Every finding on record at Mt Macrina Manor

Based on facility policy review, clinical record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for 13 of 122 residents assessed by the facility to be at risk for elopement (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13). The immediate jeopardy was cited as past noncompliance. Findings include: Review of the facility policy Elopement-Assessment, Risk and Prevention dated 1/3/26, indicated the facility will identify residents who are at risk of elopement and minimize the potential risk of elopement by identifying risk factors. Potential risk factors will be reviewed and an overall program that addresses the risks of residents who are wandering or at risk of elopement. A care plan is developed. A review of facility face sheet indicated Resident R1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated July 16, 2026, indicated diagnoses of anemia Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), diabetes, and high blood pressure. Section C1000 Cognitive skills for daily decision-making Section C0500 Brief Interview for Mental Status (BIMS) assessment indicated a score of 7, which indicates severe cognitive impairment. Review of Resident R1's Elopement Risk assessment dated [DATE] indicated the resident was at risk for wandering/elopement. Review of Resident R1's care plan dated 4/8/26, indicated resident is an elopement risk related to wandering and confusion. Goal - the resident will not leave the facility unattended, and the resident's safety will be maintained. Interventions - apply wander guard device #F1E56A. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Review of Resident R1's progress notes indicated the following: 3/13/26, the resident was found in the bathroom unsupervised.3/16/26, the resident's room was moved due to wandering.3/29/26, the resident was having exit seeking behaviors and attempting to get outdoors.4/22/26, the resident with exit seeking behaviors, wandering up and down the hallways attempting to get out of the doors to get to his car.5/25/26, the resident with exit seeking behaviors wanting to go outside to his car, trying to get outdoors when staff opens the door.8/3/26, the resident eloped from the facility. Review of a facility incident report Elopement dated 8/3/26, indicated Resident R1 exited through the main door and was unable to give a description. Review of facility submitted documentation dated 8/3/26, indicated Resident R1 exited the facility through the main entrance at 15:20. The resident was wearing a wander guard, and it did not sound. Elopement protocol was initiated at 15:25. A call to the facility alerted that the resident was outside of the facility. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) drove to the property entrance and located the resident in a nearby parking lot. The resident did not cross any roads to get into the parking lot. Upon return to the facility, the alarm did sound. During an interview on 8/12/26 at 10:00 a.m., the DON revealed that the resident was found at the [NAME] Inn Parking lot 0.4 miles from the facility. Review of DON witness statement dated 8/3/26, indicated the RN supervisor notified me at 15:33 that the resident was missing. Immediately after the receptionist received a phone call that the resident was seen outside. Staff were already outside. Nurse supervisor and Nursing Home Administrator (NHA) went outside to search. I joined a nurse in a vehicle and drove onto the main street and found the resident in a nearby parking lot. The resident was brought back at 15:40. Review of Registered Nurse (RN) Supervisor Employee E1 witness statement dated 8/3/26, indicated they were notified that Resident R1 was not in the memory unit or at activities. They went to the front desk to start elopement protocol and DON was notified. Review of LPN Employee E2 witness statement dated 8/3/26, indicated they were told the resident was missing. Received a call that the resident was seen outside. Went and got in my car and the DON and I started driving through the property. Received a call at 3:36 p.m. that the resident was in the [NAME] Inn Parking lot. Arrived at the [NAME] at 3:38 p.m. The resident got into the vehicle and returned to the facility safely. Interview and tour with Assistant Director of Nursing (ADON) Employee E4 on 8/12/26, at 10:30 a.m. indicated Resident R1exited from the main lobby entrance. All doors from the lobby to nursing units are secured and require a keypad code or staff badge to enter. All alarms are functioning and Wander Guard system is functioning. All Resident's Wander Guards were evaluated and functioning. Interview on 8/12 26, at 3:15 p.m. the Nursing Home Administrator was made aware that Immediate Jeopardy (IJ) was called due to the elopement of Resident R1 on 8/3/26. The NHA was provided with an Immediate Jeopardy template, and a corrective action plan was requested. Review of the facility's immediate action plan on 8/12/26, at 3:15 p.m. indicated the following: -On 8/3/26, at 15:30 p.m. Resident R1 had a head-to-toe assessment, and vital signs were within normal limits. No injury was noted.-On 8/3/26 all residents with wander guards were checked with tag reader against the front door and functioning.-On 8/4/26 all residents were assessed for elopement risk.-On 8/5/26 the wander guard vendor inspected the wander guard system and determined that the resident's wander guard tag malfunctioned. A second antenna system was added to main lobby to expand the range for the wander guard system. A battery backup was also added in case of power failure. New wander guard tags were replaced on all residents using wander guard.-On 8/6/26 an overall building elopement assessment was completed by the interdisciplinary safety team committee and plan was reviewed. Building elopement risk score was low based on the findings. -All Staff (135) Education was completed for wandering and elopements by 8/10/26. -Root cause was identified on 8/3/26, that wander guard did not alarm and resident eloped. -Head count was performed at time of elopement, on 8/3/26. -Care plan reviewed and updated on 8/6/26. -Doctor was called/notified of elopement on 8/3/26. -Family was notified of elopement on 8/3/26. -Reviewed and revised elopement policy on 8/4/26. -Elopement Root Cause Analysis/Performance Improvement to be reviewed at next Quality Assurance and Performance Improvement (QAPI) meeting on 10/21/26. -Elopement assessment verified as current and Resident R1 actively identified as high risk for elopement, on 8/4/26. -Monitoring audits of wander guard system function every hour daily every shift 8/3/26 for 2 weeks, then weekly times 4, then monthly times three months. The facility was back in compliance on 8/10/26. On 8/12/26, at 3:20 p.m. the following above items have successfully been verified as met per the immediate action plan, and the IJ was lifted and identified as past noncompliance. -Verified all facility staff of 135 received training. -In person interviews 23 of 23 in person staff interviews confirmed receiving training with emphasis on wandering/elopements, missing resident, and wander guard door sensor and wander guard tags. -Housekeeping staff verified 11 of 11 received education. -Therapy staff 13 of 13 staff verified received education. -Dietary staff 14 of 14 verified received education. -All new hires will be trained prior to the first shift on the floor. -Audits verified as complete to date 8/12/26. Interview with the Nursing Home Administrator on 8/12/26, at 3:45 p.m. confirmed that the facility failed to make certain residents receive adequate supervision for a resident resulting in an elopement from the facility on 8/3/26, at 15:30 p.m. (Resident R1). This placed all residents identified as an elopement risk at risk for Immediate Jeopardy and that the Immediate Jeopardy situation has successfully met the task of Past Noncompliance effective on 8/12/26, when the action plan was achieved by the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for five of eight sampled residents (Residents R17, R20, R38, R58, and R90).Findings include: Review of the facility policy Oxygen Equipment reviewed on 1/3/26, with a prior review date of 1/4/25. The policy indicates, Tubing/cannula is to be replaced weekly, C shift every Sunday . Date and initial all tubing, humidifiers and water when changed. Review of Resident R17's admission record indicated an original admission date of 9/16/22. Review of Resident R17's Minimum Data Set (MDS- a periodic assessment of care needs) dated 717/26, indicated the diagnoses of respiratory failure (lungs cannot provide enough oxygen or remove enough carbon dioxide), hyperlipidemia (high levels of fats in the blood), and hypertension (high blood pressure). Review of Resident R17's current physician orders dated 1/17/25, indicated continuous oxygen every shift, at 2 lpm via titrate to keep SPO2 > or = to 92%. Also to change oxygen tubing-change humidifier, tubing, and wash filter weekly on C shift every Sunday with date and initials (every night shift every Saturday). Review of Resident R20's admission record indicated an original admission date of 8/12/25. Review of Resident R20's MDS dated [DATE], indicated the diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), non-Alzheimer's dementia (dementia caused by vascular, Lewy body or frontotemporal dementia), and hypertension (high blood pressure). Review of Resident R20's current physician orders dated 8/13/25, indicated continuous oxygen every shift, at 2 lpm via titrate to keep SPO2 > or = to 92%. Also to change oxygen tubing-change humidifier, tubing, and wash filter weekly on C shift every Sunday with date and initials (every night shift every Saturday). Review of the clinical record indicated Resident R38 was admitted on [DATE]. Review of Resident R38's MDS dated [DATE], indicated diagnoses which included high blood pressure, Parkinson's (slow brain disorder that causes shaking, stiff muscles, and slow movement), and cirrhosis (severe, permanent scarring of the liver where hard scar tissue relaces healthy tissue, thus causing the liver to stop working). Review of Resident R38's physician's order dated 5/20/26, indicated continuous oxygen every shift, at 2 lpm via titrate to keep SPO2 > or = to 92%. Also to change oxygen tubing-change humidifier, tubing, and wash filter weekly on C shift every Sunday with date and initials (every night shift every Saturday). Review of the clinical record indicated Resident R58 was admitted on [DATE]. Review of Resident R58's MDS dated [DATE], indicated diagnoses which included high blood pressure, chronic diastolic heart failure (occurs when the heart muscle becomes stiff and cannot relax normally between beats), arthritis (conditions that cause joint pain, swelling, and stiffness). Review of Resident R58's physician's order dated 8/25/25, indicated continuous oxygen every shift, at 1 lpm via titrate to keep SPO2 > or = to 92%. Also to change oxygen tubing-change humidifier, tubing, and wash filter weekly on C shift every Sunday with date and initials (every night shift every Saturday). Review of the clinical record indicated Resident R90 was admitted on [DATE]. Review of Resident R90's MDS dated [DATE], indicated diagnoses which included high blood pressure, non-Alzheimer's dementia (umbrella term for a decline in mental ability can include vascular dementia, Lewy body dementia, and frontotemporal dementia) depression (serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy), chronic lung diseases (a long term condition that harms the respiratory system, develops slowly over time, making it hard to breathe). Review of Resident R90's physician's order dated 4/27/25, indicated oxygen prn (when necessary)-apply oxygen cannula at 2 lpm as needed t keep oxygen saturation at or above 92%, may titrate as needed. Nebulizer mask/tubing change every night shift every Saturday and date with initials on C shift every Sunday. Interview and observations on 7/27/26, at approximately 10:30 a.m. and 2:30 p.m., Registered Nurse (RN) Employee E1, confirmed Resident's R17, R20, 38, R58, and R90 were observed, with oxygen tubing connected to their oxygen concentrator/cylinder, the tubing had not been labeled and dated. During an interview on 7/28/26, at 10:30 a.m., the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure that resident's medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of eight residents (Resident R90).Findings include: Review of the facility policy Unnecessary Drug Policy dated 1/3/26, with a previous review date of 1/4/25, indicated it is the facility's responsibility that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable and psychosocial well-being free from unnecessary drugs. Review of the clinical record indicated Resident R90 was admitted on [DATE]. Review of Resident R90's Minimum Data Set (MDS- a periodic review of resident care needs) dated 6/4/26, indicated diagnoses which included high blood pressure, non-Alzheimer's dementia (an umbrella term for a decline in mental ability, different types include vascular dementia, Lewy body dementia, and frontotemporal dementia), chronic lung disease (long-term condition that harms the respiratory system, develops slowly over time making it hard to breathe), depression (serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy). Review of Resident R90's physician order dated 2/6/25, indicated to administer risperidone (an atypical antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability associated with autism, it works by changing the activity of dopamine and serotonin in the brain), 0.25mg tablet x1 at bedtime. Order states unspecified dementia, unspecified severity without behavioral disturbance, psychological disturbance, mood disturbance, and anxiety. Review of Resident R90's clinical record failed to reveal that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. During an interview on 7/30/26, at approximately 10:30 a.m. the Assistant Director of Nursing confirmed that the facility failed to ensure that the residents medication regime was free from unnecessary psychotropic medication for one of eight residents. 28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.10(a) Resident care policies.

Based on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure that a psychotropic (medications that affect mood, behavior, or mental processes) medication was used in accordance with regulatory requirements by failing to implement and document non-pharmacological interventions, failing to document any behaviors, and failing to ensure appropriate duration and rationale for a psychotropic medication order for one of eight residents reviewed (Resident R90).Findings include: A review of the policy entitled, Behavioral Assessment, Intervention, and Monitoring last reviewed 1/3/26, previously reviewed 1/4/25, indicated the facility ensures that it provides, and each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. It is understood that behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. Behaviors are defined as a response of an individual to a wide variety of factors. Behaviors or psychological symptoms of dementia describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Federal requirements for the use of psychotropic medications expect that these medications are used only when necessary to treat a specific, documented condition. These requirements further expect that individualized non-pharmacological interventions (approaches that do not involve medications, such as environmental adjustments, redirection, or comfort measures) are implemented and evaluated for effectiveness prior to the administration of a psychotropic medications, unless clinically contraindicated (not appropriate due to a medical reason). Review of the clinical record indicated Resident R90 was admitted on [DATE]. Review of Resident R90's MDS (Minimum Data Set- a periodic review of resident care needs) dated 6/4/26, indicated diagnoses which included high blood pressure, non-Alzheimer's dementia (an umbrella term for a decline in mental ability, different types include vascular dementia, Lewy body dementia, and frontotemporal dementia) chronic lung disease (a group of progressive lung conditions that block airflow and make it hard to breathe), and depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy). Review of Resident R90's physician order dated 2/6/25, indicated to administer risperidone (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and irritability associated with autism, it works by changing the activity of dopamine and serotonin in the brain), 0.25 mg tablet every night at bedtime. Unspecified dementia, unspecified severity without behavioral disturbance, psychological disturbance, mood disturbance, or anxiety. Review of Resident R90's clinical record failed to reveal that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. Documentation revealed that Resident R90 was assessed and no symptoms reported or evidenced. A review of clinical record from 6/30/26 revealed No GDR recommended at this time, GDR Rationale: Target symptoms are controlled at the current therapeutic dose. Diagnoses noted as Major neurocognitive disorder, Mild major depressive disorder. Review of Resident R90's clinical record for task list report for a task initiated on 4/22/22, Monitor-Behavior symptoms every day at 19:00, Everyday every Shift 12hr CNA (certified nursing assistant) day. Behavior Symptoms PRNPRN Task Schedule: PRN: Day (OLD), Night (OLD), Evening (OLD), CNA Days(old), CNA Evening old, CNA Nights old, 12hDay RN, 12h Night RN, 8h RN, Day, Evening, Night, Activities 8-4, Activities 11-8, Activities 4-8. Task list reviewed on 7/29/26, for the month of July revealed they have not been completed. An interview was conducted with the Assistant Director of Nursing, on 7/30/26 at approximately 10:30 a.m., to review the above findings related to the administration of a psychotropic medication without documented non-pharmacological interventions, behaviors associated for the use of this medication, and the continuation of this medication. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility in a prominent place readily accessible to residents, staff, and visitors on four of four nursing units.Findings include: Observation and interview with the Director of Nursing (DON) conducted on 5/20/26, at approximately 10:30 a.m., revealed that nurse staffing information was only posted on the nursing unit named [NAME] Street. The posting was located inside the nursing station and was not visible to any residents or visitors. During an interview with the DON on 7/28/26, at approximately 11:00 a.m., the DON confirmed the facility failed to ensure that current and accurate nurse staffing information was posted in the facility in a prominent place readily accessible to residents, staff, and visitors. 201.18(b)(3) Management.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for seven of seven residents (Resident R1, R2, R3, R4, R5, R6, and R7) and two of three employees (Employee E1 and E2).Findings include: Review of the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit dated 11/24/25, indicated:-Respiratory Virus Outbreaks: All respiratory virus outbreaks are reportable to PA DOH [NAME] (Pennsylvania Department of Health Bureau of Epidemiology) within 24 hours. -LTCF (long-term care facility) Outbreak Definitions: (1) confirmed case of respiratory virus and (1) acute respiratory illness symptomatic resident -or- (2) confirmed cases of respiratory virus. -Outbreak Checklist: Implement daily active surveillance for respiratory illness among residents and healthcare personnel (HCP) using the case line list. Include anyone with symptoms AND/OR positive tests. -Staffing: Restrict from work until at least 3 days have passed since symptom onset (or since first positive test if asymptomatic) and at least 24 hours have passed with no fever (without the use of fever reducing medicines), symptoms are improving, and HCP feel well enough to return to work. The first possible day for HCP to return to work is day 4. Day 0 is the first day that symptoms develop. If no symptoms are experienced, the first day of positive test should be used as day 0. Review of the facility policy, Infection Control - Nursing updated 12/20/25, indicated, Any HCP (healthcare personnel) who develops a fever or symptoms consisted with COVID-19 should immediately direct supervisor, and be restricted from work until at least 3 days has passed from onset of symptoms or positive COVID-19 test and 24 hours without fever. HCP is to wear a mask a minimum of 7 days after onset. If symptoms continue including fever, HCP should continue to be restricted from work until afebrile (as per PA DOH Respiratory Virus Outbreak Toolkit 11/2025). Review of a facility provided list indicated:-Resident R1 tested positive for Covid-19 on 12/29/25.-Resident R2 tested positive for Covid-19 on 01/02/26.-Resident R3 tested positive for Covid-19 on 01/03/26.-Resident R4 tested positive for Covid-19 on 01/03/26.-Resident R5 tested positive for Covid-19 on 01/04/26.-Resident R6 tested positive for Covid-19 on 01/07/26.-Resident R7 tested positive for Covid-19 on 01/10/26. Review of information submitted to the Pennsylvania Department of Health failed to include reporting of the facility outbreak of Covid-19 on 1/3/26 (two confirmed residents within 72 hours). Review of a facility provided list indicated: Registered Nurse (RN) Employee E1 tested positive for Covid-19 on 1/3/26 (Day 0). Review of facility provided staffing documents revealed RN Employee E1 returned to work on 1/5/26 (Day 2). RN Employee E1's return to work date per PA DOH guideline was 1/7/26. RN Employee E2 tested positive for Covid-19 on 1/12/26 (Day 0). Review of facility provided staffing documents revealed RN Employee E2 returned to work on 1/15/26 (Day 3). RN Employee E2's return to work date per PA DOH guideline was 1/16/26. During an interview on 01/29/26, at approximately 10:00 a.m. the Director of Nursing confirmed the facility did not maintain a line list to with information regarding positive test dates, symptoms, and length of precautions, confirmed that the facility did not report the Covid-19 outbreak beginning on 1/2/26, and confirmed RN Employees E1 and E2 returned to work prior to the return to work date specified by PA DOH guideline. During an interview on 1/29/26, at approximately 10:15 a.m. the Director of Nursing confirmed the facility failed to ensure an environment free from the potential spread of infection for seven of seven residents (Resident R1, R2, R3, R4, R5, R6, and R7) and two of three employees. 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)(d) Resident Care Policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services.

Based on observation, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of five residents reviewed (R13, R55, R96, and R112).Findings include:Review of facility policy Introduction to the Infectious Process reviewed 1/4/25, indicated contact transmission is the most important and frequent means of transmission of infections. Direct contact is described as direct physical transfer between susceptible host and an infected or colonized person such as during bathing, dressing changes, or turning residents. Direct contact transmission can also occur between two residents, or two healthcare personnel.Review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-24-08-NH dated 3/20/24, Enhanced Barrier Precautions (EBP) recommendations include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organisms (MDRO) status. EBP refer to an infection control intervention designed to reduce transmission of MDRO. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High-contact resident care activities are defined as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (urinary catheter, feeding tube, tracheostomy/ventilator, wound care (any skin opening requiring a dressing). Review of the clinical record indicated Resident R13 was re-admitted to the facility on [DATE], with diagnoses that included pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure usually over bony prominences) of sacral area (base of the spine), high blood pressure, and depression.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 6/13/25, indicated the diagnoses remain current.Review of the physician orders revealed the following: On 2/27/25, check feeding tube (soft, flexible, plastic tube that delivers liquid nutrition directly into the stomach or small intestines, bypassing the mouth and esophagus) placement and record residuals every shift On 2/27/25, feeding tube dressing: cleanse with NSS (normal sterile saline), pat dry, cover with drain sponge or dry dressing. On 2/27/25, resident is NPO (nothing by mouth) on continuous tube feeds all meds to be given via feeding tube every shift. On 7/1/25, sacrum wound: leave wound dressing in place. If soiled, change top dressing only. Review of the baseline care plan dated 2/27/25, indicated Resident R13 received tube feeding.Review of the comprehensive care plan failed to indicate interventions for enhanced barrier precautions.Review of the clinical record indicated Resident R55 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, cancer, and depression.Review of the MDS dated [DATE], indicate the diagnoses remain current.Review of the physician orders revealed the following: On 8/19/24, change ileostomy (opening between abdomen and lower small intestines) appliance every three days and as needed. Assess stoma (surgically created opening on the body) and surrounding tissue with every change.Review of the baseline care plan dated 8/20/24, indicated Resident R55 had a urinary catheter (thin, flexible tube inserted into the bladder to drain urine) and a new ostomy (surgical opening that allows waste to pass out of the body).Review of the comprehensive care plan indicated the following: On 8/20/24, staff to follow enhanced barrier precautions, including proper hand washing techniques to minimize microorganism transmission. On 8/30/24, Providers and staff must clean their hands, including before entering and leaving the room. On 8/30/24, Providers and staff must wear gloves and a gown for all high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy, ostomy, wound care, any skin opening requiring a dressing.Review of the clinical record indicated Resident R96 was re-admitted to the facility on [DATE], with diagnoses that included pressure ulcer of sacral region, gastrostomy (surgically created opening to place a tube into the stomach), and cystostomy (surgical opening created in the bladder to drain urine).Review of the MDS dated [DATE], revealed the diagnoses remain current.Review of the physician orders revealed the following: On 6/12/24, left and right posterior upper thigh wound care. Cleanse wound with soap and water after removing old dressing. Cover with a border foam dressing On 10/15/24, feeding tube dressing, cleanse with NSS, pat dry, caover with drain sponge or dry dressing every night shift. On 2/12/25, suprapubic catheter, change monthly at urology. On 5/13/25, Sacrum wound care. Cleanse with soap and water, apply collagen to wound. Keep covered at all times.Review of the baseline care plan dated 10/16/24 indicated Resident R96 was receiving tube feedings, an indwelling catheter, and a sacral wound on posterior left thigh.Review of the comprehensive care plan failed to reveal interventions for enhanced barrier precautions.Review of the clinical record indicated Resident R112 was admitted to the facility on [DATE], with diagnoses that included anxiety, carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA - type of bacteria that is resistant to many antibiotics), depression, and anxiety.Review of the physician orders revealed the following: On 8/9/25, foley catheter care every shift with soap and water.Review of the comprehensive care plan dated 8/11/25, indicated the resident has an urinary tract infection MRSA, and an indwelling urinary catheter. It failed to reveal interventions for enhanced barrier precautions.During observations on 8/11/25, between 11:00 a.m. and 12:00 p.m. failed to reveal Resident R13, R55, R96, and R112 were placed in Enhanced Barrier Precautions.During an interview on 8/12/25, at 2:20 p.m. the Director of Nursing confirmed the facility failed to implement infection control measures of enhanced barrier precautions to prevent the potential spread of infection.

Based on observation, staff interviews, and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 6/18/25.Findings include: During an interview on 8/11/25, at 10:00 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) both stated the DON has also been completing the roll as ICP.Review of the DON job description indicated the DON is responsible for the planning, organization, development, and direction of the overall operation of the Nursing Department in accordance with facility policy and procedures, state and federal guidelines, and all other entities as appropriate.Review of the Infection Preventionist job description indicated the ICP is a member of the nursing administration team whose primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with the facility's policies and procedures, state and federal guidelines, and all other entities as appropriate to ensure an effective infection control program is maintained at all times.During an interview with the Nursing Home Administrator (NHA) on 8/11/25, at 10:00 a.m., the NHA said she was unaware that the DON could not be the ICP and that, currently, there is no back-up ICP to share the functions of the ICP.Pa Code 211.12(b)(c) Nursing services

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (January 2025, and February 2025).Review of facility policy Antibiotic Stewardship Program reviewed 1/4/25, indicated the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics to provide the best resident outcomes and to reduce the threat of antibiotic resistance by organisms. Review of the facility's Infection Control surveillance for September 2024 through July 2025, failed to include documentation to indicate that antibiotic monitoring was completed for January 2025 and February 2025.During an interview on 6/11/25, at 2:40 p.m. the Director of Nursing confirmed she was unable to locate the antibiotic monitoring for January 2025 and February 2025.

Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Infection Control Program for two of ten staff members (Employees E3 and E4).Findings include: Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Infection Control Program in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Infection Control Program in-service education between 6/13/24, and 6/13/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on the Infection Control Program for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Abuse, Neglect, and Exploitation. Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Prevention of Abuse and Neglect in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have Prevention of Abuse and Neglect in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Prevention of Abuse and Neglect in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Prevention of Abuse and Neglect in-service education between 6/13/24, and 6/13/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have Prevention of Abuse and Neglect in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Prevention of Abuse and Neglect for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (third quarter 11/20/24). Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 11/20/24, failed to reveal the Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.During an interview on 8/12/25, at 2:20 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (third quarter 11/20/24), as required.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for five of 20 residents (Residents R20, R34, R39, R42, and R43).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R20 had a Quarterly MDS ARD of 6/2/25, with an MDS completion date of 6/23/25. Resident R34 had a Quarterly MDS ARD of 5/22/25, with an MDS completion date of 6/13/25. Resident R39 had a Quarterly MDS ARD of 6/12/24, with an MDS completion date of 6/30/25. Resident R42 had a Quarterly MDS ARD of 5/23/25, with an MDS completion date of 6/17/25. Resident R43 had a Quarterly MDS ARD of 5/23/25, with an MDS completion date of 6/16/25. During an interview on 8/14/25, at approximately 10:10 a.m. Registered Nurse Assessment Coordinators (RNAC) Employees E1 and E6 confirmed that the facility failed to make certain that quarterly MDS assessments were completed in the required time frame for 5 of 20 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employees E1, E2, E3, and E4).Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Resident's rights and facility responsibilities. Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Resident Rights in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have Effective Communication in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Effective Communication in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Effective Communication in-service education between 6/13/24, and 6/13/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Number of residents sampled:Number of residents cited:Findings Include:Review of facility policy, Bed Hold dated 1/4/25, indicated, Upon admission and when a resident is transferred for hospitalization or therapeutic leave, information will be provided concerning our bed-hold policy. When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer.Review of the clinical record indicated Resident R3 was readmitted to the facility on [DATE].Review of Resident R3's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/15/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and history of a stroke. Review of Section C: Cognitive Patterns indicated Resident R3 had moderate cognitive impairment.Review of a progress note dated 7/6/25, at 6:50 p.m. indicated, resident c/o (complaining of) abd (abdominal) pain and keeps dozing off glucose 380 daughter at bedside reporting to Nurse that this is not her normal requesting to send her to ER assessment done bowel sounds present times 4 resident had bm (bowel movement) today does have pain with palpation md aware will continue to follow up taken out via ambulance vitals stable see vital sheet.Further review of Resident R3's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R3 or the resident representative upon transfer.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's MDS dated [DATE], included diagnoses of a hip fracture, high blood pressure, and dementia. Review of Section C: Cognitive Patterns indicated Resident R5 was so cognitively impaired to be unable to complete the assessment interview.Review of a progress note dated 4/17/25, at 2:16 p.m. indicated that Resident R5 had hip and shoulder fractures.Review of a progress note dated 4/17/25, at 2:21 p.m. indicated emergency services were called to transport R5 to the hospital. RFurther review of Resident R5's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident R5 or the resident representative upon transfer.Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE].Review of Resident R13's MDS dated [DATE], included diagnoses of high blood pressure, and muscle weakness. Review of Section C: Cognitive Patterns indicated Resident R89 had moderate cognitive impairment.Review of a progress note dated 6/3/25, at 12:18 p.m. indicated, right 4th and 5th toe blue dusky in color. spoke with [provider] office he wants sent to ER for eval. Husband notified and agreeable. Np [nurse practitioner] aware and agreeable. [Emergency services] called for transport. [hospital] ER called for report.Review of a progress note dated 6/18/2025 1:36 p.m. indicated, Resident sent to ER by wound clinic due to wound infection and temp. resident admitted to [hospital.]Further review of Resident 13's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R13 or the resident representative upon transfer for hospitalizations on 6/3/25, and 6/18/25 Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE].Review of Resident R47's MDS dated [DATE], included diagnoses of anemia (too little iron in the body causing fatigue), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R47 was so cognitively impaired to be unable to complete the assessment interview.Review of a progress note dated 5/5/25, at 5:47 p.m. indicated, Resident fell to floor, right upper leg pain noted, legs aligned, unable to bear weight on RLE (right lower extremity), assisted to bed, [emergency services] notified.Further review of Resident 47's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R47 or the resident representative upon transfer.During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of four residents reviewed for hospitalization.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa Code: 201.29(f)(g) Resident

Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employees E1 and E5).Findings include: Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Behavioral Health in-service education between 8/11/24, and 8/11/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have Behavioral Health in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Behavioral Health for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Findings include: Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have the QAPI Program in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have QAPI Program in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have QAPI Program in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have QAPI Program in-service education between 6/13/24, and 6/13/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have QAPI Program in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on the QAPI Program for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Number of residents sampled:Number of residents cited:Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R15 had an admission date of 6/13/25, with an MDS completion date of 7/2/25. Resident R17 had an admission date of 5/19/25, with an MDS completion date of 6/19/25. Resident R27 had an admission date of 5/16/25, with an MDS completion date of 6/13/25. Resident R33 had an admission date of 7/10/25, with an MDS completion date of 7/25/25. Resident R37 had an admission date of 5/21/25, with an MDS completion date of 6/20/25. Resident R44 had an Annual MDS ARD of 5/21/25, with an MDS completion date of 6/13/25. Resident R45 had an Annual MDS ARD of 6/9/25, with an MDS completion date of 6/27/25. Resident R48 had an Annual MDS ARD of 5/9/25, with an MDS completion date of 5/30/25. Resident R53 had an admission date of 7/9/25, with an MDS completion date of 7/23/25. Resident R56 had an admission date of 7/15/25, with an MDS completion date of 7/29/25. Resident R65 had an admission date of 6/2/25, with an MDS completion date of 6/25/25. During an interview on 8/14/25, at approximately 10:10 a.m. Registered Nurse Assessment Coordinators (RNAC) Employees E1 and E6 confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for 11 of 20 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for facility staff.Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Communication - effective communication for direct care staff. Review of individual training records and the education topics provided to staff on the Annual In-Service and Abuse Training document failed to reveal documentation that training on Effective Communication was provided to staff. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Effective Communication for facility staff. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure medication in a medication cart in one of five medication carts reviewed (unused medication cart). Findings include: Review of the facility policy Medication Carts (Securing of) reviewed 1/4/24, indicated the medication cart is kept closed and locked when out of sight of the medication nurse, and all outward sides must be inaccessible to residents or others passing by. During an observation on 8/26/24, at 11:30 a.m. an unused medication cart was observed located in Town Hall room unsecured with a resident medication in the bottom drawer. During an interview on 8/26/24, at 11:35 a.m. the Director of Nursing confirmed the medications should not have been left in the unused medication cart and accessible to residents and/or visitors. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to make certain each resident receives adequate supervision and assistance to prevent accidents for one of three residents. (Resident R1). Findings include: Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated that Neglect is defined as a failure of a facility, it's employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy Feeding Residents dated 1/5/22, indicated residents will receive meals in a timely and orderly fashion and will be provided with the appropriate level of assistance. Review of Resident R1's admission record indicated admission to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/22, indicated that Resident R1 required extensive assistance for eating with assist of one physical person. Review of care plan dated 9/28/22, indicated Resident R1 will have two or less behaviors per week of grabbing and receive necessary assistance with meals. Interdisciplinary Department Team (IDT) form dated 10/21/22, indicated Nursing Assistant (NA) Employee E1 went into the room at 12:20 p.m. to pick up lunch tray after meal service and noted hot chocolate on Resident R1's lap with blisters and redness. Review of Quality Peer Review Committee form dated 10/21/22, indicated the NA Employee E1 noticed Resident R1 was attempting to climb out of bed most of the daylight shift and legs were out of the bed. Review of NA Employee E1's interview signed statement dated 10/21/22, indicated she walked into the room, noticed hot chocolate on blanket, noticed leg was red, and that Resident R1 was climbing all day, legs were off the bed at the time, and it looked as if Resident R1 pulled the table to get out. Review of NA Employee E2's interview signed statement dated 10/21/22, indicated she walked in room to help with Resident R1 and there was hot chocolate on the blanket and upper left leg was red. Interview on 11/14/22, at 11:10 a.m. Director of Rehab Employee E3 indicated Resident R1 was extensive assist of one person physical assist for eating, and that she would have needed help to eat as resident historically positions herself onto her side in a fetal position. Interview on 11/14/22, at 12:24 p.m. Registered Nurse (RN) unit manager Employee E4 indicated it was reported that Resident R1 spilled her hot chocolate, lid was still on, with burns to left thigh and hip. The burns were pink at first and then blistered and confirmed the tray should not have been left unattended with Resident R1's behaviors that morning because she required assistance of one staff for eating. Review of signed Licensed Practical Nurse (LPN) Employee E5's interview dated 10/21/22, and progress note dated 10/21/22, at 3:19 p.m. indicated NA Employee E1 noted hot chocolate on Resident R1's lap with injury of blisters to left hip and thigh: area one measured 11.5 cm x 8 cm (centimeters) with three blisters and area two measured 6 cm x 5cm with one blister. Interview on 11/14/22, at 12:28 p.m. with Director of Dietary Employee E7 and Registered Dietary Tech Employee E8 indicated a vendor came out and calibrated their hot water to dispense at 185 degrees Fahrenheit so meal time temperature would range around 155 - 160. Review of temperature logs dated 10/16/22 - 10/29/22, of tray line indicated a hot beverage result of 185 for the lunch meal on 10/21/22. Review of random test tray audit dated 10/17/22, indicated a hot beverage temperature of 155 degrees at the time Resident R1 was served. Interview on 11/14/22, at 12:13 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) Employee E6 confirmed that NA Employee E1 should not have left the tray unattended since Resident R1 demonstrated behaviors and required extensive assistance of one person physical assistance to eat. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.28(c) Nursing services 28 Pa. Code 211.28(d)(1)(5) Nursing services 28 Pa. Code 211.28(d)(3) Nursing services.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility neglected to provide the appropriate staff assistance of one person physical assist for eating, which resulted in physical harm in the form of second degree burns of left thigh and left hip for one of three residents (Resident R1) and failed to ensure resident was free from mental abuse resulting in resident feeling emotionally distressed for one of three (Resident R2). Findings include: Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated that Neglect is defined as a failure of a facility, it's employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or mental illness. Review of facility policy Feeding Residents dated 1/5/22, indicated residents will receive meals in a timely and orderly fashion and will be provided with the appropriate level of assistance. Review of Resident R1's admission record indicated admission to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/22, indicated that Resident R1 required extensive assistance for eating with assist of one physical person. Review of care plan dated 9/28/22, indicated Resident R1 will have two or less behaviors per week of grabbing and receive necessary assistance with meals. Interdisciplinary Department Team (IDT) form dated 10/21/22, indicated Nursing Assistant (NA) Employee E1 went into the room at 12:20 p.m. to pick up lunch tray after meal service and noted hot chocolate on Resident R1's lap with blisters and redness. Review of Quality Peer Review Committee form dated 10/21/22, indicated the NA Employee E1 noticed Resident R1 was attempting to climb out of bed most of the daylight shift and legs were out of the bed. Review of NA Employee E1's interview signed statement dated 10/21/22, indicated she walked into the room, noticed hot chocolate on blanket, noticed leg was red, and that Resident R1 was climbing all day, legs were off the bed at the time, and it looked as if Resident R1 pulled the table to get out. Review of NA Employee E2's interview signed statement dated 10/21/22, indicated she walked in room to help with Resident R1 and there was hot chocolate on the blanket and upper left leg was red. Interview on 11/14/22, at 11:10 a.m. Director of Rehab Employee E3 indicated Resident R1 was extensive assist of one person physical assist for eating, and that she would have needed help to eat as resident historically positions herself onto her side in a fetal position. Interview on 11/14/22, at 12:24 p.m. Registered Nurse (RN) unit manager Employee E4 indicated it was reported that Resident R1 spilled her hot chocolate, lid was still on, with burns to left thigh and hip. The burns were pink at first and then blistered and confirmed the tray should not have been left unattended with Resident R1's behaviors that morning because she required assistance of one staff for eating. Review of signed Licensed Practical Nurse (LPN) Employee E5's interview dated 10/21/22, and progress note dated 10/21/22, at 3:19 p.m. indicated NA Employee E1 noted hot chocolate on Resident R1's lap with injury of blisters to left hip and thigh: area one measured 11.5 cm x 8 cm (centimeters) with three blisters and area two measured 6 cm x 5cm with one blister. Interview on 11/14/22, at 12:28 p.m. with Director of Dietary Employee E7 and Registered Dietary Tech Employee E8 indicated a vendor came out and calibrated their hot water to dispense at 185 degrees Fahrenheit so meal time temperature would range around 155 - 160. Review of temperature logs dated 10/16/22 - 10/29/22, of tray line indicated a hot beverage result of 185 for the lunch meal on 10/21/22. Review of random test tray audit dated 10/17/22, indicated a hot beverage temperature of 155 degrees at the time Resident R1 was served. Review of facility policy Abuse - Prevention, Identification, Investigating and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property dated 1/5/22, indicated Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation or abuse. Review of facility policy Concern/Grievance dated 1/5/22, indicated a grievance is defined as an official statement of a complaint over something believed to be wrong or unfair and requiring the assistance of facility management to seek resolution when possible and that concerns of abuse, neglect, exploitation and misappropriation of property are addressed in the Abuse Policy. Review of Resident R2's admission record indicated admission to the facility on [DATE]. Review of MDS dated [DATE], indicated diagnoses of heart failure (chronic condition where the heart doesn't pump blood as well as it should), hypertension (high blood pressure), and cerebral vascular accident (CVA stroke) and review of the Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment for Resident R2 the score was 15 - cognitively intact. Review of care plan dated 9/5/22, indicated an intervention to monitor for signs of bladder dysfunction and signs of urinary tract infection due to history of stroke. Review of Resident R2's September 2022 Medication Administration Record indicated the medication of Lasix (a water pill to help prevent fluid in the lungs) twice daily at 8:00 a.m. and 6:00 p.m. for treatment of heart failure. Review of Grievance dated 9/11/22, on 11/14/22, at 1:36 p.m. indicated R2 stated NA Employee E9 was very rude and short with her and told her that she pees too much and made her feel badly and like a burden. The form failed to have any signatures of Social Worker, Director of Nursing, or Administrator indicating the status of the grievance. Review of Resident R2's interview with Social Services Employee E10 on 9/12/22, indicated Resident R2 is alert and orientated and was sitting up in bed. Reported that on Saturday night there was an aide assigned to her that she described as really mean, Resident R2 could not identify the staff member by name. Resident R2 could provide a description of her race and gender. This aide never had this staff provide her care before but she made Resident R2 not wanting to ask for any help because this staff member made her feel emotionally distressed and talked to her like she was a bother because she had to go to the bathroom. The aide did help her but Resident R2 did not want to be a bother and was apprehensive to ask for anymore help that evening. Interview on 11/14/22, at 12:13 p.m. with the Director of Nursing and Assistant Director of Nursing Employee E6 confirmed that NA Employee E1 should not have left the tray unattended since Resident R1 demonstrated behaviors and required extensive assistance of one person physical assistance to eat. Also, confirmed that NA Employee E1 neglecting to assist Resident R1 with eating resulted in harm causing second degree burns of left thigh and left hip for Resident R1. Assistant Director of Nursing Employee E6 and Director of Nursing confirmed that NA Employee E9 caused Resident R2 to endure mental abuse resulting in resident feeling emotionally distressed and apprehensive to request help. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.28(c) Nursing services 28 Pa. Code 211.28(d)(1)(5) Nursing services 28 Pa. Code 211.28(d)(3) Nursing services.

Based on a review of facility policies, clinical records and facility specific documents, and staff interviews, it was determined that the facility failed to provide adequate supervision, implement effective fall interventions and utilize the ordered two person physical assistance to promote resident safety, resulting in a preventable accident and actual harm when the resident fell from the bed during care for one of four residents (Resident R87). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing the Minimum Data Set (MDS-periodic assessment of care needs) assessments, dated October 2018, indicated that Section G: Functional Status, Question G0110 A indicates Bed Mobility is how the resident moves to and from lying position, turns side to side, and positions body while in bed. Review of Resident R87's clinical face sheet indicated the resident was originally admitted to the facility on [DATE], with readmitted s of 6/9/21, and 6/21/21. Review of the Admission MDS dated [DATE], indicated that Resident R87 had diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), [CONDITION(S)] (condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine), and cardiorespiratory (relating to both heart and lungs) debility, Review of Section G: Functional Status G0110 A, indicated that Resident R87 required two plus (two or more staff members) physical assistance for bed mobility, transfers, and toilet use. Review of a physician's order dated 4/14/21, indicated to assist resident to change position and/or shift body weight while in bed. Review of the Enabler Utilization Assessment completed by RN Employee E3 on 4/14/21, indicated that Resident R87 did not have enough mobility to turn from side to side, and that assist bars are to be initiated. Review of the baseline care plan completed by RN Employee E3 on 4/14/21, indicated that for bed mobility, Resident R87 required two plus persons for physical assistance with bed mobility. Review of the comprehensive care plan for Potential for falls related to weakness, obesity, Debility initiated 4/15/21, by Registered Nurse Assessment Coordinator (RNAC), failed to reveal any interventions to address bed mobility. Review of the Fall Risk Evaluation dated 6/9/21, completed on readmission by RN Employee E5 indicated that Resident R87 was At Risk for falls Review of the Clinical Admission Evaluation v2 (a screening completed documenting the resident's status concerning of vital signs, clinical evaluation, abnormalities, narrative notes, and MDS responses at the time of admission, or readmission to the facility) completed on 6/9/21, by RN Employee E5 indicated that Resident R87 utilized a grab bar. Review of the Kardex (a document used by NAs that outlines the residents' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 6/9/21, failed to provide any direction to the NAs for Resident R87's bed mobility status. Review of the facility Incident/Occurrence Report dated 6/10/21, indicated that the wound nurse was in the room during wound care and the resident rolled out of bed. Review of a progress note dated 6/10/21, at 6:51 a.m. indicated that Resident R87 fell out of bed while being provided wound care. The note documents bruising and a small amount of bleeding from a left hand skin tear, and report called to the hospital of impending transfer. Review of a progress note dated 6/10/21, at 7:03 a.m. indicated that Resident R87 had a hematoma (a solid swelling of clotted blood within the tissues) on the back of the head, measuring in centimeters: 4 cm x 3 cm, raised and tender to touch. Review of a progress note dated 6/10/21, at 7:21 a.m. indicated that Resident R87 had a purple hematoma to the right lower leg, 10 cm x 10 cm, raised. Review of a progress note dated 6/10/21, at 1:34 p.m. indicated that Resident R87 returned from the emergency room . A review of the facility investigation regarding Resident R87's 6/10/21 fall, included a witness statement written by RN Employee E6 that indicated she and NA Employee E7 positioned Resident R87 on her right side, and that RN Employee E6 told NA Employee E7 that she could leave. RN Employee E6 indicated that Resident R87 was on her right side, holding on to the grab bar with her left hand, and Resident R87 stated, I'm falling. RN Employee E6 indicated she attempted to go to the other side of the bed to stabilize the resident, but the resident fell to the floor. During an interview on 7/22/21, at 11:30 a.m. NA Employee E7 confirmed that she left the room after assisting to position Resident R87 on her side, while being provided care. During an interview on 7/22/21, at 1:30 p.m. the Director of Nursing and Assistant Director of Nursing confirmed that the facility failed to provide adequate supervision and utilize the ordered assistance of two which resulted in a preventable accident and actual harm. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, facility reports and clinical records and staff interviews, it was determined that the facility failed to provide the necessary assistance for a safe transfer resulting in harm for one of seven residents reviewed (Resident R11) and failed to maintain a safe environment in three of four public restrooms observed (Rehab Unit and Oaks Extension Unit). Findings include: The facility policy titled, Abuse Policy - Investigation of Alleged Resident Abuse or Misappropriation of Resident Property, reviewed 1/11/16, defined neglect as the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care to residents. The recapitulation (a review or summary) of the physician's orders [REDACTED]. The quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated 4/12/16, indicated that these [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Nursing Care Instructions (a tool to direct the staff as to the level of assistance a resident required) reviewed 5/2/16, indicated that Resident R11 required a wheelchair or walker (device to stabilize a person's balance while walking) with the assistance of two staff for ambulation and transfers and a mechanical lift could also be used for transfers. Review of the information dated 5/27/16 submitted by the facility, indicated that on 5/27/16 at 8:10 p.m., the Licensed Practical Nurse (LPN) was called to the room by Nurse Aid (NA), Employee E1, and found the resident on the floor with the right leg bent behind him/her and a walker upright in front of the resident. The resident complained of right leg and hip pain, was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A written statement from Employee E1 dated 5/27/16, indicated that Resident R11 requested assistance to the bathroom, he/she had assisted the resident independently at the time of the fall with injury. During an interview on 6/20/16 at 11:00 a.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility staff failed to provide the physician ordered assistance for Resident R11 during a transfer which resulted in harm. During observations on 6/20/16 through 6/24/16, the public bathrooms on the Rehab Unit and the Oaks Extension Unit corridors were noted to be unlocked. The bathrooms did not contain a call bell to be used to summon assistance in an emergency. During observations on 6/20/16 through 6/24/16, residents were observed in the Rehab Unit and Oaks Extension Unit passing by the unlocked bathrooms unsupervised and out of sight of unit staff. During an interview on 6/24/16 at 12:30 p.m., the Nursing Home Administrator confirmed that the Rehab Unit and the Oaks Extension Unit corridors public bathrooms did not contain a call bell and had been unlocked. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/1/15. 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/1/15, 6/6/14. 28 Pa. Code 201.29(a)(d)Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/1/15, 6/6/14.