom and staff watched him on a one-to-one basis until Resident 16 was moved to another room. Employee 1 stated Resident 16 is very social and was frequently observed walking up and down the hallway on a regular basis and often spoke to others about her boyfriend. An interview with Resident 91 was attempted on July 9, 2024 however the resident was not available as he was out at an appointment on the day of the survey. An interview with Resident 16 was conducted on July 9, 2024, but she was unable to recall the event and shared pictures of her boyfriend with the surveyor, that were on her dresser next to her bed in her new room. An interview with Employee 2, RN, at 12:52 PM on July 9, 2024, revealed that the residents were both separated that evening and placed on every 15 minute security checks. Resident 16 was moved to another room in a different building of the facility (facility comprised of two separate buildings on the same campus). A telephone interview was conducted with Resident 16's interested representative, a close friend, on July 9, 2024, at 11:46 PM. The resident's friend stated that Resident 16 is a long time friend, and she was not surprised of her actions with the male resident. The resident's friend stated that Resident 16 may have thought the male resident was her boyfriend. She stated that the resident may not want to remember what happened because she is very forgetful and may not want to accept what happened because of the loyalty she has to her boyfriend. The resident's friend stated that the resident can be very outgoing and that she wished had the opportunity to speak with facility staff to apprise them of the resident's resident's behavior and relationship with her boyfriend. The resident's representative stated that she believed that information would be necessary for the facility to explain the resident's behaviors. Resident 16's interested representative also relayed that she could never allow the resident's boyfriend to be aware of this sexual encounter because of the negative effects it would have on their relationship and also did not wish to notify the resident's daughter of the event due to the humiliation and embarrassment. A review of the resident's admission paperwork revealed that her daughter signed the documents upon admission and remained listed as a second emergency contact. The resident's friend was listed as the primary contact. A review of Resident 16's care plan, at the time of the survey, did not identify the significance of the resident's relationship with her boyfriend. Neither Resident 16's or Resident 91's care plans, identified any history of sexual behaviors. Resident 16 is cognitively impaired and did not possess the ability to consent to sex with Resident 91. A repeat BIMS score was obtained shortly after the encounter and her score was assessed at a 3 indicating severe cognitive impairment. Applying the reasonable person concept, in the case of Resident 16, who is unable to cognizantly speak for herself due to severe cognitive impairment, and the assessment of how most people would react to the situation of being sexually abused by Resident 91, Resident 16 would have been negatively affected by Resident 91's actions. A review of Resident 106's clinical record revealed admission to the facility on [DATE], with diagnoses which include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 3. A review of Resident 12's clinical record revealed admission to the facility on [DATE], with diagnoses which included intermittent explosive disorder and epilepsy. A review of the resident's annual Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 3. A facility incident report dated June 21, 2024, at 2:30 PM indicated that Resident 109, a cognitively intact resident, reported observing Resident 12 hit Resident 106 in the stomach as Resident 106 was walking in the hallway. The residents were redirected and separated and placed on increased supervision. Assessment completed and no injuries were noted. Applying the reasonable person concept, in the case of Resident 106, who is severely cognitively impaired, and the assessment of how most people would react to the situation of being physically abused by Resident 12, Resident 106 would have suffered psychosocial harm and humiliation. An interview with the nursing home administrator on July 9, 2024, at approximately 1:00 PM confirmed that the facility failed to ensure that Residents 16 was free from sexual abuse perpetrated by Resident 91 and Resident 106 was free from physical abuse perpetrated by Resident 12. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on review of clinical records and select facility policy, observations, and staff and resident interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident 181) out of 14 sampled residents, placing the 65 residents out of 238 residents residing in the facility, identified at risk for elopement, including Resident 142, in immediate jeopardy to their health and safety. Findings include: Review of facility policy entitled Elopement/ Unauthorized absence, last revised by the facility February 6, 2024, revealed that elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility will identify residents with potential/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. The corresponding procedures included: -all residents will be assessed for the risk of elopement -residents identified at risk will have interventions promptly implemented to reduce the risk of elopement -residents identified at risk will have their picture and face sheet form placed in the binder that is kept in an area accessible by staff. Upon determining that a resident cannot be located, a head count (of residents) will be conducted. If the resident is still missing, code green using the resident name, room number and unit name will be announced. The clinical supervisor or designee will notify the administrator, the Director of Nursing and the attending Physician. The highest-ranking staff member becomes the Team Leader and coordinates the search process. If the resident is not located on the premises, the team leader will direct staff to conduct an external search. A review of a facility policy Resident leave of absence revised April 25, 2024 revealed, that a leave of absence is defined as, time away from the facility, either on or off the property, where the resident is not under the direct care or supervision of facility staff, regardless of the amount of time, and someone other than facility stff has assumed responsibility for the resident during such time. Corresponding procedures were noted as: -The resident/responsible party will be requested to sign-out of the facility, which indicates the resident's/responsible party's acceptance of responsibility for self/resident while participating in an LOA and reminded to sign back in and alert staff upon return. -prior to leaving the facility, the charge nurse will request the address and phone number of the location where the resident will be, if known and estimated date and time of return. A review of the clinical record revealed that Resident 181 was admitted to the facility on [DATE], with diagnoses, which included bipolar disorder ( a mental health condition that causes extreme mood swings between depression and mania or hypomania) and difficulty walking. The resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a score of 13-15 indicates intact cognition). He independently propelled on the nursing unit in the wheelchair. The resident was homeless prior to this recent admission to the facility. When reviewed at that time of the survey ending May 31, 2024, there was no evidence that an elopement risk assessment had been completed upon the resident's admission or at any time prior to his elopement from the facility. There was also no documented evidence at the time of the survey ending May 31, 2024, of a physician order permitting the resident to go out on a leave of absence. An anonymous facility employee reported a concern to the State Survey Agency reporting that on Saturday May 18, 2024, Resident 181, a resident residing on the second floor of the the Blue building (facility is comprised of two facilities on the same campus), left the facility unsupervised, without staff knowledge, and walked independently with his cane, traveling approximately 0.5 miles to a convience store. The nursing supervisor was called, found him brought him back to the building, but staff did not document the incident in the resident's clinical record. A review of Resident 181's clinical record, conducted during the survey on May 31, 2024, confirmed that there was no documentation in the resident's clinical record regarding the resident's elopement. Observation and interview conducted on May 31, 2024 at 10 AM revealed that Resident 181 was in his room on the second floor of the Blue building seated in his wheelchair. In the presence of the surveyor, Resident 181 wheeled to the nurses station and signed his name and the time in the resident sign out book. There was no nursing staff at the nurses desk or anywhere in the immediate vicinity at that time. The resident and the surveyor then entered the elevator, exited on the first floor, passed the front desk (which was also unattended at that time) and wheeled outside through front entrance into the parking lot area. An interview at that with Resident 181, revealed that he stated that on Saturday May 18, 2024, early in the morning he signed the Leave of Absence (LOA) sheet, in the binder on the nurses desk (on the second floor resident unit). He stated that there was no nursing staff in the area at the time he signed out. He also stated that he goes out of the building several times a day, unaccompanied, stating that he does not tell anyone he is leaving the floor. Resident 181 stated that on Saturday May 18, 2024 he left the second floor in his wheelchair and had his cane with him. He took the elevator downstairs and left the building through the front entrance. When he got outside, he stood up from his wheelchair, and walked with his cane off the facility campus. He stated that it took him about an hour to walk from the facility to the convience store, stopping 4 to 5 times, sitting on the curb to rest. He stated that when he got to the store, he was shopping and he was approached by a gang of people from the facility. He stated that he was approached by a male nurse from the facility as well as 2 female nurse aides. These employees took him in a car and brought him back to the facility. He stated that the male nurse yelled at him and took his outside privledges away. Resident 181 stated that he is not steady on his feet and it was not easy to walk, and that he had to cross a busy street to get to the convenience store. Interview May 31, 2024 at 11:15 AM Employee 6, a nurse aide, stated that she worked 7 AM to 3 PM on Saturday May 18, 2024. She explained that residents who are independent can sign themselves out in a book that is at the nursing station, to go outside. Therapy and other services also use this book to sign residents off the unit. Employee 6 said, but if a resident leaves LOA (leave of Absence) there are papers to be signed in the resident's medical record. She stated sometimes people forget to sign in and/or out in this book, and staff have at times, needed to search for a resident because they didn't sign out. She stated she went on break with another aide sometime between 9:30 AM and 10:30 AM heading to a nearby convience store. While traveling in the car they noticed a resident sitting on the curb at the convience store. They returned to the facility and told the nursing supervisor that they saw the resident at the convience store. The nursing supervisor and two other staff members went to get the resident. Employee 6 stated she never saw any other employees with the resident or near the resident when they saw him sitting on the curb. She also stated that no facility staff member had asked her for a witness statement to give her account of the incident. An interview with Employee 7, a nurse aide, conducted at approximately 11:00 AM on May 31, 2024, revealed that she worked on Saturday May 18, 2024, during 7 AM to 3 PM shift. Employee 7 stated that she had not taken care of the resident who eloped, but recalled hearing the Code [NAME] (the facility's elopement code) sound and she participated in performing a head count and checked rooms for the missing resident, but were unable to find him. She stated that she heard the resident was found at the convience store and was returned to the facility. She stated no facility staff member had asked her for a witness statement as part of an investigation into incident. An interview with Employee 1, a nurse aide, on May 31, 2024, at 11:15 AM revealed the employee was working the dayshift on May 18, 2024. The employee stated the facility called a Code Green, the code called when a resident elopes from the facility. Employee 1 stated they began to look for the resident. Employee 1 stated she did not find him but heard he was found at the Turkey Hill down the street. Employee 1 stated that when residents are leaving the unit, they are supposed to sign out in the book that sits on the nursing station. She stated that the book is not supervised and at times, staff doesn't know who has signed themselves off the units. Employee 1 stated that if they are looking for a resident and cannot find them, they will check the book to see if they signed out. Employee 1 stated that there is no real procedure for ensuring the residents are signing the book or staff monitoring when residents are leaving the unit. An interview with Employee 2, LPN, (license practical nurse) on May 31, 2024, at 11:25 AM revealed this nurse was working the dayshift on May 18, 2024. Employee 2 stated that Resident 181 went out for fresh air during the first cigarette break around 8:30 AM. Employee 2 stated that Employee 3, RN, called a Code [NAME] when the resident could not be found on the unit. Another employee who was on break saw the resident at the Turkey Hill down the street. Employee 2 stated that the resident was brought back to the facility at approximately 9:30 AM. Employee 2 stated that the resident was allowed to sign the book on the unit and go outsides on the facility grounds for fresh air independently. Employee 2 stated that staff don't monitor the book unless they need to check on a specific resident, and there is no procedure in place to ensure residents are signing the book and staff monitoring to ensure the residents return to the unit. An interview with Employee 4, nurse aide, on May 31, 2024, at 11:35 AM revealed the employee was working the dayshift on May 18, 2024. Employee 4 stated that while she was on her 15 minute break, she went to [NAME] Donuts to get a coffee. The employee stated when she was leaving [NAME] Donuts to return to the facility, she spotted the resident sitting on the curb at the Turkey Hill. The employee stated the resident was alone in the parking lot of the store, with no staff with him or nearby. Employee 4 stated that she did not see him outside in the facility parking lot prior to him leaving the facility and did not see him outside for the morning smoke break. Employee 4 stated that she came back to the facility and told Employee 3 (RN) and Employee 5 RN that the resident was at the Turkey hill. Employee 3 called a Code Green, and he drove his car down to the Turkey Hill to pick the resident up. Employee 4 stated that there is no procedure in place to supervise residents signing out to leave the unit and confirm their return. The employee stated the residents are not supervised and sign themselves out. Employee 4 stated that if they can't find a resident, they would look in the book to see if they signed themselves off the unit. Employee 4 stated there have been times when a resident was not on the unit but did not sign off in the book. There was no evidence that the facility had interviewed their staff to determine when staff had last seen the resident, or how he was able to exit the nursing unit and building without staff awareness of the resident's whereabouts. The facility failed to demonstrate that staff adequately monitored this resident's whereabouts and activities. Nursing staff outside the building on a break called the facility to inform the facility staff that the resident had left the building as facility staff were unaware and the duration of the resident's absence could not be determined due to the lack of investigation by the facility. At the time of the survey ending May 31, 2024, the facility had not investigated the incident to determine the circumstances and how long the resident was gone. Interview with the Director of Nursing on May 31, 2024, at approximately 2:00 PM, revealed that staff had informed her of the incident and she came into the facility on [DATE]. The DON confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident. The DON also confirmed that the facility failed to investigate the resident's elopement to prevent recurrence and the incident was documented in the resident's clinical record or reported to the State Survey Agency. A review of the LOA binder located at the second floor nurses desk revealed on May 31, 2024, revealed the names of residents who signed out to leave the floor independently on multiple days. The residents' names were not listed on the list of residents approved to sign out and leave the floor independently provided during the survey by facility administration. This was confirmed during the survey by the DON and NHA on May 31, 2024, at 11:30 AM. Further, at the time of the survey of May 31, 2024, facility administration could not locate the sign-out sheet for May 18, 2024. Clinical record review revealed that Resident 142 was admitted to the facility on [DATE], with diagnoses to include schizophrenia, anxiety, major depression, bipolar disorder and difficulty walking and was moderately, cognitively impaired with a BIMS score of 10 (8012 indicates moderate cognitive impairment). A review of the LOA binder located on the second floor nurses station, revealed that May 29, 30 and 31, 2024, Resident 142 signed herself and left the floor. Review of the resident's clinical record revealed no evidence that the resident could leave the floor and the facility independently, which was confirmed by Director of Nursing during interview on May 31, 2024, at 1 PM. Immediate Jeopardy was called on May 31, 2024, due to the facility's failure to timely identify resident absences from the facility and prevent elopements. Lack of functioning operational procedures for monitoring residents who are signing out to leave the unit, building and facility grounds. The facility was notified of the Immediate Jeopardy on May 31, 2024, at 1:30 PM and the IJ template provided to the facility. An immediate plan of correction was requested and received on May 31, 2024. The plan included: - Identify residents who go outside independently and have the ability to be affected -policy and procedure reviewed with residents affected to ensure they know the process for leaving the unit -Therapy screen current residents affected to ensure they are able to leave safely -Residents with cognitive impairment will be reviewed to ensure the elopement assessments are accurate and interventions are in place to prevent elopement -review of current residents to ensure residents have an appropriate LOA order, if issues identified, call Physician for appropriate orders -Staff were made aware if a resident is not independent to go off the unit and outside and ensured they knew the policy for leaving the unit and/or LOA, Staff were educated that is a resident is not independently able to leave the unit, they must be stopped and supervision provided. -current staff educated on the LOA policy/procedure and the elopement policy and procedure -elopement drill completed on all shifts The Immediate Jeopardy was lifted on May 31, 2024, at 4:40 PM when the removal plan was verified as completed. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on review of clinical records, the facility's diet manual and select facility incident reports, and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet the resident's individual needs, which caused a choking incident and aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization of one of 14 residents reviewed (Resident 196). Findings Include: Review of Resident 196's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing). Review of resident's current care plan dated March 5, 2024, and in effect on April 21, 2024, revealed the resident required the assistance of one staff person with eating. Resident 196's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 9, 2024, indicated that the resident was provided a mechanically altered diet (a diet that required a change in texture of food) daily. Resident 196 had a current physician order for a regular Pureed texture diet with nectar thickened consistency liquids (liquids thickened to the consistency similar to apricot nectar) initially dated March 27, 2024 (pureed diet is a type of diet that consists of foods with a smooth pudding-like consistency). A review of a facility incident report dated April 21, 2024, at 5:45 p.m. indicated that Employee 7 (RN) was called to the unit to assist Resident 196, because he was coughing. Employee 7 arrived to find resident coughing mucous out, and eventually spits out a small piece of shrimp. Further stating that only a small amount of food was eaten from the top of the resident's meal plate. Review of employee witness statements for this incident revealed none of the nurse aide employees interviewed as witnesses indicated that they had provided feeding assistance to the resident during the dinner meal on April 24, 2024. Review of nurse aide tasks dated April 21, 2024, revealed Employee 6 (NA) provided resident 196's ADL (activities of daily living) care of toileting and other tasks associated with activities of daily living. Employee 6's witness statement indicated that she was not in the room with Resident 196 when he was eating his dinner meal on April 21, 2024. There was no documented evidence that any staff member was present when Resident 196 began eating his dinner meal on April 21, 2024. A review of facility planned menu for the evening meal on April 21, 2024, revealed that Shrimp Scampi over angel hair pasta was the dinner for residents receiving pureed diets. A review of the recipe for pureed shrimp scampi indicated that the shrimp and pasta servings should be separately put into the food processor, should be blended until smooth, served scoop of blended pureed shrimp over blended pureed pasta. Further review of resident's clinical record revealed that a stat chest x-ray was ordered by the physician at 5:45 p.m., on April 21, 2024. At approximately 10:00 p.m., the mobile x-ray company responded that they would not be able to make it to the facility until the next morning. Resident 196 was sent to the emergency room at approximately 10:19 p.m., on April 21, 2024, due to potential aspiration and drop in Spo2 (what percentage of your blood is saturated) registering in the 60's (normal range is 95-100%) requiring 2 liters of oxygen. Hospital documentation dated April 22, 2024, indicated that Resident 196 had acute respiratory failure requiring 4 liters of oxygen to maintain oxygen levels above 89%, had scattered rhonchi, moist respirations and an elevated temperature. The resident was started on Rocephin and Flagyl for likely aspiration pneumonia. Interviews with the director of nursing (DON) and nursing home administrator (NHA) on May 31, 2024, at approximately 3:00 p.m. the DON and NHA confirmed that the facility failed to serve food to Resident 196 that met the resident's individual needs for safe swallowing and consistent with the current prescribed pureed diet with nectar thick liquids resulting in a choking episode and aspiration pneumonia. Refer 677 28 Pa. Code 211.6 (a) Dietary Services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and staff interviews, it was determined that the facility failed to ensure that six residents (Residents 212, 93, 203, 178, 487, and 152) were free from physical abuse perpetrated by other residents (Residents 3, 188, 225, 212, 221, 213, and 56) out of 41 residents sampled for abuse prevention, which resulted in serious harm and injury to one resident, a fractured leg and hip (Resident 203). Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 212's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dementia with behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 18, 2023, revealed that the resident was severely cognitively impaired. A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dementia and unspecified psychosis. The resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired. A facility investigation report dated January 3, 2024, revealed that at 8:40 PM Resident 212 was outside Resident 3's room. The residents appeared to be arguing. At that time Resident 3 hit Resident 212 in the left side of her face. A review of a witness statement from Employee 6, NA (nurse aide), dated January 3, 2024, revealed that the employee was walking through the hallway when she heard Resident 212 and Resident 3 arguing. Employee 6 indicated she walked over to see what was going on and saw Resident 3 hit Resident 212 on the cheek. A review of a witness statement from Employee 7, NA, dated January 3, 2024, indicated that she was in front of Resident 3's room and heard the residents arguing. The employee indicated that she and Employee 6 were telling the residents to calm down and Resident 3 hit Resident 212. Applying the reasonable person concept, in the case of Resident 212, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 3, Resident 212 would have suffered psychosocial harm and humiliation. An interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 212 was free from physical abuse perpetrated by Resident 3. A review of Resident 212's clinical record revealed admission to the facility on [DATE], with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), anxiety, and major depressive disorder (persistent depressed mood or loss of interest in activities). A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS (Brief Interview for Mental Status - a tool to assess cognition) score of 3 (0-7 represents severe cognitive impairment). The resident's initial care plan dated June 19, 2023, indicated that Resident 212 exhibited the following behaviors due to anxiety and depression: verbal aggression directed at others, non-nonsensical and rambled speech, exit-seeking, verbal outbursts, talking to self, removes clothes, wanders, yells at peers, propels self into other resident's rooms under stop sign, and holds/pushes other residents wheelchairs. The planned interventions were to administer medications as ordered, provide opportunity for positive interaction, encourage activity distraction, and reorient as needed. A review of Resident 178's clinical record revealed admission to the facility on [DATE], with diagnoses to include vascular dementia with behavioral disturbances, anxiety, and major depressive disorder with severe psychotic symptoms. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 3. A nursing note dated February 9, 2024, at 9:45 PM indicated Resident 212 had increased confusion and behaviors, and was wandering into other residents' rooms. Nursing noted on February 12, 2024, at 1:00 AM indicated that Resident 212 exhibited increased agitation and restlessness and was wandering into residents' rooms looking for her purse and cigarettes. On February 12, 2024, at 10:28 AM nursing indicated that resident displayed agitation, increased anxiety and verbal outbursts. A nursing note dated February 12, 2024, at 12:55 PM indicated that Resident 212 had increased behaviors of yelling outbursts and cursing at staff. Nursing documentation dated February 14, 2024, at 7:34 PM indicated that Resident 212 had increased behaviors, yelling at staff and peers, wandering, and refusing assistance. A nursing note dated February 16, 2024, at 10:58 AM revealed Resident 212 was an aggressor of physical aggression with a peer. The note indicated that Resident 212 was observed wheeling herself into the dining room for activities. The Activities Assistant observed Resident 212 speaking loudly with a peer. The activities aide came and tried to separate the residents but was unable to do so prior to the physical incident occurring. Review of the facility investigation report dated February 16, 2024, at 10:20 AM, revealed that Resident 212 stood up from her wheelchair and punched another resident (Resident 178) on the left side of her face after a verbal aggression, causing Resident 178 to sustain a small abrasion. Review of the ACT-13 Mandatory Abuse Report dated February 16, 2024, at 12:15 PM, revealed the facility identified Resident 178 as the victim and Resident 212 as the perpetrator. The facility reported that Resident 178 was seated in the dining room participating in activities at 10:20 AM. At that time, Resident 212 was observed rolling in her wheelchair into the room, where the activities program was occurring. The activities aide could see Resident 212 and Resident 178 talking to one another and, as she walked over, Resident 212 stood up from her wheelchair and struck the left side of Resident 178's face. The actions taken by facility included immediately separating the resident and placing both on increased supervision. New orders for lab work obtained for Resident 212. A review of Employee 5 (Activities Assistant) witness statement dated February 16, 2024, (no time indicated) revealed that she was getting the morning snack ready for the residents around 10:15-10:20 AM when she heard Resident 212 arguing with Resident 178. She walked over to separate the residents but Resident 212 stood up from her wheelchair and punched Resident 178 in the left cheek. Resident 212 was removed from the dining room and two nurses' aides came in to assist. Afterwards, Resident 178 told Employee 5 that she called Resident 212 a whore in response to her repeatedly accusing Resident 178 of stealing her purse, clothes, etc. Applying the reasonable person concept, in the case of Resident 178, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 212, Resident 178 would have suffered psychosocial harm and humiliation. The facility was aware of the physically aggressive behavior of Resident 212 but failed to demonstrate sufficient supervisory measures of this resident to monitor her whereabouts to prevent the physical abuse of another resident. During an interview with the Nursing Home Administrator on April 19, 2024, at approximately 9:45 AM, it was confirmed that the facility failed to protect Resident 178 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent resident-to-resident alterations. Clinical record review revealed that Resident 93 had diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. Resident 93's quarterly Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment, had no behaviors, and required staff assistance for eating. Clinical record review revealed that Resident 188 was admitted to the facility on [DATE], and had diagnoses which included bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and Lewy body dementia (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function). Resident 188's admission MDS assessment dated [DATE], indicated that the resident had severe cognitive impairment, inattention, disorganized thinking, verbal and physical behaviors, puts others at significant risk of physical injury, intrudes on the privacy or activity of others, and wandering behavior. A review of Resident 188's care plan, dated March 11, 2024, revealed that the resident was identified to exhibit behaviors due to cognitive status which include agitation, verbal outbursts, physical aggression, combativeness, stands unassisted, attempts to transfer, and attempting to hit, choke, and punch staff. Interventions planned were to allow resident to vent thoughts and feelings, always approach in a calm, relaxed manner, encourage to express feelings, listen with empathy and non-judgmental acceptance, compassion, and ensure residents feels safe in environment. A nurses note dated March 15, 2024 at 6:58 PM indicated that Resident 188 was observed hitting Resident 93 on top of the head while staff were feeding Resident 93. Employee 1, a nurse aide, witnessed the abuse, and attempted to redirect Resident 188, the aggressor. Resident 188 then struck Employee 1 (nurse aide) in the stomach and arms. Resident 188 was immediately redirected out of the area and brought to the resident's room. Physician and resident representative notified. Increased supervision per protocol. Plan to Redirect Resident 188 to high visibility areas to maintain watchful eye. Review of the facility investigation dated March 15, 2024, at 5:30 PM indicated that no injuries were observed to Resident 93 at the time of the incident. Review of Employee 1 (nurse aide)'s witness statement revealed that after Resident 188 hit Resident 93, Employee 1 made sure Resident 93 had no red marks on top of her head and Resident 93 seemed fine. Employee 1 was standing behind Resident 188's chair trying to redirect him to sit back down in his chair. As Employee 1 tried to redirect Resident 188, Resident 188 hit Employee 1 in the stomach and arm. Resident 188 became agitated while Employee 1 was assisting him back into his chair. Interview with employee 1 (nurse aide) on April 18, 2024, at 1:05 PM revealed that on the date of the incident she was feeding Resident 93 in the unit 5 (blue building third floor) dining room. At the same time, Resident 188 was also in the dining room at a table with other residents. Resident 188 was repeatedly attempting to stand from his wheelchair. Employee 1 stated that she was the only employee in the dining room at this time as other staff were passing meal trays in the hall for residents who eat in their rooms. Employee 1 stated that Resident 188 started hanging on the table with his hands while attempting to stand and seemed to be getting aggressive. Employee 1 brought Resident 188 closer to where she was feeding Resident 93 so she could supervise Resident 188. Resident 188 stood up again and when she asked him to sit down he grabbed the back of Resident 93's wheelchair and hit her on the top of the head. Employee 1 stated that Resident 93 did not seem to realize she was hit on the head. Employee 1 stated that Resident 188 then punched her twice. Employee 1 stated that after the incident she was able to get to the nurses station for assistance. The facility failed to protect Resident 93 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a physical abuse of another resident. Applying the reasonable person concept, in the case of Resident 93, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 188, Resident 93 would have suffered psychosocial harm and potential injury. During an interview with the administrator on April 18, 2024, at 2:00 PM, it was confirmed that the facility failed to protect Resident 93 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a resident-to-resident altercation. A review of Resident 225's clinical record revealed admission to the facility on [DATE], with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), and paranoid schizophrenia (a severe mental health disorder in which a person interprets reality abnormally, experiencing hallucinations, delusions, and extremely disordered thinking and behaviors). An admission Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. The resident's initial care plan dated February 5, 2024, and revised March 25, 2024, indicated that she was an independent ambulator on the unit and was impaired in her ability to make herself understood and to understand others related to Spanish-speaking only. According to the resident's care plan, she exhibited behaviors of repetitiveness, anxiousness, looking for her checks, refused activity programs and showers, and accusatory regarding her clothing. The planned interventions were to approach the resident in a calm manner, be reassuring, allow resident to vent thoughts and feelings, and ensure resident feels safe in environment. A review of Resident 203's clinical record revealed admission to the facility on [DATE], with diagnoses to include dementia, anxiety, and hypertension (a condition in which the force of the blood against the artery walls is too high) A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. A review of the resident's care plan, initially dated June 20, 2023, indicated that Resident 203 was bilingual, communicating in Hindi and English. A review of a nursing note dated March 22, 2204, at 7:35 PM revealed that Resident 203 was observed in the doorway of the lounge on the east wing of Blue 3. She was speaking in loud voice to Resident 225. According to the witness, the aggressor, Resident 225, pushed Resident 203 causing her to fall on the floor. The nurse, who witnessed the event, separated them immediately. Resident 203 was assessed for injuries and noted the resident with left leg in abduction. The resident was tearful and guarding her leg with her hands. A review of ACT-13 Mandatory Abuse Report dated March 22, 2024, at 7:15 PM identified Resident 203 as the victim and Resident 225 as the perpetrator. The report indicated that Resident 225 was observed to push Resident 203. Actions taken by the facility included immediate separation, increased supervision for the perpetrator and to send the victim to the ER to be evaluated for left hip abduction and pain. The report also indicated that both residents have a diagnosis of dementia. A review of an Employee 4's (licensed practical nurse) witness statement dated March 22, 2024, (no time indicated) revealed the date of the incident was March 22, 2024. According to the employee's witness statement she reported that Resident 203 was standing in the doorway of the South dining room. Resident 225 was standing in front of her, and they were speaking loudly to each other in their native languages. Resident 225 pushed Resident 203, and Resident 203, fell backwards. Resident 203's left leg was rotated out and she had pain with movement. The supervisor came to the floor to assess the resident. A nursing note on March 22, 2024, at 8:15 PM, revealed Resident 203 was sent to the hospital, where she was diagnosed with a left leg and hip fracture. Review of the x-ray report dated March 22, 2024, at 10:33 PM revealed that Resident 203 sustained an acute fracture of the left proximal femur (upper leg) and an acute nondisplaced fracture of the left hip as a result of the fall. A nursing note dated April 1, 2024, at 5:14 PM revealed Resident 203 was readmitted to the facility from the hospital on April 2, 2024, at 5:00 PM status post a left hip fracture. A review of Resident 203's Physical Therapy Evaluation upon return to the facility from the hospital dated April 2, 2024, revealed that the resident sustained a left hip fracture as a result of being pushed by another resident. The resident underwent a left hip ORIF (open reduction internal fixation- surgical procedure to stabilize and heal a broken bone using hardware to hold the bone together). Prior to the incident and fall, the resident was independent to transfer and ambulate on the unit. Since suffering the fall, fracture, and surgery, the resident was totally dependent on staff to stand and perform transfers. The resident was no longer able to ambulate. The facility failed to prevent the physical abuse of Resident 203 perpetrated by Resident 225, which resulted in Resident 203 being pushed to the ground, sustaining a left hip fracture which required surgical repair. As a result of the fall, Resident 203 experienced a significant decline in her functional abilities, transfers and ambulation and was now dependent on staff for her mobility needs. During an interview with the Nursing Home Administrator on April 19, 2024, at approximately 9:30 AM, it was confirmed that the facility failed to ensure that Resident 203 was free from physical abuse perpetrated by Resident 225. A review of Resident 221's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have dementia with other behavioral disturbance. A quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired. A review of Resident 487's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included mild neurocognitive disorder due to known physiological condition without behavioral disturbances and reduced mobility. An admission MDS dated [DATE], indicated the resident was cognitively intact. A progress note dated April 11, 2024, at 10:11 AM revealed that Resident 221 was noted to have verbal behaviors including yelling/screaming and verbal aggression towards staff and her roommate, Resident 487. She was encouraged to be respectful to roommate, no mood concerns at present time and staff will continue to monitor. A facility investigation dated April 12, 2024, at 1:24 AM revealed that staff heard yelling from Resident 221's and Resident 487's room. Upon entering the room staff observed Resident 221 attempting to remove a shirt from Resident 487, who was sitting on her bed. Resident 221 was stating that it was her shirt. While Resident 221 was attempting to remove the shirt from Resident 487, Resident 221 pulled Resident 487's hair. No injuries were noted. Staff separated the residents. Resident 221 stated she is going through my stuff; she is going to end up eating everything. Resident 221 was assessed to have a superficial scratch on her chest measuring approximately 4.5 centimeters (cm) long. Resident 221 was placed on increased supervision. The local police department and Area on Aging Agency (AAA) was notified of the altercation between the residents involved. Resident 487 had a room change to a different unit in the building. A review of a witness statement from Employee 4, Licensed Practical Nurse (LPN), dated April 12, 2024, revealed that the employee was working at the desk and heard yelling coming from the East wing, went down the hall and found Resident 221 trying to take a shirt off Resident 487's body and immediately separated the residents. Resident 487 was sitting on Resident 221's bed and holding Resident 221's necklace. A review of a witness statement from Resident 487 on April 12, 2024, revealed that I put the blue shirt on because it was cold and then {Resident 221} came in and thought I was stealing it, she tried pulling it off me until she took it off completely. I did not get hurt; I would have offered her money for it. Further review of progress notes dated April 12, 2024, at 1:36 AM revealed that during the altercation when Resident 221 forcefully attempted to remove a shirt from Resident 487. Resident 487 stated that she got me real good with those knuckle punches and pointed to her head. An interview with the NHA and DON on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 487 was free from physical abuse perpetrated by Resident 221. Review of clinical record of Resident 213 revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia. A 5-Day/Admission Minimum Data Set assessment dated [DATE], indicated that Resident 213 was severely cognitively impaired with a BIMS score of 1. A review of Resident 152's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included schizoaffective disorder. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately impaired with a BIMS score of 12. A review of Resident 213's clinical record revealed the resident had been intrusively wandering into other resident rooms since his admission on February 8, 2024, which occurred almost daily while in the facility. A review of a facility investigation dated February 21, 2024, revealed Resident 213 wandered into Resident 152's room and would not leave. Resident 152 punched Resident 213 in the face. Resident 152 went to the nurses' station and informed Employee 8 LPN that he had punched Resident 213 in the face. A review of a witness statement from Employee 8 LPN (Licensed Practical Nurse) dated February 21, 2024, revealed the employee was at the nurses' station when Resident 152 walked up to the desk and told her that Resident 213 came in his room and would not leave so he punched him in his face. Employee 8 noted that Resident 152 had blood on his hand. Employee 8 went to Resident 152's room and saw Resident 213 was still in Resident 152's room and he was on the floor and bleeding. Resident 213 was assisted back to his room and an ice pack was applied. Resident 213's clinical record revealed that the resident had a 3 cm by 3 cm laceration on his forehead. An x-ray was completed and there was no fracture to his nose noted. The facility failed to protect Resident 152 from physical abuse and failed to effectively monitor and supervise this resident with known episodes of intrusive wandering behaviors to prevent physical abuse. An interview with the NHA and DON on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 152 was free from physical abuse perpetrated by Resident 213. A review of Resident 203's clinical record revealed admission to the facility on [DATE], with diagnoses to include dementia, anxiety, and hypertension (high blood pressure). A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. A review of Resident 56's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included schizophrenia. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired. A review of a facility investigation dated January 29, 2024, revealed Resident 203 was outside Resident 56's room. Employee 10, NA (Nurse Aide), was taking Resident 56 out of her room and Resident 56 punched Resident 203 in the chest. A review of a witness statement from Employee 10 NA (nurse aide) dated January 29, 2024, revealed the Resident 56 was leaving her room and saw Resident 203 and started calling her derogatory names and then struck out and punched Resident 203 before Employee 10 could stop her. Applying the reasonable person concept, in the case of Resident 203, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 56, Resident 203 would have suffered psychosocial harm and humiliation. An interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at approximately 1:45 PM confirmed that the facility failed to ensure that Resident 203 was free from physical abuse perpetrated by Resident 56. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on review of clinical records, select facility policy and investigative reports, and resident and staff interview, it was determined that the facility failed to ensure that one resident out of 25 sampled residents out was free from physical abuse resulting in serious injury, a fractured hip. (Resident 201). Findings including Review of a facility policy entitled Abuse Policy and Procedure with a policy review date of January 17, 2023, revealed It is the policy of the facility to protect our residents from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Abuse as used in this policy will refer to the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical pain or mental anguish and to misappropriation of resident property. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping, pinching, and kicking. Our facility is committed to protecting our residents from abuse. Prevention of abuse is to include monitoring residents with needs and behaviors. Review of Resident 201's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included dementia without behaviors disturbance [a group of symptoms affecting memory, thinking and social abilities], anxiety, unspecified lack of coordination, and depression. Review of Resident 201's annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that the resident had severe cognitive impairment and ambulated without an assistive device. Review of Resident 201's comprehensive care plan initiated on October 26, 2018, identified that the resident had self-care deficits with a noted intervention to supervise the resident when ambulating without an assistive device. Review of Resident 185's clinical record revealed that she was most recently admitted to the facility on [DATE], with diagnoses of paranoid schizophrenia [involves a range of problems with thinking (cognition), behavior and emotions. Signs and symptoms may vary, but usually involve delusions, hallucinations, or disorganized speech, and reflect an impaired ability to function], major depressive disorder, anxiety, and unspecified psychosis [is the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not and a disconnection from reality can happen for several reasons, including many different mental and physical conditions]. A review of Resident 185's annual MDS dated [DATE], revealed that the resident had Brief Interview for Mental Status [(BIMS) section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information], revealed that the resident had scored 13 and indicated that she was cognitively intact. Resident 185's care plan dated as initiated on April 23, 2019, identified that Resident 185 had an altered or at risk for altered behaviors and/or mood due to diagnosis of depression with a noted goal that the resident would be free of behavioral outbursts and/or unusual behaviors daily thru next review. Intervention planned were to to remove the resident from negative stimuli and model calm behaviors. The resident's care plan, initiated April 23, 2019, identified that Resident 185 exhibited behaviors such as verbal aggression toward staff and peers at times, curses at staff, dumps water pitcher, accusatory statements directed at others, enters other resident's rooms, and goes through their clothing, noted with a history of bumping into other residents, self-propels and ambulates, crawls and scoots on floor, undresses in hallway, puts toothpaste on self, grabs at staff's hair, states she is not going to eat at times, states that she is leaving at times, wandering behaviors at times, attempts to enter the elevator noted with exhibiting paranoid behaviors, noted with verbal and vocal outbursts, noted with repetitive questions and vocalizations. Review of an incident reported dated June 6, 2023, at 4:00 PM, revealed that Resident 201 was attending an activity when she was approached by Resident 185. Resident 185 then pushed Resident 201, causing Resident 201 to fall to the floor. Resident 201 was observed lying on the floor in the dining room with staff around her. Resident 201 had pain and was grabbing her left leg and crying. Resident 201's left leg was externally rotated. According to the incident report, the incident was unprovoked. As a result of the fall, Resident 201 was admitted to an acute care facility and treated for subtrochanteric fracture of the left hip [a fracture in the upper part of the femur, the upper bone of the thigh that extends from hip to knee] as a result of being pushed by Resident 185. A fall witness statement completed by Employee 1, an activities aide, dated June 6, 2023, at 4:04 PM, revealed that Resident 201 was just ambulating when she was deliberately pushed by another resident {Resident 185}, and she fell to the floor onto her left side. The facility failed to protect residents from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a resident-to-resident altercation and serious injury to Resident 201. The facility incident revealed that the facility interviewed all like residents that were capable of being interviewed to identify concerns regarding abuse and/or neglect. Residents that were not capable of participating in an interview were assessed by licensed nurse staff and body audits were completed to rule out or confirm abuse and/or neglect. The facility did not identify any negative findings related to abuse and/or neglect. During interview with the Director of Nursing (DON) on June 21, 2023, at 12:00 PM, confirmed that the facility failed to consistently monitor residents with known physical aggressive behaviors to prevent resident to resident abuse that resulted in Resident 201 sustaining a major injury, a fractured hip. This deficiency is cited as past non-compliance. To identify other resident that had the potential to have the potential to be affected, on June 7, 2023, the interdisciplinary team (IDT) reviewed all residents with a BIMs of 12 or higher located on unit Blue 3 to ensure that residents were appropriate for that unit and any issues were corrected, as needed. To prevent a reoccurrence, the Nursing Home Administrator (NHA)/designee provided education to all residents regarding abuse, types of abuse, examples of abuse, how to report abuse, and what to do and what not to do. Education was completed on June 7, 2023. To monitor and maintain on-going compliance the NHA/designee will interview five residents weekly for four weeks, and then monthly for two months on abuse. Additionally, to monitor and maintain on-going compliance the Director or Nursing (DON)/designee will complete body checks on five residents weekly, then monthly for two months to rule out abuse. Any negative findings will be corrected as needed. Results of audits will be brought to QAPI for review and revision as indicated. The facility's immediate corrective action plan was completed June 8, 2023. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management

Based on a review of clinical records and select facility incident reports, and staff interview, it was determined that the facility failed to provide sufficient staff supervision, timely assistance with activities of daily living and implement effective interventions to prevent falls with serious injuries (right femoral neck and rib fractures) sustained by one resident at high risk for falls (Resident 162) and to prevent a fall with serious injury (neck and clavicle fractures) to one resident at high risk for falls (Resident 193) out of four sampled residents. Findings include: A review of the clinical record revealed that Resident 162 was admitted to the facility on [DATE], with diagnoses that included metabolic [CONDITION(S)] (neurological disorder caused by a chemical imbalance in the brain) and anxiety. Review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2020, indicated that the resident had a BIMS Score (Brief Interview for Mental Status - a tool to assess cognitive function) of 5 (a score of 0-7 indicated that the resident is severely cognitively impaired), required the extensive assistance of two staff with activities of daily living (ADLS - routine activities that people tend do every day without needing assistance, eating, bathing, dressing, toileting, transferring [walking] and bowel/bladder continence) including ambulation, transfers and toileting; had an indwelling Foley catheter (a flexible tube placed in the bladder to drain urine); and was occasionally incontinent of bowel and was not on a bowel toileting program. Further review of the clinical record revealed a physician order dated January 6, 2021, to discontinue the resident's Foley catheter. A review of the resident's care plan, initially dated December 18, 2020, revealed the resident was at risk for falls. The facility's planned interventions to prevent falls included to implement preventative fall interventions/devices (no description provided), a low bed, maintain call light within reach, educate resident to use call light (although the resident was severely cognitively impaired), and maintain items within reach. A revision was made to the resident's care plan dated December 21, 2020, indicating that the resident was non-compliant with transfer status, yells out and attempts to self-transfer to look for family members. The resident was assessed as severely cognitively impaired, but the facility's planned intervention included to educate the resident about the risk of not complying and benefits of complying. A Fall Risk assessment dated [DATE], indicated that Resident 162 was at high risk for falls. Review of nurses' notes dated between January 10, 2021 and January 23, 2021, revealed that Resident 162 made numerous attempts of self-transfers and wandering into other residents' rooms. A facility incident report, used to collect and analyze circumstances of the resident fall, dated January 24, 2021, at 1:05 AM revealed that staff observed the resident sitting on the floor in front of the toilet in her bathroom, her back was against the toilet and both legs were flexed under her. The resident stated, I was going to the bathroom. The immediate action taken by the facility was to apply a bed alarm and to place the resident on a 3-day bowel and bladder tracking to assess toileting needs. A stat (immediate) X-ray was ordered at that time and revealed a minimal displaced fracture of the right femoral neck [a type of hip fracture of the femur (thigh bone) just below the ball of the ball-and-socket hip joint]. The resident was transferred to the emergency room and admitted to the hospital. Further review of the incident report indicated that the resident was last seen in bed at the beginning of the shift (11:00 PM). There was no documented evidence of when the resident was last toileted and/or any care provided to the resident when last observed by staff at 11:00 PM A nurses' note dated January 27, 2021, noted that the resident was readmitted to the facility. Review of the resident's Hospital Discharge Summary dated January 27, 2021, indicated that the resident was being discharged status post IM rod pinning (intramedullary rods- the pieces of bone are moved back into the right position, then held in place using rods) of the right femoral neck without complication. Review of nurses' notes between February 11, 2021, and February 18, 2021, revealed that Resident 162 made numerous attempts of self-transfers and wandering into other residents' rooms. Review of a facility incident report dated February 19, 2021, at 5:57 PM noted that Resident 162 was found on the bathroom floor sitting on buttocks. The resident revealed that she was trying to go to the bathroom and stated, I don't know honey when staff asked why she did not wait for help. The incident noted that gripper socks and a sensor alarm were in place as fall prevention interventions at the time of the fall. The resident's wheelchair was locked and secured. The sensor alarm (an alarm which sounds when movement detected), which was on the wheelchair was sounding at the time of this fall. The resident was last seen about 30 minutes prior self-propelling in the hall in her wheelchair. There was no indication in the investigation as to when the resident had last been toileted prior to the fall. Interventions implemented after the current fall included a 3-day bowel and bladder assessment (which had also been planned after the resident's similar fall on January 24, 2021) and every two-hour check and change toileting. A note added to the facility incident report on February 22, 2021, revealed that the resident presented with tenderness and discomfort to the left side of the chest. The CRNP (Certified Registered Nurse Practitioner) was notified. An X-ray was ordered, which revealed an acute-subacute mildly displaced lateral 6th rib fracture. The physician and responsible party were notified with a new pain management recommendation by the physician. Bilateral fall mats and increased supervision were ordered at that time. Interview with the Director of Nursing on April 30, 2021, at approximately 12:00 PM failed to provide evidence that the facility had provided Resident 162, who was at high risk for falls, with sufficient staff supervision and timely assistance with toileting needs to prevent falls, which occurred under similar circumstances, both resulting in injury. The facility was aware that the resident was at high risk for falls, required staff assistance for transfers, ambulation, and toileting, and displayed unsafe behaviors of self-transfer attempts and unsafe toileting, but failed to timely implement adequate staff supervision at the frequency necessary to prevent a fall with serious injury (fractured right femoral neck) and a second fall, which resulted in a rib fracture, both of which occurred during the resident's attempts to self-toilet. A review of the clinical record revealed that Resident 193 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. Review of a quarterly Minimum Data Set assessment dated , February 13, 2021, indicated that the resident had a BIMS Score of 10 (a score of 8-12 equates to moderate cognitive impairment), required the extensive assistance of two staff with activities of daily living including mobility, transfers, and toileting and one person physical assistance for ambulation; has not been on a trial of a toileting program, was occasionally incontinent of urine, and continent of bowel. A review of the resident's care plan initially dated September 9, 2020, revealed that the resident was at risk for falls related to dizziness and a history of falls. The facility's planned interventions to prevent falls were to implement preventative fall interventions/devices (no description provided), gripper socks at all times, maintain call light within reach, educate resident to use call light, and maintain items within reach. A revision was made to the care plan dated February 16, 2021, revealed that the resident was non-compliant with transfer status, attempts to self-transfer, and unplugs bed alarm. The facility planned intervention included to educate resident the risk of not complying and benefits of complying. There was no intervention planned to increase supervision of the resident. Review of nurses' notes dated between March 17, 2021 and March 26, 2021, revealed that Resident 193 made numerous attempts of self-transfers and self- ambulating. A nurses' note dated March 26, 2021, at 9:42 PM noted that the resident continued to self-transfer throughout the shift. Staff reeducated the resident on the importance of using the call bell and waiting for assistance with no success. Nursing noted, Will continue to monitor. A nurses' note dated March 27, 2021, at 11:35 AM indicated that staff were alerted to the resident room. The note stated, Resident noted in a supine position (lying face upward) on the floor, right outside the door, of the opposing room. The resident fell through the door of the opposing room, hitting another nurse aide with the door. The resident's alarm was not sounding at this time. Resident has been known to tamper with device. No physical injuries noted. Resident fell on right side of body. Gripper socks in place, area free of clutter. Resident complained of shoulder pain, Tylenol given. Review of a facility incident report dated March 27, 2021, at 11:35 AM noted Resident 193 was going to the bathroom without staff assistance. The resident was found on the floor between the bathroom and opposing room. The last time the resident was visualized was by a nurse aide at 8:30 AM during the delivery of the resident's breakfast tray. The immediate action taken was to increase supervision times 72 hours. The physician and responsible party were notified. A stat X-ray was positive for a clavicle (collar bone) fracture. A physician order was received to transfer the resident to the emergency room and the resident was admitted to the hospital. The resident was also diagnosed with a C7 (the seventh cervical vertebra in the neck region) fracture. Review of a statement by Employee 7 (nurse aide), noted that while helping another resident, the door of the bathroom slammed open and hit Employee 7 on the back. Employee 7 turned around and saw Resident 193 lying on the bathroom floor (shared bathroom between two resident rooms) with her pants pulled down. The resident's alarm was not ringing. Further review of the incident report revealed no indication that the facility's investigation had determined the last time the resident had been toileted prior to the fall. Staff had not observed the resident for three hours according to the facility incident report. A, Post Fall Huddle Fall Scene Investigation Form, dated March 27, 2021, at 11:35 AM noted that the root cause of the fall was that the resident did not call for staff assistance. The resident was noted to be last toileted at 8:30 AM. However, review of the investigation and witness statements revealed no documented evidence that the resident was toileted at 8:30 AM. Interview with the corporate nurse on April 30, 2021, at approximately 11:30 AM failed to provide evidence that the facility provided adequate supervision, effective interventions and timely assistance with toileting to prevent the fall with injury for Resident 193 who was identified as a high risk for falls, had a history of falls, and displayed unsafe behaviors. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 5/31/19, 9/25/20 28 Pa Code 211.12(a)(c)(d)(5) Nursing services Previously cited 5/31/19, 8/2/19, 9/25/20, 1/27/21 28 Pa Code 211.12(d)(1)(3) Nursing services Previously cited 5/31/19, 8/2/19, 9/25/20

Based on a review of clinical records, facility provided documentation and select investigative reports and staff interview, it was determined that the facility failed to consistently provide sufficient staff assistance with activities of daily living to prevent a fall resulting in a serious injury, a fractured left femur, for one out of 35 sampled residents (Resident 380). Findings include: A review of the clinical record revealed that Resident 380 was readmitted to the facility on [DATE], with diagnoses, that included muscle weakness, difficulty walking, abnormalities of gait and mobility and [MEDICAL CONDITION]. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 9, 2020, revealed that Resident 380 was cognitively intact, required extensive assistance with activities of daily living including bed mobility, dressing, toileting, and personal hygiene and was total dependent with transfers. A review of the resident's care plan revealed initially dated November 21, 2019, revealed that the resident was identified at risk for falls. The planned approaches revealed that the resident was to be transferred with mechanical lift with black sling with assistance of two staff. The resident' care plan did not address the resident's need for assistance with bed mobility until September 15, 2020, after the resident experienced a fall on that date. The resident's care plan then noted for the problem/need of ADL (activities of daily living) self-care performance, that the resident required assistance of two staff for bed mobility. During an interview on September 25, 2020, at approximately 8:20 AM, the Director of Nursing stated that the resident's need for assistance with bed mobility was not addressed on the resident's care plan upon the resident's readmission to the facility on [DATE]. A review of facility incident investigation along with nursing documentation and facility provided documentation indicated that on September 15, 2020, at approximately 10:00 AM one staff member was washing Resident 380, while the resident was in bed. During the provision of this care, the resident rolled out bed onto the floor landing on her left side. Resident 380 complained of pain of the left knee with movement. Nursing medicated the resident for pain and the physician was notified at that time. The physician ordered stat x-rays. The radiology report dated September 15, 2020, indicated that Resident 380 had sustained a comminuted (a break or splinter of the bone into more than two fragments) fracture involving left distal femur (leg bone) with modest displacement. The physician was notified of the results and new order was noted to send the resident to the hospital for evaluation and treatment. Resident 380 was admitted to the hospital on September 15, 2020, and had returned to the facility on [DATE]. A review of hospital discharge summary dated September 21, 2020, at 4:19 PM revealed that Resident 380 had a fracture involving left distal femur and had underwent surgical intervention of the left femur, open reduction and internal fixation (ORIF), (a type of surgery used to stabilize and heal a broken bone). Continued review of the facility's incident report revealed that the facility conducted a building wide review of resident bed mobility assistance including resident interviews regarding care provided by staff. Care delivery guides and care plans were updated to reflect the same bed mobility assistance. Staff education was completed regarding following the same. During an interview on September 25, 2020, at approximately 8:20 AM, the Director of Nursing confirmed that the facility had failed to include the need for two person staff assistance with bed mobility on the resident's care plan upon the resident's readmission to the facility on [DATE]. The DON verified that the resident was morbidly obese, at risk for falls and assessed on September 9, 2020, to require two staff to assist with bed mobility and repositioning. The DON further confirmed that the nurse aide providing care to resident on September 15, 2020, failed to ensure that two people were present to assist with the resident's bed mobility to prevent the fall with serious injury. The DON stated that the nurse aide failed to follow the care delivery guide, which is a tool to be used by direct staff to provide individualized resident ADL assistance. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, the Director of Nursing (DON)/designee completed a house-wide audit of care delivery guides and care plans to ensure all residents had a care directive for bed mobility and they match. All negative findings were corrected. To prevent this from recurring the Director of Staff Development provided education to nursing staff regarding risk factors with failure to follow the Care Delivery Guide as documented and proper bed mobility safety with residents that are assist of 2. To monitor and maintain ongoing compliance the Risk Manager/Designee audit and interview 5 residents during bed mobility care weekly x 4 then monthly x 2. Any negative findings will be immediately corrected. Results of audits will be brought to QAPI for review and revision as indicated. The facility's immediate corrective action plan was completed September 15, 2020. 483.25 (d)(1)(5) Free of Accident Hazards/supervision/devices Previously cited 6/22/18, 5/31/19 28 Pa. Code 211.12(a)(d)(1) Nursing services Previously cited 6/22/18, 5/31/19, 8/21/19 28 Pa. Code 211.12(c)(d)(5) Nursing services Previously cited 11/17/18, 5/31/19

Based on a review of clinical records, medication error reports, select incident and accident reports and facility policy and staff interview, it was determined that the facility failed to ensure that one resident was free from significant medication errors, resulting in one resident's transfer to the hospital (Resident 210) out of 15 residents sampled. Findings include: A review of the facility pharmacy policy, dated as reviewed by the facility (MONTH) (YEAR), revealed that prior to medication administration, facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time and for the correct resident. Review of the clinical record of Resident 210 revealed that the resident was admitted to the facility on (MONTH) 1, (YEAR), and had [DIAGNOSES REDACTED]. A review of a nurse's note dated (MONTH) 22, 2019, at 10:01 p.m. and a Medication Error Report dated (MONTH) 22, 2019, qt 9:54 p.m. revealed that staff reported that patient inadvertently received the wrong meds .the LPN (Employee 1) adminstered medication in a cup of Medpass to another resident .upon placing thew cup on the table (in dinning room) to wipe her mouth .the resident grabbed the cup and drank the balance of the content .vital signs blood pressure 80/60 mmHg (normal range for blood pressure is around 120/80 mmHg or lower - blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels), pulse 76, respirations 16 .resident noted to be lethargic and non-responsive to tactile stimuli (sensation of touch and texture) .MD/RP advised .new orders to send to emergency room for evaluation secondary to [MEDICAL CONDITION]. A review of a nurse's note dated (MONTH) 22, 2019, at 10:09 p.m. revealed that the nurse spoke to hospital ER .resident has admitting [DIAGNOSES REDACTED]. Further review of the Medication Error Report investigation revealed that Resident 210 drank Resident 228's 5:00 p.m. medications that were in a cup on a table in the dinning room. These medications included: [MEDICATION NAME] 5 mg. (a medication used to treat high blood pressure), Atorvastatin 20 mg. (a cholesterol and triglyceride lowering medication), Eliquis 2.5 mg. (an anticoagulant ), [MEDICATION NAME] 20 mg. (a medication used to treat high elevated blood pressure), Magnesium oxide 500 mg. (a supplement), [MEDICATION NAME] 10 mg. (a medication used to treat moderate to severe dementia), [MEDICATION NAME] 7.5 mg. (an anti-depressant), [MEDICATION NAME] 25 mg. (an antipsychotic medication) and [MEDICATION NAME] 25 mg. (a medication used to treat high blood presure). A review of a Hospital Discharge Summary dated (MONTH) 24, 2019, revealed that EMS called and her BP was 54/40. The summary indicated that the resident was somewhat hypotensive in the 90/50 range after examination and after receiving normal saline. The discharge summary also included the resident did manifest some [MEDICAL CONDITION] (low blood pressure) which gradually began to improve and is slowly coming up at this point, is stable, in time for return to the skilled nursing facility. A review of the Medication Error report and nursing documentation both dated (MONTH) 22, 2019, revealed that Resident 210 received another resident's (Resident 228's) 5:00 p.m. medications. An interview on (MONTH) 2, 2019 at approximately 1:08 p.m., with both Nursing Home Administrator and Director of Nursing confirmed that on (MONTH) 22, 2019, at approximately 5:00 p.m., medications prepared for Resident 228, by Employee 1 (LPN), were taken by Resident 210 in error, which resulted in Resident 210's transfer to the hospital for evaluation and supportive treatment due to her change in condition. Refer F 868 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 5/31/19 28 Pa. Code 211.5(g)(h) Clinical records Previously cited 5/31/19 28 Pa. Code 211.9(a)(1)(k) Pharmacy services previously cited 5/31/19

Based on a review of clinical records and select investigative reports and staff interview, it was determined that the facility failed to consistently provide preventative measures as planned for a resident's safety to prevent a fall resulting in a fractured nose and lacertation for one out of 36 sampled residents (Resident 174). Findings include: A review of the clinical record revealed that Resident 174 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS) Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care)dated (MONTH) 29, 2019, revealed that Resident 174 was moderately cognitively impaired, required assistance with activities of daily living including ambulation and transfers and ambulated with a walker or wheelchair. A review of the resident's care plan for at risk for falling initially dated (MONTH) 3, (YEAR), revealed that anti-roll back devices were applied to the resident's wheelchair. The addition of this intervention to the resident's care plan was not dated. During an interview on (MONTH) 30, 2019, at approximately 1 PM, the Director of Nursing confirmed that the anti-tippers were placed on Resident 174's wheelchair on (MONTH) 14, 2019, as a fall preventative measure. A review of a facility incident investigation and nursing documentation dated (MONTH) 29, 2019, at 6:17 PM revealed that Resident 174 was found on the floor in his room. Staff noted that the resident was on the floor, with his wheelchair and overbed table bed behind him. The use of anti-tippers to the wheelchar, which had been planned for the resident on (MONTH) 14, 2019, were noted to on the facility's investigative report, as a preventative measure. Resident 174 had sustained a laceration above his right eye and his nose was bleeding. Nursing applied first aide and called the attending physician. A new order was noted to send this resident to the hospital for evaluation and treatment. A review of hospital emergency room discharge documentation dated (MONTH) 29, 2019, at 11:49 PM revealed that Resident 174 had a laceration with sutures and a nose fracture. A CT (A CT scan or computed tomography scan makes use of computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas of a scanned object, allowing the user to see inside the object without cutting) of the facial bones, dated (MONTH) 29, 2019, revealed bilateral nasal bone fractures. Resident 174 returned to the facility with a diagnose of a laceration of the right eye brow with sutures and a [MEDICAL CONDITION]. An additional note dated (MONTH) 1, 2019 (no time indicated) revealed that during the facility investigation, it was identified that Resident 174 already had anti-tippers to the wheelchair ordered prior to the fall on (MONTH) 29, 2019, but housekeeping staff had conducted facility building wide power-washing of resident wheelchairs. The facility identified that Resident 174 did not have the correct wheelchair, with the anti-tippers in place, at the time of the fall on (MONTH) 29, 2019, which resulted in the fractured nose and laceration. The facility conducted a building wide sweep to verify that all resident wheelchairs and preventative equipment were in place appropriately for residents with wheelchairs. Staff education was completed regarding ensuring wheelchairs and preventative interventions are replaced correctly when removed from units for deep cleaning. An employee witness statement (no date or time indicated) from Employee 4 (housekeeping director) stated that he had received verbal in-service on (MONTH) 29, 2019, with the housekeeping staff that handles wheelchair cleaning after he was made aware that there was an incident related to a resident, who did not receive the correct wheelchair after cleaning, which may have resulted in the residents fall on (MONTH) 29, 2019. During an interview (MONTH) 30, 2019, at approximately 1 PM the Director of Nursing stated that at the time of this resident's fall on (MONTH) 29 2019, the facility had identified that Resident 174's did not have the correct wheelchair. She confirmed that housekeeping took his chair to be cleaned prior to the fall and returned the wrong chair to the resident. The chair that was returned to the resident after cleaning did not have the antiptippers in place. This deficiency is cited as past non-compliance. The facility's corrective action plan was to immediately conduct a full house audit for the White building to identify those residents with wheelchairs to ensure residents had their own wheelchairs and that no issues were identified. To prevent reoccurrence, the wheelchairs were labeled with the room numbers and bed (of the residents). The Housekeeping Director provided verbal education to wheelchair cleaning staff to ensure that residents correct wheelchairs were returned. Formal education the the housekeeping department on wheelchair cleaning and return of wheelchairs to appropriate resident occurred on (MONTH) 17, 2019. During the twice a month wheelchair cleaning, any wheelchairs that are identified as not being labled, are brought to the nurses attention to ensure the wheelchair is labeled and placed with the appropriate resident. Issues are reported to the housekeeping director and an audit is completed. The housekeeping supervisor will report any rends at the quality assurance meeting. The facility's immediate corrective action plan was completed (MONTH) 18, 2019. 28 Pa. Code 201.18(e)(1) Management previously cited 6/22/2018, 4/3/19 28 Pa. Code 201.29 (a)(c) Resident rights previously cited 7/26/2018, 4/3/19 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services previously cited 6/22/2018, 11/17/2018, 4/3/19

Based on a review of clinical records, medication error reports, select incident and accident reports and facility policy and staff interview, it was determined that the facility failed to ensure that two residents were free from significant medication errors, resulting in one resident's transfer to the hospital (Resident 19 and 27) out of 36 residents sampled. Findings include: A review of the facility pharmacy policy, dated as reviewed by the facility (MONTH) (YEAR), revealed that prior to medication administration, facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time and for the correct resident. Review of the clinical record of Resident 19 revealed that the resident was admitted to the facility on (MONTH) 11, (YEAR), and had [DIAGNOSES REDACTED]. The resident was noted to be cognitively intact. A review of (MONTH) 2019 recapped physicians orders revealed that at 9 AM Resident 19 was scheduled to receive the following medications: [REDACTED]. A review of the clinical record of Resident 27 revealed that at 9 AM the resident was scheduled to receive the following medications: [REDACTED]. A review of a facility investigative report and nursing documentation dated (MONTH) 20, 2019, revealed that on that date at 1:15 PM, Resident 19 was noted to have a change in condition. The resident had increased lethargy. His vital signs were obtained. The resident's blood glucose level was obtained via a fingerstick and noted to be 65 mg\dl (normal blood glucose levels are noted to be between 80 and 130 mg/dL before meals and less than 180 mg/dL two hours after meals). Staff offered food and drink and the resident's blood glucose was rechecked and was noted to be 104 mg\dl. Resident 19 was noted to be awake and alert to person and place. He stated the nurse gave me a shot this morning and I thought it was odd. The report stated that CNA (nurse aide) reported observing Employee 1, LPN (licensed practical nurse) give Resident 19 a shot in the arm. The physician was made aware and a new physicians order obtained to send Resident 19 to the hospital and treated with fluid hydration. A review of a facility investigation report and nursing documentation dated (MONTH) 20, 2019, at 1:15 PM revealed that Resident 27 received his roommate's (Resident 19) morning medications. The physician was contacted and a new order was obtained for this resident to receive his correct AM medications. Resident 27 had a [DIAGNOSES REDACTED].\dl. An interview (MONTH) 30, 2019 at approximately 1 PM, the Director of Nursing confirmed that on (MONTH) 4, 2019, at approximately 9 AM Employee 1 (LPN) administered the incorrect medications to both Residents 19 and 27, which resulted in Resident 19's transfer to the hospital for evaluation and supportive treatment. Refer F 658 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services previously cited 4/3/19, 11/17/18, 6/22/18 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services. previously cited 4/3/19, 11/7/18, 6/22/18 28 Pa. Code 211.5(g)(h) Clinical records previously cited 11/7/18, 6/22/18 28 Pa. Code 211.9(a)(1)(k) Pharmacy services previously cited 11/7/18, 6/22/18

Based on observation, a review of clinical records and select facility policy and staff interview it was determined that the facility failed to provide sufficient staff supervision necessary to prevent falls with serious injuries (neck and [MEDICAL CONDITION]) to one resident (Resident 264) at risk for falls, prevent elopements by one resident (Resident 242) and prevent a resident with known unsafe behavior from removing life-sustaining equipment (Resident 515) a total of three of 35 sampled residents. Findings include: A review of the clinical record of Resident 515 revealed admission to the facility on (MONTH) 12, (YEAR), at 6:00 PM with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. A review of a social services note dated (MONTH) 13, (YEAR), at 3:30 PM revealed that this resident was alert, but a BIMS Score (Brief Interview for Mental Status - a tool to assess cognitive function) was not yet completed. The hospital documentation dated (MONTH) 25, (YEAR), prior to the resident's admission to the facility revealed that Resident 515's pre-operation status included, significant swelling of the upper airway anatomy from [MEDICAL CONDITION] (swelling) related to the cervical trauma. There was also an extreme amount of thick upper airway secretions coating the upper airway mucosa (lining). This created a challenge in placing an endotracheal tube (a tube placed into the mouth and into the trachea (windpipe) to maintain an airway during surgery). A [MEDICAL CONDITION] was placed to maintain this resident's airway. A review of a hospital physician's note dated (MONTH) 7, (YEAR), at 7:28 AM revealed that the resident was positioned in a chair with a pressure pad alarm intact and functioning, the call bell in reach and a one to one sitter. A review of a physician progress notes [REDACTED]. stay. This physician's progress note, dated (MONTH) 8, (YEAR), at 11:54 AM indicated that the resident's tongue base was severely prolapsed posteriorly (tongue was occluding the airway, making it difficult to breath), occluding the laryngeal additus (the opening that connects the pharynx and the larynx). The (patient's) airway compromise continues at the tongue base level; continue the [MEDICAL CONDITION] status. A review of admission physician's orders [REDACTED]. collar while providing neck stabilization; cervical collar on at all times except hygiene,[MEDICAL CONDITION] care every shift with suctioning. Nursing documentation dated (MONTH) 13, (YEAR), at 4:45 AM revealed that the resident was in bed, awake with confusion, alert to person, but confusion to place and time. Nursing noted that Resient 515 removed the Aspen collar and the connected oxygen from the trach. One to One nursing intervention was provided to the resident at that time with little success, according to nursing documentation. The resident stated, I need to get to my house, can you take me there? Nursing staff reapplied the Aspen collar and oxygen. A nurses note dated (MONTH) 16, (YEAR), at 4:10 AM revealed that upon nursing staff's arrival to Resident 515's room, the resident's Aspen collar [MEDICAL CONDITION] were completely dislodged. The Licensed Nurse made several unsuccessful attempts to reinsert the trach. The physician was contacted along with emergency transport services. The resident was sent to the hospital where [MEDICAL CONDITION] reinserted. The resident returned to the facility that morning at 7:30 AM. Nursing services implemented every 15 minute checks for this resident upon readmission to the facility. A nurses note dated (MONTH) 17, (YEAR), at 12:08 AM indicated that nursing was called to Resident 515's room. Upon entering the room, the resident had removed the Aspen collar and also the [MEDICAL CONDITION]. The [MEDICAL CONDITION] could not be reinserted according to the documentation. The resident's SPO2 level was 78% (the level of oxygen in the blood, normals 95 to 100 %). 911 Emergency services was called as well as the physician. At 12:45 AM the resident's SPO2 saturation was still 78%. The resident was transported to the emergency room for evaluation and treatment. On (MONTH) 17, (YEAR), at 4:00 AM the facility had received a telephone call from a representative at the hospital informing the facility that Resident 515 had expired. The facility was aware of the resident's unsafe behavior of attempting to remove the [MEDICAL CONDITION]. The facility failed to institute safety measures to monitor and alert staff to unsafe acts, failed to attempt safety approaches to deter the resident's ability to remove the [MEDICAL CONDITION] and failed to provide necessary and sufficient staff supervision, at the level and frequency required, to prevent the resident from removing the life sustaining equipment. A review of the clinical record revealed that Resident 264 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 16, (YEAR), revealed that the resident was severely cognitively impaired and required the extensive assistance of two staff with activities of daily living (ADLS - routine activities that people tend do every day without needing assistance, eating, bathing, dressing, toileting, transferring (walking) and bowel/bladder continence) including ambulation, transfers and bed mobility. A review of the resident's care plan dated (MONTH) 9, (YEAR), revealed that the resident was at risk for falls due to a history of falls prior to admission to the facility. The facility planned for the use of a low bed and safety alarms to be placed on the resident's wheelchair and on her bed (alarms alert staff by a loud sound when the resident stands up from the wheelchair or tries to exit the bed). The care plan dated (MONTH) 15, (YEAR), also revealed that the resident had behaviors including attempts to self-transfer, verbal outbursts, refusal of care and throwing items at staff. The facility planned interventions included the use of outside psychiatry services and providing 1:1 support as needed. Review of nurses' notes and care plan revealed that the resident had incurred falls without injury on (MONTH) 10, (YEAR) and (MONTH) 11, (YEAR). Review of the Physical Therapy (PT) progress notes dated (MONTH) 19, (YEAR), revealed two short-term goals for the resident to transfer bed to wheelchair with minimum assistance and transfer sit to stand with minimum assistance. The resident required moderate assistance for transfers. The resident's goals were unmet, however, due to the resident's resistiveness to physical therapy treatment, deficits with bilateral (both) lower extremity muscle strength and deficits with safety awareness. A facility investigative report form entitled Incident/Accident report, used to collect and analyze circumstances of the resident fall, dated (MONTH) 18, (YEAR), at 5:50 AM revealed that the resident was observed on her right side, lying on her bathroom floor, bleeding from the right forehead. The staff applied pressure and ice and the bleeding stopped. Interventions planned in response to this fall included neurowatch (checking for resident's level of consciousness and signs of nervous system impairment) and ice PRN (as needed) for forehead. A statement from Employee 4 (Nursing Assistant) indicated that the resident was last toileted at 4:15 AM. Employee 4 noted that the employee heard (the resident's) alarm sound, went to room and found resident laying on the floor of her bathroom. Review of an Incident/Accident report dated (MONTH) 20, (YEAR), at 10:50 AM revealed that Employee 5 (Occupational Therapist) found Resident 264 unresponsive on (MONTH) 19, (YEAR), at 10:50 AM. Employee 6, RN, assessed the resident and the resident was sent to Emergency Department. The resident was admitted to the hospital. Review of the resident's hospital admission form dated (MONTH) 19, (YEAR), revealed that the resident had a closed fracture (break or crack in a bone that does not come through skin) of third cervical vertebra (third vertebra in neck that is positioned at almost the same level as your lower jaw) due to a fall. Resident 264 returned to the facility on (MONTH) 22, (YEAR). Review of resident's care plan revealed new interventions added (MONTH) 23, (YEAR), that included increased supervision and a three-day bowel and bladder program. Review of Social Service notes dated between (MONTH) (YEAR) and (MONTH) of (YEAR), revealed that Resident 264 continued to have increased behavioral symptoms including attempts to self-transfer and verbally and physically aggressive behavior with staff. Review of nurse's notes and resident's care plan revealed that the resident had falls without injury on (MONTH) 9, (YEAR) and (MONTH) 29, (YEAR). Observation of Resident 264 on (MONTH) 19, (YEAR), at 9:00 AM revealed that the resident made numerous attempts to self-rise from the wheelchair without staff assistance, anxiousness and restlessness. Review of Incident/Accident report dated (MONTH) 19, (YEAR), at 4:05 PM revealed that Resident 264 was found on the floor of the west hallway on her left side. A mobile X-ray was completed in the facility and concluded that the resident had an acute (recent onset) fracture of her left hip (broken hip). Resident 264 was sent to the hospital on (MONTH) 19, (YEAR). A statement by Employee 7 (Activity Aide) indicated that the resident was in an activity and was attempting to stand up without assistance. The resident was striking out at employee and yelling at employee. Employee 7 took the resident out of the activity and was walking down hallway when Employee 7 heard another resident's chair alarm sounding and left Resident 264 to attend to the other resident. According to Employee 7's statement Resident 264 stood up (from the wheelchair) and attempted to walk without assistance. Review of the facility's Post Fall Huddle fall scene investigation dated (MONTH) 19, (YEAR), the resident's fall was caused by lack of supervision. The facility failed to adequately supervise Resident 264, who was identified at risk for falls, had a history of [REDACTED]. Review of the facility Elopement Policy dated (MONTH) (YEAR), indicated that the facility will identify residents with potential and/or actual risk factors for elopement and protect the residents through development and implementation of safety interventions. When the Elopement Assessment score is 4 or higher, the resident is identified as, at risk for elopement. Review of the clinical record revealed that Resident 242 had [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment dated (MONTH) 11, (YEAR), indicated that the resident's BIMS score was 12 (a score of ,[DATE] is indicative of moderately impaired cognition). Review of a facility Incident Report dated (MONTH) 12, (YEAR), at 4:00 PM noted that the resident exited the building without staff supervision. The staff found the resident sitting by the park bench near the main entrance of the facility. The resident was escorted back into the building. The resident was last seen on the unit at 3:30 PM according to the report. Review of the resident's Elopement Risk completed by the facility dated (MONTH) 12, (YEAR), (following the elopement), noted that the resident continued to score 0 (no risk for elopement). Interview with the Director of Nursing on (MONTH) 22, (YEAR), at approximately 10:00 AM failed to provide documented evidence that the facility had developed effective interventions to prevent further elopements for the resident. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited [DATE] 28 Pa Code 211.12(a) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records and select resident incident/accident reports, staff and resident interview, it was determined that the facility failed to provide planned staff supervision and/or staff assistance based on individual resident needs to promote resident safety and prevent falls for two residents sampled (Residents A1 and A2) that resulted in serious injury, a fractured hip and pelvis, for one of those two residents (Resident A2). Findings include: A Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) completed for Resident A2 on August 6, 2017, revealed the resident had no cognitive impairment. The resident required extensive assistance from one staff member for activities of transferring, ambulation, dressing and toileting. A review of the resident's plan of care, reviewed and revised by the facility on September 13, 2017, revealed that the resident was identified to be at risk for a fall or a fall related injury due a history of a previous fall prior to admission that resulted in a fracture of the right hip and fracture of the cheek bone. A review of Resident A2's Safety Care Plan & Communication Tool utilized by nursing staff as a snapshot of resident needs and services, along with the amount of staff assistance required when providing care, revealed that the resident required a walker and the assistance of one staff member for all transfers and ambulation and one staff member for assistance with dressing and toileting. Progress note documentation dated October 10, 2017, at 6:45 p.m. revealed that Resident A2 was found on the floor in the resident's bathroom, sitting up. The resident relayed that she slipped and fell . Review of an incident/accident report dated October 10, 2017, as a result of the resident's fall, revealed that the assigned nurse aide (Employee 1) had assisted the resident out of bed and provided the resident with the walker and then proceeded to attend to the resident's roommate's bed linens while in the residents' room. Resident A2 then ambulated by herself to the bathroom for toileting. Resident A2 was found on the bathroom floor sitting up and facing the toilet. The resident stated at the time that she had slipped. During an interview with Resident A2 on November 1, 2017, the resident stated that prior to that fall, when staff provided her the walker, she always ambulated to the bathroom by herself and used the toilet. The resident relayed that the slip occurred when she was pulling up her pants after using the toilet. The resident stated that she would not do it again and will make sure that the staff member assists and accompanies her next time. Further review of progress notes for Resident A2 dated October 12, 2017, at 2 p.m., revealed that the resident began to complain of bilateral (both sides) pelvic pain. The physcian was notified and x-rays were ordered and completed that same day. X-ray results reported that evening at 10:45 p.m. revealed that the resident sustained [REDACTED]. A review of the hospital discharge summary dated Ocotber 20, 2017, revealed that the resident had been admitted for that hospitalization due to a left hip fracture and fracture of the pelvis sustained from a simple mechanical slip and fall at the nursing home. The Nursing Home Administer and Director of Nursing Services confirmed during interview on November 1, 2017, at 3 p.m. that Resident A2 was not provided the staff assistance with transfers and toileting as planned to prevent the fall with injuries An MDS assessment of Resident A1 dated August 22, 2017, revealed that the resident's cognition was moderately impaired. The resident required extensive assistance from two staff members for activities of transferring, ambulation, dressing and toileting. A review of resident's plan of care, dated as reviewed by the facility on August 29, 2017, and October 20, 2017, revealed that the resident was at risk for falls due to previous falls sustained at the facility. A review of Resident A1's Safety Care Plan & Communication Tool utilized by facility nursing staff as a snapshot of resident needs and service, along with the amount of staff assistance required when providing care to the resident, revealed that the resident required the assistance of two staff members for all transfers and ambulation and two staff members for assistance with dressing and toileting. The Safety Care Plan & Communication Tool revealed that due to past attempts to self trasnfer without any staff assistance and frequent incontinence of urine the facility planned interventions, that included a toileting schedule to be implemented by staff upon the resident arising, before and after meals, at night, and through the night at 12 a.m., 2 a.m. and 4 a.m. and 15 minute safety checks. A review of a nurse progress note dated October 27, 2017, at 4:30 a.m. revealed that that the resident was found on the floor of the resident's room. The resident was incontinent of urine. The resident stated I was going to get washed up. The bed was wet, the sheets were wet. I stood up and it was slippery. A review of the facility's investigation into the resident's fall without injury dated October 30, 2017, revealed a written statement from the nurse aide assigned to the resident's care that evening (Employee 2), which provided indicated that the resident was last observed at 3:40 a.m. Employee 2 failed to conduct the 4 a.m. and 4:15 a.m. 15 minute safety checks of the resident and failed to perform the resident's 4 a.m. scheduled toileting plan. Employee 2 noted that the safety checks and toileting plan were not completed because the employee was busy at that time. At 4:30 a.m., when leaving the staff bathroom, Employee 2 was alerted to the resident's fall. A review of Employee 3 and Employee 4's statements (nurse aides) revealed that one aide was assisting the licensed nurse on duty with another resident and one aide was in the unit's sitting room updating documentation for the employee's assigned resident hall. There were three nurse aides assigned to the resident's floor from 3 a.m. to 7 a.m. at the time of the fall A review of facility information gathered for their investigation revealed that on October 27, 2017 during the 11 PM to 7 AM tour of nursing duty 11 residents were planned for scheduled toileting for 4 a.m. and of those 11 residents, three of those residents required the assistance of two staff members to perform that task. The facility failed to assure that the safety interventions of 15 minute checks or the planned 4 a.m. toileting schedule to prevent falls due to unassisted transfers were implemented resulting in a fall without any injury for this resident. The Nursing Home Administer and Director of Nursing Services confirmed during interview on November 1, 2017, at 3 p.m. that Resident A1 was not provided the assistance of two staff members for transfer from bed and scheduled toileting or the 15 minute safety checks planned for the resident's safety from falls and the potential for injury. 483.25 (h) Free of Accident Hazards/supervision/devices Previously cited 5/5/17, 6/23/16 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 5/5/17, 6/23/16

Based on a review of clinical records and facility reports of resident incidents and accidents and staff interview, it was determined that the facility failed to consistently provide adequate supervision and/or staff assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls and injury for three of 31 residents reviewed (Residents 5, 143 and 134). Findings include: A review of the clinical record revealed that Resident 5 had [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2016, indicated that the resident was severely cognitively impaired and required assistance of staff with activities of daily living (are routine activities that people tend do every day without needing assistance. There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and bowel/bladder continence) including ambulation and transfers. The resident's balance during transitions (between transfers and ambulation) and walking was not steady and the resident was only able to stabilize with staff assistance. A review of nursing documentation dated December 6, 2015, revealed that the resident had a fall from her wheelchair with no injury. A review of the resident's care plan for the problem of the resident's risk for falls, initially dated February 18, 2015, revealed that the resident was at risk for falling and had a history of [REDACTED]. The facility planned interventions to prevent falls included that the resident wear appropriate footwear and keeping the area around the resident free of clutter. A bed and chair alarm (devices that emit an audible alarm to alert staff of unassisted attempts to rise from the bed or chair) were implemented (no implementation date was noted) and later discontinued (no discontinue date was noted). The care plan that the facility developed to prevent resident falls contained no evidence of the resident's need for staff supervision and assistance with transfers and ambulation to prevent falls due to the resident's increased risk for falls and assessed needs for assistance with these activities of daily living. A review of the resident's current care plan for an identified problem of getting upset with the resident's daily schedule, initially dated March 2015, revealed that the resident had episodes of being delusional (having false or unrealistic beliefs or opinions), tearfulness, yelling out, ambulating without assistance and wandering into other residents' rooms. The facility's planned interventions included the goal that the resident not harm self or others by providing a stable schedule, monitoring for changes in the resident's behavior, providing diversional activities and redirection with one to one (supervision from staff). A nurses' note dated February 14, 2016 at 2:00 p.m., indicated that the resident was tearful at times. One to one was provided by the staff and redirection, and emotional support was provided by nursing according to this nursing entry. A nurses' note dated February 15, 2016 at 3:30 a.m., indicated that the resident was found lying on her back in the hallway outside the doorway of her room (the resident resided in the window bed of a two bed resident room). The resident was complaining of pain in the right hip. The resident was transferred to the emergency roiagnom on that date and admitted to the hospital with [REDACTED]. A review of a, Fall Scene investigation Report (facility investigative report forms used to collect and analyze the circumstances of a resident fall) dated February 15, 2016 at 3:30 a.m., revealed that the resident's fall was unwitnessed, but the facility had determined that the resident was ambulating prior to the fall. The report noted that staff found the resident greater than 15 feet from the transfer surface (the resident's bed). The staff indicated that the last time the resident was toileted was at 2:00 a.m., but the staff failed to indicate if the resident had voided, was wet, dry, or soiled at that time. This section of the report was left blank. The facility described the resident as alert, but confused. The root cause of the fall was not identified and that section was also left blank on the report. A review of the, Pain Data Collection and Assessment (facility form used to record results of pain assessments) dated February 15, 2016, completed after the fall, indicated that the resident was experiencing severe pain on movement. The resident's current mood was described as crying and wandering. A, Staff Witness Statement from Employee 8 (a Nurse Aide) dated February 15, 2016, regarding the resident's fall noted that she was doing paperwork and heard a bang in the hallway. Employee 8 ran to the phone and called Code Bounce (the facility alert announcement to alert staff that a resident had fallen). Employee 8 further noted that she was on the unit by herself because the other nurse aide was at lunch. A Staff Witness Statement from Employee 9 (a Licensed Practical Nurse - LPN) indicated that she responded to a Code Bounce and found the resident lying in the hallway. Interview with the Director of Nursing (DON) on June 22, 2016 at 2:00 p.m., failed to provide documented evidence that sufficient staff supervision and effective safety interventions were provided to this resident to prevent this fall with serious injury. A review of the clinical record revealed that Resident 143 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of a quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired, required staff assistance for activities of daily living, including the extensive assistance of two staff for transfers and ambulation. The MDS assessment also indicated that the resident was unsteady while walking and turning around and was only able to stabilize (balance) with staff assistance. Review of the resident's care plan dated September 2015 through June 2016, revealed that three of the problematic areas identified on the care plan were the resident's impaired cognitive skills, potential for injury due to falls and refusal and/or resistiveness to care that included assistance with transfers and wearing shoes. The care planned interventions from September 2015 through June 2016, included the use of a wheelchair, medication review as needed, assistance of two staff for transfers and ambulation with a roll-walker (an assistive device used for support while walking), gripper socks, call light within reach, low-bed, staff re-approach the resident when the resident is agitated and increased monitoring for safety when the resident refuses safety measures. A review of the nursing documentation dated November 5, 2015 at 1:30 p.m., revealed that the resident tried to ambulate independently. On November 16, 2015 at 10:00 p.m., the resident made several attempts to transfer without assistance from the staff. On December 1, 2015 at 7:00 p.m., the resident attempted to self-transfer several times and on January 10, 2016 at 9:45 a.m., nursing documented that the resident ambulated without staff assistance. A review of a nurses' note dated January 30, 2016 at 10:00 p.m., indicated that the resident displayed increased behaviors that evening. The resident made several attempts to self-transfer and that the staff provided redirection with one to one, which had been effective for short periods. Nursing further noted that when trying to toilet the resident at the resident's request, the resident became physically aggressive to the staff and several interventions attempted were ineffective. Nursing administered an antianxiety drug, Ativan, which was prescribed for the resident on an as needed basis. While the nursing staff were monitoring the resident for the effectiveness of the drug, the resident continued to display behavioral symptoms. The nursing entry also noted that the Registered Nurse (RN) on duty was aware. A review of a nurses' note dated January 31, 2016 at 2:55 a.m., and an Event Report (a facility form completed as part of the facility's Risk Management program to compile initial information and details of resident incident/accidents) dated January 31, 2016, revealed that the resident was found on the floor in the hallway. Further review of the Event Report revealed that the resident had poor safety awareness, was awake and out of bed since 10:00 p.m., that evening and behavioral issues were noted. The resident had been removing the resident's clothing at the nursing station and staff were unable to redirect the resident at times. Review of two, Staff Witness Statements written by the nurse aides on January 31, 2016, revealed that one nurse aide had been off the resident unit at the time of the resident's fall and the other nurse aide was returning from break and was on her way to the bathroom when she heard the resident yell. The facility's, Fall Scene Investigation Report indicated that the resident complained of left shoulder pain and physician's orders [REDACTED]. A review of a hospital Discharge Summary dated February 2, 2016, revealed that the resident suffered a left transverse fracture of the surgical neck of the humerus (a break in the upper arm bone) as the result of the fall. A review of the resident's January 2016, Target Behavior Monitoring Tool (a facility form used to track and monitor behaviors targeted for the treatment with psychoactive medications) revealed that the interventions attempted in response to the resident's behaviors during the month of January 2016, included diversional activities, support, reassurance and medication were all ineffective in modifying or stopping the resident's behavioral symptoms. There was no documented evidence that facility staff had increased staff monitoring of the resident during episodes of increased behavioral symptoms when other forms of intervention were ineffective in deterring the resident's unsafe behaviors that included attempts at independent transfers and ambulation. An interview with the Director of Nursing (DON) on June 23, 2016 at approximately 9:10 a.m., failed to provide evidence that the resident, who was known to exhibit unsafe behaviors, was adequately monitored and/or supervised when other attempted interventions were unsuccessful in stopping the resident's behaviors. A review of the clinical record revealed that Resident 134 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of a quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired, required staff assistance for activities of daily living, including the extensive assistance of two staff for transfers and ambulation. The MDS assessment also indicated, in the area of balance during walking and turning around, that the resident was not steady and only able to stabilize with staff assistance. Review of the resident's care plan dated June 2015 through June 2016, revealed that three of the problematic areas identified were impaired cognitive skills, potential for injury due to falls and the resident's refusal and/or restiveness to care that included assistance with ambulation and transfers and use of a wheelchair. The care planned interventions in effect through June 2016, included the use of a wheelchair, medication review as needed, increased supervision for 72 hours, gripper socks, the resident's call light within reach, staff were to reapproach the resident when the resident was agitated and increased monitoring for safety when the resident refused safety measures. A review of a Psychiatry Evaluation dated November 1, 2015, revealed that Resident 134 was admitted to the facility from home due to his increased confusion and impaired safety issues. Resident 134 was seen by psychiatry at the request of the staff because of the resident's increased anxiety, restlessness and impulsivity. In this evaluation report, the Psychiatrist indicated that the resident's judgement was poor and his insight lacking. A review of the nursing documentation from November 8, 2015 at 7:30 p.m. through May 13, 2016 at 7:00 a.m., indicated that the resident displayed episodes of similarly documented behavior that included the following: resident seen attempting to ambulate & stand up assisted, attempting to transfer unassisted - 1 to 1 effective for short periods of time, ambulating without assist in room - redirection effective, attempting to self-ambulate in hallway without assistance - will continue to monitor, redirection noted to be successful at times and continuously removing clothes & walking on unit unassisted - redirected back to room with staff assistance several times 1 to 1 & reassurance ineffective. Examples of these types of behavior were noted by nursing staff on 61 occasions and documented in the resident's clinical record during this time frame. A review of a nurses' note dated October 23, 2015 at 12:20 a.m., and Event Report dated October 23, 2015, revealed that a nurse aide responded to hearing a bang and found the resident on his back on the floor in front of his closet. The Event Report indicated that the resident appeared to be attempting to get dressed and that the resident required the assistance of two staff for transfers to the wheelchair. The facility added interventions at the time, which included that staff were to dress the resident in pajamas or sweats for bed and the completion of a medication review. A review of a nurses' note dated November 8, 2015 at 7:10 a.m., and an Event Report dated November 8, 2015, revealed that an LPN responded to a bang finding the resident on the floor with his wheelchair behind him. At 7:00 a.m., a nurse aide found the resident attempting to get out of bed and transferred him to his wheelchair and the resident then self-propelled out into the hallway. The nurse indicated that the resident was attempting to get back into his bed at the time of the fall. Further review of the report revealed that the resident has poor safety awareness secondary to cognition. Review of, Staff Witness Statements completed by a nurse aide dated November 8, 2015, revealed that the resident, at times, transfers himself and is not easily directed. The facility in-serviced staff to ambulate the resident every shift when the resident is restless and to increase supervision as additional interventions to prevent falls. A review of a nurses' note dated November 15, 2015 at 8:15 p.m., and corresponding Event Report revealed that the resident ambulated to the nurses' station wanting to make a phone call to his daughter when he lost his balance and fell to the floor while talking to his family member. New interventions added at the time of this fall included that staff were to offer the resident a standard chair when utilizing the phone and for staff to offer the resident ambulation. A review of a nurses' note dated January 22, 2016 at 4:50 p.m., and the corresponding Event Report revealed that the resident was found sitting on the floor of the resident's room. The report indicated that the resident may have tripped over his pant leg because he pulls his pants down continuously. A review of the, Fall Scene Investigation Report revealed that the resident complained of pain in his left wrist. The physician's orders [REDACTED]. Review of three attached, Staff Witness Statements from nurse aides dated January 22, 2016, revealed that the three nurse aides were off the unit at the time of the resident's fall. New intervention added at the time of this fall included obtaining suspenders from the resident's family. A review of a nurses' note dated February 17, 2016 at 1:30 p.m., and the corresponding Event Report revealed that the resident was in the sitting room on the unit and attempted to stand up to turn on the TV when he apparently slid out of the wheelchair onto the floor. The wheelchair brakes were unlocked at the time of the fall. Review of two attached, Staff Witness Statements from nurse aides dated February 17, 2016, revealed that the resident had displayed increased behaviors throughout that morning. A new intervention added at the time of this fall included offering TV in his own room prior to the afternoon activity. A review of a nurses' note dated March 11, 2016 at 5:40 p.m., and corresponding Event Report revealed that the resident was found on the floor of the hallway with his feet propped up on the wheelchair. Intervention added at the time included increasing supervision. Review of a SBARR - Physician Communication form (Situation Background Assessment Recommendation Referral, a facility form used for nursing to physician communications) on April 10, 2016, revealed that Resident 134's behaviors were increasing - constant ambulation without assistance, constant changing clothes, all interventions - 1 to 1, redirection, fluids, snacks, ambulation with staff unsuccessful. In response to the SBARR, the physician increased the resident's Seroquel medication (an antipsychotic drug) and Xanax (an antianxiety medication) and requested a psychiatric consult. A review of a nurses' note dated April 16, 2016 at 10:15 p.m., and the corresponding Event Report revealed that an LPN heard a thump and found the resident sitting on the floor in his room near his wheelchair. Intervention added at the time was a review of his current medications, which were just increased on April 10, 2016. A review of a nurses' note dated April 18, 2016 at 12:30 p.m., and the corresponding Event Report revealed that the resident was in his wheelchair in the hallway when he stood up and lost his balance, falling to the floor. Staff were unable to get to the resident before he fell . Review of two, Staff Witness Statements written by nurse aides dated April 18, 2016, revealed that the resident was very anxious and had tried to walk several times that day in addition to being non-compliant and hard to redirect. Intervention added at the time was for staff to obtain a urine sample. A review of a nurses' note dated June 4, 2016 at 7:30 p.m., and the corresponding Event Report revealed that staff heard the sound of a wheelchair crash and found the resident in his room on the floor with his wheelchair on its side next to him. Review of two, Staff Witness Statements from nurse aides dated June 4, 2016, revealed that the two nurse aides were off the unit at the time of the resident's fall. Interventions added at the time included for staff to obtain a urine sample and for physical therapy to screen the resident. Review of a, Nursing Communication To Rehab (a facility form used for nursing to communicate with rehabilitative therapy staff) dated June 4, 2016, revealed that the physical therapist determined that no physical therapy was indicated at the time. A review of a nurses' note dated June 6, 2016 at 1:45 p.m., and the corresponding Event Report revealed that the LPN heard a loud bang and found the resident in his room on the floor with his wheelchair facing him. The resident was apparently in the dining room/activity room when he wheeled himself out of the room prior to this fall, according to the Event Report. Review of three, Staff Witness Statements from nurse aides dated June 6, 2016, revealed that the resident was non-compliant; continually attempting to walk and transfer by himself. Interventions added at the time called for increased staff supervision and a medication review. A review of a nurses' note dated June 7, 2016 at 2:15 p.m., and corresponding Event Report revealed that the resident was found on the floor in the hallway after having collided with another resident. A sleep assessment was initiated as an added intervention to prevent falls. There was no documented evidence that the facility had provided the resident the type and degree of staff supervision required to prevent repeated unsafe behaviors, falls and injury. The facility instituted approaches following each fall, but the facility failed to provide increased staff supervision of the resident during the resident's at risk periods of unsafe behaviors displayed and the identified ineffectiveness of other attempted interventions. Interview with the Director of Nursing (DON) on June 23, 2016, at approximately 9:10 a.m., failed to provide evidence that the resident, who had a history of [REDACTED]. of behaviors to promote safety and prevent additional injury from repeated falls. 483.25(h) Free of Accident hazards/supervision/devices Previously cited 7/31/15 28 Pa. Code 211.12 (a) Nursing services Previously cited 6/9/16, 4/28/16, 2/11/16, 1/26/16, 10/7/15, 7/31/15 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 6/9/16, 4/28/16, 1/26/16, 10/7/15, 7/31/15 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 6/9/16, 4/28/16, 3/15/16, 2/11/16, 1/26/16, 10/7/15, 7/31/15

Based on a review of clinical records, select facility policy and event reports and staff interview, it was determined that the facility failed to implement timely and sufficient measures to prevent the development of pressure sores for two of 30 sampled residents (Residents 200 and 82). Findings include: A review of the clinical record revealed that Resident 200 had [DIAGNOSES REDACTED]. The facility's Wound Prevention and Treatment Overview policy dated as reviewed by the facility April 3, 2015, revealed that the facility was to identify specific factors placing a resident at risk for development of pressure sores and to implement individualized interventions to protect the resident from the development. A nurse's note dated June 22, 2015, at 6:00 p.m., revealed that a nurse aide noted a new area on the resident. Review of an Event Report dated June 22, 2015, at 4:30 p.m., indicated that pressure areas were found on the resident's right inner and left butt. The facility's investigation into the pressure areas revealed that the indwelling urinary catheter was improperly positioned and bunched up underneath the resident, creating pressure and the development of these pressure sores. It was noted that the left buttock pressure area measured 1 centimeter by 1.5 centimeters and that the right inner buttock measured one centimeter by 1.8 centimeters. The areas were identified as deep tissue injuries (DTI - is a pressure related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise) Interview with the director of nursing (DON) on July 30, 2015, at 9:10 a.m., failed to provide evidence that staff timely identified and acted upon the improper positioning of the indwelling urinary catheter to prevent pressure development. A review of Resident 82's clinical record revealed that the resident had [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], revealed that the resident was cognitively impaired, required staff assistance for bed mobility and transfers and was identified at risk for developing a pressure sore. The resident's Braden score (an assessment tool that determines the risk of pressure sore development) on March 3, 2015, was 14 indicating that the resident was at moderate risk for the development of pressure ulcers (Braden score 13-14 moderate risk). Review of the resident's comprehensive care plan dated May 12, 2015, indicated that Resident 82 was at risk for developing a wound due to the following contributing factors that included pressure, incontinence and moisture. Interventions at the time included weekly skin assessments, pressure reduction cushion when out of bed, low air mattress, check and change every two hours for incontinence and turn and reposition when in bed every two hours. A nurse's note dated June 12, 2015, at 7:20 a.m., revealed that staff assessed resident for area on sacrum noted to be pressure Stage II (localized injury to the skin and/or underlying tissue which may present as a partial thickness loss of dermis presenting as a dry or shinny shallow open ulcer with a red pink wound bed). In addition, the nursing entry indicated that the physician and responsible party were notified, the resident is a two hour turn and reposition and out of bed to a geri chair (an alternate seating device (chair) used for comfort and positioning and to decrease the potential prevention of falls from attempts of self transfer). Also noted on assessment were three intact blisters to top of wound. A nurse's note dated June 12, 2015, at 3:15 p.m., noted a clarification of the wounds that the sacral wound was unstageable (considered unstageable due to the presence of slough (dead tissue that can appear yellow, tan, grey, green or brown), which may obscure the actual depth of the ulcer and the amount of tissue loss) with 50% purple discoloration, 25% slough and 25% unstageable. Review of the facility's corresponding Skin Grid for Pressure Ulcers dated June 12, 2015, indicated the sacral wound as unstageable measuring 5.2 centimeters (cm) by 5.5 cm by less than .01 cm with three blisters a top of the wound measuring .5 cm by .5 cm, .25 cm by .25 cm and .25 cm by .25 cm. Review of an Event Report dated June 12, 2015, identified the skin alteration as pressure related. The area was noted to be an unstageable pressure ulcer to sacrum with areas of granulation, slough and deep purple discoloration. Findings, cause and/or determination of event indicated that the resident recently transitioned from a wheelchair to a geri chair with a pressure reduction cushion; resident sits reclined with knees in chest and screen sent to physical therapy for positioning. Review of a Nursing Communication to Rehab form dated May 27, 2015, revealed that occupational therapy (OT) recommended the use of a geri chair and the discontinuation of the wheelchair due to safety. The form also indicated that nursing was to consult OT for geri chair positioning, if needed, and there is no potential for positioning back to the wheelchair. A review of the TAP Tool (turning and repositioning form) dated June 10, 2015, revealed that from 8:00 a.m. to 4:00 p.m. there was no documented evidence that the resident was turned and repositioned. Further review of the form revealed that the documentation indicated the resident was placed in a wheelchair on June 10, 2015, from 4:00 p.m. to 8:00 p.m. contrary to the recommendations made by OT on May 27, 2015, for the discontinuation of the wheelchair. Also on June 11, 2015, the documentation revealed that the resident was placed in a wheelchair, not the geri chair, from 4:00 p.m. to 8:00 p.m. Interview with the director of nursing (DON) on July 30, 2015, at 9:01 a.m., was unable to provide documented evidence that the resident was screened by occupational therapy for positioning when out of bed in the geri chair to determine if the resident was properly positioned. The DON was also unable to explain why the documentation indicated the resident was not turned and repositioned and/or placed in the recommended seating device prior to the development of the pressure area. The facility was also unable to provide evidence that adequate preventative measures were implemented and/or assessed to prevent the development of the pressure sore. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 8/14/14, 1/9/15, 2/25/15 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. Previously cited 2/25/15

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to provide appropriate care and services to prevent complications with the use of a feeding tube for one of four residents reviewed with feeding tubes (Resident CR1). Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a PEG tube (percutaneous endoscopic gastrostomy feeding tube) inserted on February 18, 2011, to provide nutrition due to her difficulty swallowing and mild duodenitis (inflammation of the small intestine). The clinical record revealed that on February 18, 2011 the resident had an EGD (esophagogastroduodenoscopy, a diagnostic procedure of esophagus, stomach, and small intestine) done with placement of a PEG tube and physician order's for this tube to be changed on May 27, 2011, by the physician. The most current Minimum Data Set (MDS - periodic assessment tool used to identify care needs) assessment dated [DATE], indicated that the resident was severely impaired cognitively and required extensive assistance with activities of daily living. As per interview with the nursing home administrator on June 30, 2011, at 10:00 AM, the PEG tube was changed by the physician on June 16, 2011, due to a physician schedule appointment change. A review of the report of consultation dated June 16, 2011 written by the surgeon revealed that the PEG tube was changed, site was clean, no drainage, indicating this first change was without difficulty. The tube was okay to be used and a follow up visit was to be scheduled in three months. The resident returned to the facility at 3:15 PM on June 16, 2011, and the tube feeding formula was resumed. Tube feeding orders dated March 28, 2011, indicated the resident was to receive [MEDICATION NAME] 1.5 (enteral nutritional formula) at 50 cc per hour for 20 hours per day to total 1000 cc of feeding total. The physician order [REDACTED]. Nursing documentation in the clinical record dated June 17, 2011, at 8:00 PM revealed that at 3:00 PM on that date this resident's feeding tube was found out of the ostomy site (tube surgical insertion site) with the balloon deflated (balloon anchors the tube position in the stomach), Employee 1, a Registered Nurse, reinserted the feeding tube "with some difficulty." Employee 1 wrote that placement was checked with air and [MEDICAL CONDITION] contents were returned. The resident tolerated the procedure with some anxiety and complained of pain, for which Tylenol 650 mg was administered. The tube was then flushed with 30 cc of water and the tube feeding was resumed at 50 cc per hour and an abdominal binder (protects tube insertion site, holds tube in place) was applied. The next nursing documentation entry was dated June 18, 2011 at 5:45 AM, written by Employee 2, the RN Supervisor, which indicated that the resident complained of pain as she was rubbing her abdomen stating "it's too sharp", at this time the abdominal binder was removed and a gauze wrap was secured the tube feeding. Employee 2 documented that the resident had positive bowel sounds (active bowel activity) and her abdomen was soft. Nursing documentation at 8:00 AM June 18, 2011, indicated that the tube feeding was turned off at beginning of shift and turned back on at 50 cc per hour due to the resident's complaints of pain. At 9:00 AM nursing documentation written by Employee 3, an LPN, noted that tube placement was checked and the PEG tube was not in place, the site around the tube was red and swollen, with a small amount of yellow drainage around the site. The feeding was stopped at this time. The resident complained of nausea and the abdomen had crepitus (A clinical sign characterized by a peculiar crackling, crinkly, or grating feeling or sound under the skin, often due to gas, most often air, that has penetrated and infiltrated an area where it should not normally be.) The resident's physician was called at this time. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. At 1:00 PM on June 18, 2011, Employee 4, an RN was called to assess the resident's condition and noted that the resident was ashen in color, complained of abdominal pain, the site of the feeding tube had small amount of yellow drainage. Employee 4 instilled air into the tube to check for proper placement, gurgling sounds were heard, but distant. Close inspection found the area below the resident's left breast to her pubic area to be [MEDICAL CONDITION] (swollen) with crepitus upon palpation. Aspiration of the stomach contents returned pink frothy mucous. The physician was again paged and at this time (1 PM) and he ordered the resident to be sent to the emergency room of the local hospital. The resident was transported to the emergency room at 3:00 PM via stretcher accompanied by transport personnel. Interview with the nursing home administrator and director of nursing on June 30, 2011 at 12:50 PM failed to explain the delay in transferring the resident to the hospital; the resident was not sent to the ER until 3 PM, two hours after the order was received to transport the resident (1 PM). A review of an incident/accident report dated June 18, 2011, at 1:00 PM indicated that Employee 4, RN was called to assess the resident who had an ashen appearance, drainage around her PEG tube site and [MEDICAL CONDITION] and crepitus from her left breast to pubic area the resident complained of abdominal pain. The resident's recorded vital signs at this time were BP 110/62, pulse 74, respirations 18 and temperature 97.5 with an oxygen saturation of 94%. Statements were obtained from nursing staff regarding this resident, Employee 5, RN indicated that she was notified by Employee 1, RN that this resident's PEG tube was found dislodged. Employee 5, RN stated that she along with Employee 1, RN went together to replace the resident's feeding tube. Employee 5 stated that they attempted to replace the tube, while the resident was sitting in her wheelchair, but found that the positioning was not good so the resident was placed in bed. Employee 5, RN attempted to place the tube, but was not able to do it. Employee 1, RN then replaced the tube and the tube feeding was resumed after checking for placement. Interview with Employee 5, RN on June 30, 2011, at 12:50 PM revealed that this RN with 8 years of practice, stated that she was not proficient in inserting feeding tubes, stating that she attempted to reinsert the tube under the guidance of Employee 1, RN to gain experience in the procedure. However, she stated she was not able to insert the tube so she did not want to continue and Employee 1 then inserted the tube. A review of the facility's policy Enteral Tube Feeding revised July 2010 revealed a procedure to "provide staff training as needed." A review of the facility's "Clinical Competency Validation" for the skill "Gastrostomy Tube Replacement (site established more than four weeks) revealed in the area of performance "5. position resident on back and drape area" and "16. (bold print) If any resistance is met stop immediately and notify physician." The NHA and DON were interviewed on June 30, 2011, at 1 PM regarding Employee 1's training in insertion of feeding tubes, but the facility was unable to provide documented evidence that Employee 1 was proficient in reinserting feeding tubes. Employee 1, RN indicated in her statement that the tube feeding was found out and she and Employee 5, RN reinserted a 20 Fr/20 cc (size of tubing) feeding tube and resumed the feeding. A statement obtained from the 11 PM to 7 AM shift nurse aide, Employee 6 revealed that the resident was yelling out that she did not feel good and Employee 6, nurse aide stated that she tried to make her comfortable. Employee 6 stated that the tube feeding was not running at the time of her care (no documentation as to the time Employee 6 cared for this resident). She stated that the resident complained that her stomach was hurting and that she was nauseous. Employee 6 noted that she reported to the Employee 7, LPN (the facility did not obtain a statement LPN, Employee 7) that the tube feeding was not running and the resident was in pain and complaining she felt she was going to vomit. Employee 6 stated that she loosened the abdominal binder and reported to supervisory nursing staff several times during the night that there was a big change in the resident and that she was complaining of too much pain in her stomach with a sick feeling. At 5:45 AM Employee 2, the RN Supervisor took the binder off and wrapped the tube in guaze. Employee 6 stated that by the time she left to go home (the end of the 11 PM to 7 AM shift) the resident seemed to be in more pain than ever after the feeding was resumed. A review of the hospital emergency room report revealed that the resident was admitted to the emergency room at 3:23 PM on June 18, 2011, at this time her heart rate was fast at 138 BPM (beats per minute), a temperature of 104.7 degrees Farenheit, blood pressure 109/43, respirations of 20-40 breaths per minute and an oxygen saturation of 81%. At 5:25 PM the resident's blood pressure was 86/40. At 5:35 PM the emergency room physician attempted to remove the feeding tube, but he was unable to do so, the resident complained of pain and he was unable to deflate the balloon. A review of the emergency room clinical report revealed that the resident's CAT Scan (diagnostic imaging study) of the abdomen revealed that the tip of the feeding tube was in the upper left abdominal wall with subcutaneous [MEDICAL CONDITION] (air) and stranding, cannot exclude a small amount of free intraperitoneal air. The resident's white blood count was low at 1.7 The resident was placed on a [MEDICATION NAME] drip at 6:39 PM (medication used to increase blood pressure). The emergency room physician spoke with the resident's attending physician at 7:21 PM and made him aware of the lab and x-ray reports and that he was unable to deflate the balloon of the feeding tube in order to remove it. The emergency room physician indicated that his impression of the resident was that the resident had an acute hypoxemic [MEDICAL CONDITION] due [MEDICAL CONDITION] (infection of th blood), SIRS (systemic [MEDICAL CONDITION] response syndrome - a response of the immune system to infection related [MEDICAL CONDITION], high temp, fast heart rate, fast respiratory rate) secondary to peritonitis, (inflammation of the thin wall of the abdomen) PEG tube placed in the abdominal wall, (improper positioning of tube) septic shock, ( a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure), urinary tract infection, and dehydration. They agreed to send the resident to the intensive care unit. The resident ceased to breathe at 4:45 AM on June 19, 2011, of cardiopulmonary arrest and septic shock. Interview with the nursing home administrator on June 30, 2011, at 10:20 AM confirmed that the facility did not report this unusual event regarding the misadventure with the resident's tube feeding to the State Survey Agency. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services previously cited deficiency 5/17/11, 3/15/11, 12/3/10, 10/13/10, 8/20/10, 7/20/10 28 Pa. Code 211.10(a)(d) Resident care policies previously cited 12/3/10

Based on review of clinical records and Event Reports and staff interviews, it was determined that the facility failed to provide sufficient staff assistance planned for safety to prevent accidents that resulted in serious injury for one resident out of four residents sampled (CRA-1). Findings include: A review of an Event Report sent to the State Survey Agency revealed that on [DATE] at approximately 8:15 A.M., Resident CRA1 was being assisted with a bedpan request by Caregiver 1 and when the resident rolled to the right side, the bed bolster gave way, the resident fell to the floor and the resident sustained [REDACTED]. Resident CRA1's quarterly minimum data assessment (MDS) dated [DATE], revealed that the resident required extensive assistance from two persons for bed mobility. The MDS also identified that the resident was able to understand and be understood and had no cognitive deficits. During an interview with the facility's administrator on [DATE], at approximately 9:45 AM, the administrator relayed that the resident's care delivery guide, last updated on [DATE] identified that the resident required two individuals for any type of bed mobility for safety reasons due to the type of pressure sore prevention mattress the resident had been changed to in [DATE]. The administrator stated that prior to [DATE], the resident utilized ? enabler rails on each side of the bed for which the resident was able to hold onto and turn while in bed. However, in [DATE], the new mattress did not allow the enablers to be kept on the bed and positioning bed bolsters were placed on the bed to define the edge of the mattress and prevent the resident from rolling out. The bed bolsters were not planned as enablers for the resident to self position while in bed. For safety, bed mobility and positioning required the assistance of two persons to prevent an accident such as falling out of bed as directed on the resident's care delivery guide (care plan). A review of the resident's activity of daily living detail report from February 1, 2011 through 1 A.M. on [DATE] revealed, however, that the resident consistently was provided with assistance from only one person with bed mobility and that the resident was mostly independent in that activity. A review of a written statement provided by Caregiver 1, obtained by the facility on [DATE] subsequent to the resident's fall and hospital transfer, revealed that the resident had requested the bed pan and while bending over to get the bedpan from the cabinet, the resident had already turned by grabbing onto the bolster to turn; the bolster gave way and the resident fell to the floor. Interviews conducted on [DATE], with Caregiver 2 at 10:15 AM; Caregiver 3 at 10:30 AM and Caregiver 4 at 10:40 AM identified to have provided only one person assistance for bed mobility in February 2011, verified that the resident had always been independent with bed mobility by turning for the bed pan and were unaware that it would not be safe for the resident without a second person present. There was no evidence that the facility had assured that two persons had been implemented and provided for the resident's safety with bed mobility as planned in the care delivery guide or that the resident had been instructed regarding safety in bed mobility since the loss of the enablers that allowed the resident to independently assist with turning prior to the utilization of the bed bolsters in [DATE]. A verbal report received by the facility's administrator from the coroner on [DATE] at 9 A.M., revealed that the resident had expired the previous week while hospitalized due to complications secondary to the cervical spine fracture the resident sustained [REDACTED]. 483.25 (h) Free of Accident Hazards/Supervision/Devices Previously cited [DATE] 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited [DATE] 28 Pa Code 211.11 (d) Resident care plan Previously cited [DATE]