Every finding on record at Northampton County-Gracedale

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts, prevent an elopement (unauthorized departure from the facility), and ensure that medications were administered as documented for one of six sampled residents. (Resident 1) In addition, the facility failed to provide adequate supervision to a resident with known behaviors and a history of substance abuse (Resident 2). This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed December 18, 2025, revealed staff were to assure the safety and security of all residents. Review of the facility policy entitled, One to one (1:1), Behavioral Intervention, last reviewed December 18, 2025, revealed staff would remain within arm's length or within visual sight of the resident at all times when providing 1:1 intervention. Review of facility policy entitled, Medication Administration Policy, last reviewed December 18, 2025, revealed staff were to remain with the resident while medication was swallowed. Staff were to never leave medication in a resident's room without orders to do so. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], and diagnosed with including: Schizoaffective Disorder, Bipolar type (chronic mental health condition that combines delusions and hallucinations with severe mood swings), Diabetes (a chronic condition where the body either cannot produce insulin or cannot effectively use the insulin it makes), and Chronic Kidney Disease (kidneys are damaged and cannot filter blood as they should, causing waste and fluid to build up in the body). According to Resident 1's Minimum Data Set (MDS) assessment (periodic evaluation of resident care needs) dated March 19, 2026, the resident had no memory impairment and could walk independently. Review of Resident 1's care plan revealed Resident 1 had impaired cognitive function and thought processes related to diagnoses of schizoaffective disorder, recall difficulty, and instances of delusional thinking. On January 1, 2026, the physician ordered Resident 1, based on a smoking assessment, was able to leave the nursing unit and smoke independently. Review of Resident 1's medication administration record (MAR) revealed on May 13, 2026, LPN 1 (Licensed Practical Nurse) documented Resident 1 was administered Risperidone 4 milligram (mg) tablet (atypical antipsychotic) on evening shift and Perphenazine 16 mg tablet (antipsychotic) at bedtime. Employee (LPN 1) indicated on the MAR to see the progress note for the following physician orders: Benztropine mesylate 2 mg tablet (anticholinergic), Divalproex sodium 500 mg tablet (used to manage manic phases of bipolar disorder), Hydralazine 50 mg tablet (antihypertensive), and blood glucose (sugar) checks before meals and at bedtime. Further review of May 13, 2026, at 10:39 p.m., revealed Employee (LPN 1) documented medications were never given as Resident 1 was off the unit. Review of Resident 1's blood glucose summary revealed LPN 1 documented results for the resident's blood glucose on May 13, 2026, at 8:34 p.m. twice, with results of 152 milligrams per deciliter (mg/dL) and 156 mg/dL. Employee (LPN 1) then struck out the results at 10:34 p.m. and 10:39 p.m. and documented Resident 1 declined. Additional review of clinical record revealed on May 14, 2026, a nurse noted Resident 1 had eloped (unauthorized departure from the facility) and returned to the facility at 1:00 a.m. Review of facility documentation revealed Resident 1 was observed on camera footage leaving the facility on May 13, 2026, at 5:08 p.m. Review of written statement dated May 14, 2026, Nurse Aide (NA) 1 stated she last saw Resident 1 at 4:00 p.m. on May 13, 2026, and never saw him again for the rest of her shift. Review of written statement dated May 14, 2026, NA 2 reported not seeing Resident 1 on May 13, 2026, at 5:00 p.m. and then again at 7:00 p.m. when passing water. NA 2 spoke with NA 1 and reported the resident missing to the nurse, LPN 1, at 9:00 p.m., at which time no action was taken, including reporting to the Nursing Supervisor. Review of the local police department's report, Resident 1 was standing outside the police station at 10:11 p.m. The officer called the facility to see if Resident 1 was missing; the Nursing Supervisor was unaware at that time of Resident 1 missing from facility. In an interview on May 14, 2026, at 9:45 a.m., the Director of Nursing confirmed on May 13, 2026, LPN 1 falsely documented Resident 1's medications administered as ordered and resident's blood sugar was checked but altered the clinical record after the facility received the phone call from the police. The facility failed to monitor a resident's whereabouts, prevent elopement from the facility, and ensure that medications were administered as documented. Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including; Chronic Obstructive Pulmonary Disease (long-term lung disease that makes it hard to breathe), chronic pain syndrome (pain that lasts longer than three months in one or more parts of the body), and a history of alcohol and opioid (type of pain medication) abuse (chronic use that causes clinically significant distress, harm, or impairment). According to Resident 2's MDS assessment, dated April 23, 2026, the resident had no memory impairment and could walk independently. Review of Resident 2's care plan revealed Resident 2 had a behavior problem with taking medications related to pocketing narcotics (pain medication) in his mouth. Interventions included for staff to monitor the resident for swallowing medications by asking the resident to open his mouth, stick out his tongue, and pull his cheeks out to verify that medications were swallowed and to report to the provider if the resident were to refuse to cooperate. On October 27, 2025, the physician ordered that Resident 2 was allowed to go on independent leaves of absence (LOA). The resident was not to leave the facility with scheduled or as needed medication. Review of Resident 2's clinical record revealed on March 28, 2026, a nurse noted Resident 2 had an unopened can of an alcoholic beverage in his room during a room clean-up and was removed. Further review of the clinical record revealed on March 31, 2026, a nurse noted the resident smelled of alcohol, his face was red, flushed, and sweaty, yet the resident reported it was his cologne. He then came back to the nurses' station with a bottle with no label and containing clear liquid stating it was mouthwash. Resident 2 left the unit and returned 90 minutes later with the same noted condition. Additional review of Resident 2's clinical record revealed on April 1, 2026, a nurse noted while speaking to Resident 2 about alcohol consumption when taking scheduled narcotics and possible adverse effects, Resident 2 stated, I am a biker, that's what we do; we drink, smoke, play pool, and party. The nurse noted her observation of the resident had bottles with unidentified amber colored liquid in the same bottle from March 31, 2026, and in an apple juice bottle. Resident 2 was questioned about what was in the bottles. Resident 2 stated he was not drunk and told the nurse to leave the room. Continued review of Resident 2's clinical record revealed on April 2, 2026, the physician noted he spoke with Resident 2 about his alcohol misuse then discontinued alprazolam (classified as a benzodiazepine - medication used to treat anxiety) for safety, and the resident's oxycodone, an opioid (pain medication), would be continued with close monitoring. On April 2, 2026, the physician ordered 1:1 supervision due to the resident's inappropriate behavior. Review of Resident 2's clinical record revealed on May 5, 2026, at 1:40 p.m., a nurse noted Resident 2 returned from an independent leave of absence with an ataxic gait (unsteady, uncoordinated walking pattern with irregular foot placement and body swaying), profuse sweating, slurred speech, and verbal aggression, and was causing a disturbance on the nursing unit. Resident 2 was taken outside to the smoking area to diffuse the situation while on 1:1 observation. The 1:1 staff reported Resident 2 was verbally aggressive and causing a disturbance in the smoking area where other residents were frightened, causing the other residents to leave. On May 5, 2026, at 3:13 p.m., the physician noted; he told the nurse to send Resident 2 to the emergency room and to call the police. On May 5, 2026, at 3:28 p.m., a nurse noted that Resident 2 was exhibiting violent behavior and slurred speech. During this episode, Resident 2 had a witnessed fall and hit his head. Resident 2 had increased agitation and combative behavior, posing a safety risk to himself and others. At 4:45 p.m. emergency services responded to the unit. Resident 2 left the facility at 4:59 p.m. The nurse noted that while attempting to transfer Resident 2 to the stretcher, and while cleaning up the area, found on the floor in a wrapped up blanket were: 12 to 15 marijuana vape cartridges, one bottle of [NAME] vodka, two 12 ounce (oz) empty bottles of Fireball, one 12 oz empty bottle of Southern Comfort whiskey, a large hunting knife, a wallet with $43.00 and cards, and a container of Resident 2's untaken prescribed medications, which were identified by the pharmacist as six allopurinol 100 mg tablets (prevents and lowers uric acid levels), one atorvastatin 20 mg tablet (used to lower cholesterol), two duloxetine 60 mg capsules (antidepressant), eight gabapentin 400 mg capsules (pain medication), two loratadine 10 mg tablets (allergy medication), 36 melatonin 5 mg tablets (natural sleep aid), one multivitamin tablet, 27 oxycodone 10 mg tablets (opioid), 11 of which were partially dissolved, two ropinirole 1 mg tablets (used to treat restless leg syndrome) , 1/2 tablet of trazadone 150 mg (antidepressant), two vitamin D3 capsules, one Tylenol 325 mg tablet, and two Tessalon Perles (cough medication). The police confiscated the vape, cartridges, and knife. Review of Resident 2's clinical record revealed on May 6, 2026, at 2:12 a.m., a nurse noted that Resident 2 returned to the facility upset, yelling at staff, and waking up his roommates regarding his wallet. On May 7, 2026, the nurse noted, that while the 1:1 staff left to get their coat and to ensure 1:1 monitoring was ongoing, the nurse entered the room and observed Resident 2 with his back turned and head lowered with a tiny straw held to his nostril, inhaling, moving right to left, then left to right, with a white powdery substance that disappeared from the table. The resident quickly grabbed antifungal powder and poured it over the substance and stated it was now antifungal powder. The facility failed to provide adequate supervision and interventions to prevent Resident 2 from pocketing medications that were administered, returning to the facility intoxicated more than once, and having narcotic medications, illegal marijuana vape cartridges, alcohol, and a weapon in a room shared with other residents. The facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent elopement (Resident 1). Additionally, the facility failed to provide adequate supervision to monitor a resident with a known history of substance abuse during medication administration, resulting in diversion and stockpiling of prescribed medication, returning to the facility from a leave of absence intoxicated more than once, and possession of illegal marijuana vape cartridges, alcohol, and a weapon (Resident 2) constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 1 was placed on 1:1 observation on May 14, 2026. 2. Resident 1 was moved to a secure unit on May 14, 2026. 3. Resident 1 had a wander guard placed on May 14, 2026, and will be checked every shift beginning May 14, 2026. 4. Speech therapy was requested to do a more detailed cognitive evaluation of Resident 1's abilities. 5. Residents without elopement risk and/or independent smokers will be allowed to move throughout the facility without restriction, but staff will account for residents as specified beginning May 14, 2026: during a.m. care, meals, medication administration times, during p.m. care, and an hour before the end of each shift. 6. Beginning May 14, 2026, the night shift nurse on each unit will run the census for the upcoming day. Each nursing unit will use their census to account for each resident during a.m. care, meals, medication administration times, during p.m. care, and an hour before the end of each shift. If resident is not visibly present on the unit at any of the above times, staff will immediately page for the resident to return to their unit. If the resident does not answer the page within 10 minutes, the nurse on the unit will instruct the staff on the unit to check the unit and will call the supervisor to check the outdoor smoking area. If the resident is not found, elopement code will be called by the supervisor and elopement procedures will commence. 7. Supervisors will collect the census sheets daily and review to ensure completion. ADONs will review census sheets weekly x 4 weeks, then biweekly for 2 months, then monthly. Results will be reported to QAPI (Quality Assurance, Performance Improvement) committee. 8. Supervised smokers will continue to be supervised while outside smoking. 9. The facility educated all staff in the facility on the facility's procedure regarding census and accountability during specified times, elopement procedures, reeducation about not signing off on any care, treatment or medications until after performance of the task. All staff that were available on May 14, 2026, were immediately educated. All staff were educated via e-mail on May 14, 2026. Staff must sign and acknowledge the trainings on their next scheduled workday. 10. The facility policy, Resident Leave of Absence, was updated on May 14, 2026, and compliance with the updated policy will be implemented. The updates included if a resident returns and appears intoxicated, the resident will be searched for contraband (drugs, alcohol, weapons, etc.) upon returning from leave of absence. If the resident refuses the search, the resident will no longer be permitted to go on a leave of absence, resident room will be searched, and resident will be placed on 1:1 supervision until further review by interdisciplinary team which will include staff as well as the resident's primary care physician. Compliance with the policy will be audited through High-Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings. 11. Process that requires residents leaving on Leave of Absence (LOA) to sign out of the building before leaving and to sign back in will continue. The Nursing Home Administrator (NHA) will remind responsible parties (RP), including residents that are their own RP's, of the process through the automatic messaging feature in the facility's electronic health record completed on May 14, 2026. 12. The NHA will remind RP's not to take any person off the nursing units, out of the building or off the property. Message to include they cannot assume a person is not a resident just by appearance. This was completed through the automatic messaging feature in the facility's electronic health record on May 14, 2026. 13. Knife and contraband were removed by staff and locked in secure area. Hoarded medications were checked by the pharmacist, and all the medications were the resident's prescribed medications. All items were turned over to the police when they arrived on May 6, 2026. 14. Resident's order for oxycodone was discontinued and suboxone sublingual was ordered. 15. An audit will be completed weekly by nursing administration of leave of absences of identified risk residents to ensure search was complete. Results to be reported to QAPI. 16. Residents who come under suspicion for not swallowing their medications shall have orders for mouth checks after medication administration added to their order list by May 15, 2026. Refusals to be reported to the physician. The physician will be consulted for discontinuing narcotics for residents who are non-compliant. 17. ADONs to complete observations of medication administration for five residents with a mouth check order per week for four weeks, then three residents for four weeks, and random sampling afterwards. Results will be reported to QAPI committee. 18. Education was provided to staff on changes to LOA policies, signs and symptoms of intoxication, process to follow if intoxication is suspected, and following the current policy for medication administration ensuring residents swallow their medication. All staff that were available on May 14, 2026, were immediately educated. All staff were educated via e-mail on May 14, 2026. Staff must sign and acknowledge the trainings on their next scheduled workday. The survey team validated that the Immediate Jeopardy was removed on May 14, 2026, at 10:12 p.m., through verification of facility training and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. CFR 483.25(d)(2) Free of Accident/Hazards/SupervisionPreviously cited 9/19/25, 9/23/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement and develop a comprehensive care plan to meet the current needs for one of six sampled residents. (Resident 2)Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), chronic pain syndrome (pain that lasts longer than three months in one or more parts of the body), and a history of alcohol and opioid (used to relieve pain) abuse (chronic use that causes clinically significant distress, harm, or impairment). Review of the care plan revealed that Resident 2 had a behavior problem with taking medications related to pocketing narcotics with an intervention for staff to monitor the resident for swallowing medications. On March 28, 2026, a nurse noted that that the resident had an unopened can of alcoholic beverage in his room during a room clean-up and it was removed. On March 31, 2026, a nurse noted that the resident smelled of alcohol, his face was red, flushed, and sweaty, stating that Resident 2 reported it was his cologne then came back to the nurses' station with a bottle with no label and some clear liquid stating it was mouthwash. On April 1, 2026, a nurse noted that while speaking to Resident 2 about alcohol consumption, he stated I am a biker, that's what we do; we drink, smoke, play pool, and party. The nurse also noted that the resident had some bottles with unidentified liquid, amber in color, in the same bottle from March 31, 2026, and in an apple juice bottle. On May 5, 2026, at 1:40 p.m., a nurse noted that Resident 2 returned from an independent leave of absence with an ataxic gait (unsteady, uncoordinated walking pattern with irregular foot placement and body swaying), sweating profusely, and slurred speech, and was verbally aggressive and causing a disturbance on the nursing unit. On May 5, 2026, a nurse noted that after transferring Resident 2 to the stretcher, in a wrapped up blanket on the floor, were: 12 to 15 marijuana vape cartridges, one bottle of [NAME] vodka, two 12 ounce (oz) empty bottles of Fireball, one 12 oz empty bottle of Southern Comfort whiskey, a large hunting knife, and a container of Resident 2's untaken prescribed medications, which were identified by the pharmacist as six allopurinol 100 mg tablets (prevents and lowers uric acid levels), one atorvastatin 20 mg tablet (used to lower cholesterol), two duloxetine 60mg capsules (antidepressant), eight gabapentin 400 mg capsules (pain medication), two loratadine 10 mg tablets (allergy medication), 36 melatonin 5 mg tablets (natural sleep aid), one multivitamin tablet, 27 oxycodone 10 mg tablets (opioid), 11 of which were partially dissolved, two ropinirole 1mg tablets (used to treat restless leg syndrome) , 1/2 tablet of trazadone 150 mg (antidepressant), two vitamin D3 capsules, one Tylenol 325 mg tablet, and two Tessalon Perles (cough medication). On May 7, 2026, the nurse noted Resident 2 was observed with a tiny straw held to his nostril, inhaling a white powdery substance while on 1:1 observation. The care plan failed to address Resident 2's alcohol and opioid abuse and failed to include interventions to safely manage the resident's independent leaves of absence or develop interventions specific for those behaviors. Additionally, the facility failed to implement interventions to monitor Resident 2 for medication pocketing during administration. In an interview on May 14, 2026, at 12:10 p.m., the Director of Nursing confirmed that the intervention for staff to ensure that Resident 2 swallowed all his medications was not implemented and that there was no care plan developed to address Resident 2's history of alcohol and opioid abuse, including the associated safety risks after returning from independent leaves of absence. CFR 483.21(b)(1) Comprehensive Care PlansPreviously cited 9/23/25 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, policy review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in following the established policies and procedures of the facility set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of six residents sampled for medication administration. (Resident 1)Findings include: Review of Pennsylvania Code Title 49, Chapter 21, Subchapter B. Practical Nurses, revealed guidelines which included that an LPN shall follow the written, established policies and procedures of the facility. A licensed practical nurse shall document and maintain accurate records. A licensed practical nurse may not falsify or knowingly make incorrect entries into the patient's record or other related documents. Review of the facility policy entitled, Medication Administration Schedule, last reviewed December 18, 2025, revealed that the exact time of medication administration was to be documented in the medication administration record (MAR). If medication was administered early, late, or was omitted, the reason was also documented. Medications scheduled for evening shift are administered between 4:00 p.m. and 7:45 p.m. and medications scheduled for bedtime are administered between 8:00 p.m. and 11:00 p.m. Review of the facility policy entitled, Medication Administration Policy, last reviewed December 18, 2025, revealed that staff were to identify the resident before administering any medication. Staff were to check the arm band or photograph, ask the resident their name, or check with other staff members if necessary. The resident has the right to refuse medication. The nurse was to document accordingly. Review of Resident 1's medication administration record (MAR) revealed that on May 13, 2026, LPN 1 documented that Resident 1 was administered risperidone 4 milligram (mg) tablet (atypical antipsychotic) on evening shift and perphenazine 16 mg tablet (antipsychotic) at bedtime. LPN 1 indicated on the MAR to see the progress note for the following physician orders: benztropine mesylate 2 mg tablet (anticholinergic), divalproex sodium 500 mg tablet (used to manage manic phases of bipolar disorder), hydralazine 50 mg tablet (antihypertensive), and blood glucose (sugar) checks before meals and at bedtime. On May 13, 2026, at 10:39 p.m., LPN 1 noted medications were never given, Resident 1 was off the unit. A review of Resident 1's blood glucose summary indicated that LPN 1 documented results for the resident's blood glucose on May 13, 2026, at 8:34 p.m. twice, with results of 152 milligrams per deciliter (mg/dL) and 156 mg/dL. LPN 1 then struck out the results at 10:34 p.m. and 10:39 p.m. and documented that Resident 1 declined. On May 14, 2026, a nurse noted that Resident 1 had eloped (unauthorized departure from the facility) and returned to the facility at 1:00 a.m. Review of facility documentation revealed that Resident 1 was observed on camera footage leaving the facility on May 13, 2026, at 5:08 p.m. In a written statement dated May 14, 2026, Nurse Aide (NA)1 stated that she last saw Resident 1 at 4:00 p.m. and never saw him again for the rest of her shift. In an interview on May 14, 2026, at 9:45 a.m., the Director of Nursing confirmed that LPN 1 falsely documented in Resident 1's clinical record that medications were administered and blood glucose was checked when the resident was not in the building and altered the MAR after receiving a phone call from the police regarding the resident's elopement. 28 Pa. Code 211.10(c) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 37 sampled residents. (Resident 24 and 377)Findings include: Clinical record review revealed that Resident 24 had diagnoses that included dementia (a progressive decline in thinking, memory, and judgment) and a history of falls. Review of Resident 24's MDS assessment dated [DATE], indicated that the resident did not have any falls since the prior assessment which was dated November 3, 2025. A nurse's note dated November 24, 2025, stated that the resident had a fall on that date. In an interview on April 30, 2026, at 2:36 p.m., the Director of Nursing (DON) confirmed that Resident 24's MDS assessment dated [DATE], was inaccurate and should have captured the fall that occurred on November 24, 2025. Clinical record review revealed that Resident 377 had diagnoses that included Alzheimer's disease (a progressive disease that affects memory, language problems, and body function) and chronic kidney disease. Review of Resident 377's MDS assessment dated [DATE], indicated that the resident was receiving dialysis while a resident. There was no documentation in the clinical record that indicated the resident was receiving dialysis. In an interview on April 29, 2026, at 12:45 p.m., the DON confirmed that the MDS was inaccurate and that Resident 377 was not on dialysis at that time. CFR 483.20 (g) Accuracy of AssessmentsPreviously cited 4/16/25

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for two of five sampled residents who were ordered psychotropic medications. (Residents 18 and 361)Findings include: Clinical record review revealed that Resident 18 had diagnoses that included schizoaffective disorder bi-polar type, dementia, and anxiety disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had cognitive impairment. A review of the care plan revealed that the resident had mood problems related to the disease process of schizoaffective disorder, exhibited behaviors of yelling out, and presented as anxious and restless. On August 7, 2025, a physician ordered for staff to administer an anti-anxiety medication (Ativan) as needed for anxiety. The order did not include a date to indicate when staff was to stop administering the as needed medication. Review of the Medication Administration Records (MAR) revealed that the as needed Ativan was administered two times in January 2026, five times in March 2026, and one time in April 2026. In an interview on May 1, 2026, at 9:27 a.m., the Director of Nursing stated that the as needed order was to have a stop date of 14 days. Clinical record review revealed that Resident 361 had diagnoses that included metabolic encephalopathy, heart failure, and peripheral vascular disease. On March 31, 2026, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every four hours as needed for anxiety. The order did not include a date to indicate when staff were to stop administering the as needed medication. Review of Resident 361's MAR revealed that staff had administered the lorazepam on April 26, 2026. There was no documented evidence that the physician had re-evaluated continued use of the as needed anti-anxiety medication beyond 14 days. In an interview on April 30, 2026, at 2:21 p.m., the Director of Nursing confirmed that there had been no date added to the order to indicate when staff were to stop administering the anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for four of 37 sampled residents. (Residents 9, 10, 171, 234)Findings include: Clinical record review revealed that Resident 9 had diagnoses that included end stage renal disease and dialysis. On March 27, 2026, a physician ordered that staff obtain an occult blood stool test for three days. A review of Resident 9's clinical record revealed there was no documented evidence to support that the occult blood test was obtained as ordered. Clinical record review revealed that Resident 10 had diagnoses that included type 2 diabetes mellitus with diabetic kidney complications and acute respiratory failure. A physician's order dated August 29, 2025, directed staff to measure the resident's blood sugar before meals and at bedtime every day, and to notify the physician if the resident's blood sugar was below 70 milligrams per deciliter (mg/dL) or above 300 mg/dL. Review of Resident 10's Medication Administration Records (MAR) revealed that Resident 10's blood sugar was above 300 mg/dL once in January 2026, seven times in February 2026, and seven times in March 2026. There was no documented evidence that the physician was notified of those incidents. Clinical record review revealed that Resident 171 had diagnoses that included hypertension (high blood pressure) and dementia (a progressive decline in thinking, memory, and judgment). A physician's order dated March 24, 2026, directed staff to administer a blood pressure medication (carvedilol) two times a day. The physician ordered that staff were not to administer the medication if the resident's heart rate (the number of times a person's heart beats per minute) was less than 60 beats per minute. Review of Resident 171's MAR, revealed that staff administered carvedilol two times in March 2026 and six times in April 2026, when Resident 171's heart rate was less than 60 beats per minute. In interviews on April 30, 2026, at 1:54 p.m., and 2:36 p.m., the Director of Nursing confirmed that that the ordered occult blood stool test for Resident 9 was not done, there was no evidence that the physician was notified when Resident 10's blood sugar was higher than 300 mg/dL, and that Resident 171's medication was administered outside the ordered parameters as identified. Clinical record review revealed that Resident 234 had diagnoses that included cerebral infarction, vascular dementia, and muscle weakness. A physician's order dated June 24, 2025, directed staff to apply Prevalon boots (devices to prevent heel pressure injuries) while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on April 28 and 29, 2026, between 8:20 a.m., and 2:25 p.m., revealed Resident 234 in bed and the Prevalon boots were not applied. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse for two of ten sampled residents (Residents 2 and 4), resulting in physical harm for one resident. (Resident 2)Findings include: Review of the facility policy entitled, Abuse Prevention, last reviewed March 24, 2025, revealed that residents had the right to be free from abuse. Review of the facility policy entitled, Resident to Resident Altercations, last reviewed March 24, 2025, revealed that facility staff would monitor residents for aggressive behavior towards other residents or staff. The events would be reviewed for possible measures to prevent additional incidents and necessary changes to the care plan would be made. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included mood affective disorder (condition that affects a person's emotional state), anxiety, non-compliance with medical treatment, alcohol-induced dementia, psychosis (difficulty telling the difference between what is real and what is not), and alcohol induced psychotic disorder. Review of the care plan revealed that the resident had a behavior problem and was verbally and physically aggressive towards staff and peers and refused medication, assistance, and care. Review of the Minimum Data Set assessment (a periodic assessment of resident care needs) dated August 19, 2025, revealed that his cognitive status was a 99 meaning the interview was not successful and the assessment could not be completed. On August 12, 2025, nursing staff noted that Resident 1 was upset with his admission to the facility, was verbally abusive with staff, and refused care. The nurse practitioner was made aware of the behaviors. On August 13, 2025, a nurse practitioner noted that the resident had a history of uncooperative, non-compliant, and verbally and physically abusive behaviors and hospitalizations for psychiatric services. The nurse practitioner noted that prior to admission to the facility, the resident continued to be anxious, hallucinated, and responded to internal stimuli. It was noted that upon admission, he was verbally abusive to staff and attempted to swing at them. Review of the clinical record revealed that throughout the resident's admission to the facility, nursing, social services, and therapy staff documented that he continued to display behavioral disturbances and verbal aggression towards staff. Redirection was often unsuccessful, and he would not permit staff to enter his room. Resident 1 raised a fist at staff when obtaining his meal tray and yelled at staff to get out of his room. Clinical record review revealed that Resident 2 had diagnoses that included cognitive communication deficit, dementia, and insomnia. Review of the care plan revealed that the resident had a language barrier, was an elopement risk due to disorientation, and exhibited behaviors such as wandering and rummaging. Interventions included that staff distract the resident from wandering by offering diversions, structured activities, food conversation, television, or a book. A care plan note dated September 30, 2025, revealed that the resident spent the majority of his time ambulating on the unit and wandering in and out of rooms. Review of facility documentation dated October 6, 2025, revealed that Resident 2 was observed in Resident 1's room and was noted to be naked with skin tears to the top of his head, right side of the forehead, and left elbow, and ecchymosis (bruising) to the left eye. There was also blood noted coming from his right elbow and top of his buttocks. Resident 1 was observed with blood on the front of his shirt and bruising to the knuckles of his left hand. No injuries to cause bleeding were observed on Resident 1. There was also blood observed on the bed sheets, floor, and wall of Resident 1's room. When questioned about the incident by law enforcement, Resident 1 stated that someone was in his room. Resident 2 was transferred to the hospital with injuries that required treatment. Review of the hospital Discharge summary dated [DATE], revealed that the resident was assessed due to being the victim of an assault with head injury and required wound care for soft tissue injuries. Clinical record review revealed that on October 14, 2025, Resident 2 was observed with altered mental status, increased confusion, was unable to feed himself, and was stumbling during ambulation. The resident was sent to the hospital for evaluation and found to have a hematoma (collection of blood outside of the blood vessels) to the left gluteal (buttocks) region and an acute fracture of the coccyx (bone of the pelvis). Review of facility documentation dated October 15, 2025, confirmed that the resident sustained a fracture of the coccyx, which was documented as believed to be from the assault from Resident 1 on October 6, 2025. There was a lack of evidence to support that the facility provided adequate interventions for Resident 1, who had known and continuing aggressive behaviors, and did not wish for others to enter his room, resulting in physical abuse with actual harm to a cognitively impaired resident (Resident 2) who wandered into Resident 1's room. In an interview on October 17, 2025, at 1:33 p.m., Registered Nurse (RN) 1 confirmed that there was no evidence that interventions were in place to prevent other residents from entering Resident 1's room. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], and had diagnoses that included mood disorder, dementia, frontotemporal neurocognitive disorder (brain disorder that mainly affects the frontal and temporal regions of the brain), and hallucinations. On August 15, 2025, nursing staff documented that Resident 3 was wandering around the unit and following staff. On August 16, 2025, nursing staff documented that the resident was confused, wandered into the nurse's station, was touching everything, and was difficult to redirect. On the same date, nursing staff documented that the resident continued to wander the nursing unit, entered another resident's room, and was rummaging through the closet. On August 16, 2025, the physician documented that the resident had a history of shadowing caregivers and occasional inappropriate behavior. Clinical record review revealed that Resident 4 had diagnoses that included anxiety and depression. Review of the Minimum Data Set assessment (a periodic assessment of resident care needs) dated August 2, 2025, revealed that the resident did not have cognitive impairment. Review of facility documentation dated August 16, 2025, revealed that Resident 4 reported to staff that Resident 3 entered his bathroom, touched his penis, and only left the room when he repeatedly told her to get out. On August 16, 2025, at 11:35 p.m., nursing staff documented that the resident was agitated and anxious from the incident with Resident 3 and requested an anti-anxiety medication (Ativan). There was no evidence that the facility implemented interventions for increased monitoring for Resident 3, a resident with wandering behaviors, to protect other residents on the nursing unit from abuse, resulting in sexual abuse to Resident 4. Based on the findings, the facility failed to ensure that Residents 2 and 4 were free from physical and sexual abuse, which resulted in actual harm to Resident 2. CFR 483.12 (a)(1) Freedom from abuse, neglect, and exploitation Previously cited 6/25/2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a provider (physician or designee) was notified in a timely manner of a resident who left the facility against medical advice (AMA). In addition, the facility failed to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services for one of six sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Discharging a Resident without a Physician's Approval, last reviewed March 2025, revealed that if a resident or representative requested a discharge earlier than outlined in the plan of care and without approval from the physician or provider (against medical advice), the resident's physician or provider was to be notified promptly. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included problems related to living alone, altered mental status, history of cerebral vascular accident (a stroke, a medical condition involving the interruption of blood flow to a part of the brain resulting in brain damage), muscle weakness, cognitive communication deficit (difficulty with communication from impaired cognitive function), metabolic encephalopathy (brain dysfunction from metabolic disturbances), and below the knee amputation. Review of the care plan revealed that the resident had a performance deficit with activities of daily living, limited physical mobility, impaired cognitive function, and short-term memory loss, and his discharge plan was uncertain. Review of Resident 1's history and physical, dated September 22, 2025, revealed that the resident's physician documented that the resident had hospital induced delirium, his decision-making capacity was to be re-evaluated before discharge, and that he seemed to lack the ability to understand potential problems after leaving the facility, which included not having a home and not being able to drive. On September 22, 2025, a nurse documented that the resident required assistance with opening and closing medication bottles, was not able to state what time medications were to be taken, was not able to state the proper doses of medications and was not able to dispense the proper number of medications. A social services note dated September 22, 2025, revealed that the discharge plan was uncertain, and indicated that the resident's family members did not wish to be involved in his care and he no longer had a home or a vehicle. A social worker's note dated September 25, 2025, indicated that the resident was in the facility lobby and expressed a desire to call a taxi to leave the facility and that Physician Assistant (PA) 1 assessed the resident and stated that he had capacity to make his own decisions and the discharge would be against medical advice (AMA). There was a lack of evidence to indicate that PA 1 performed a capacity evaluation at any point while Resident 1 was in the facility. In an interview on October 2, 2025, at 12:54 p.m., PA 1 stated that he did not perform a capacity evaluation on Resident 1 and that assessment was to be done by a resident's physician. PA 1 also confirmed that there was no evidence that the resident was re-evaluated to determine capacity to make his own decisions, he was not notified about Resident 1's AMA discharge until September 29, 2025, and notification should be at the time of the discharge. PA 1 confirmed that he did not perform an assessment to determine Resident 1's decision-making capacity, despite the social worker's note dated September 25, 2025, which indicated he had made that determination. On September 25, 2025, a nurse noted that the resident did not seem to have the insight regarding the level of care required for him at home, how he would perform aspects of care, or how he would get to any follow-up appointments. A nursing note dated September 25, 2025, revealed that Resident 1 required assistance from two staff members for transfers, continued to attempt to transfer himself independently, and was not compliant with using the safe level of assistance to transfer. On September 27, 2025, at 2:30 p.m., a nurse documented that the resident stated that he wanted to sign himself out of the facility and signed the paperwork to leave AMA. At 2:45 p.m., staff documented that the resident left the facility AMA with his belongings, no medications, no confirmed or safe destination, and had only a wheelchair for transportation. In an interview on October 2, 2025, at 11:25 a.m., Registered Nurse (RN) 1, stated that the resident signed his own AMA paperwork. RN 1 also stated that staff outside of the building had contacted the nursing supervisor's office to inform them that the resident had left the building in the wheelchair. There was no further instruction provided or intervention implemented at that time. RN 1 stated that approximately 10 minutes later, the police contacted the nursing supervisors' office to inquire if the facility was familiar with Resident 1. RN 1 was unaware of Resident 1's location at the time of that phone call. Review of facility documentation entitled, Discharge Against Medical Advice, revealed that the resident and nursing supervisors signed the form on September 27, 2025. There was no evidence that the resident's practitioner or any on call provider was notified of the AMA discharge in a timely manner. There was no evidence that a provider was made aware until September 29, 2025, two days after the resident had signed himself out of the facility. In an interview on October 2, 2024, at 1:37 p.m., Medical Doctor (MD) 1 confirmed that at the time of Resident 1's history and physical assessment on September 22, 2025, the resident's capacity to make decisions needed to be re-evaluated before his discharge from the facility, and that a re-evaluation was not completed. There was a lack of evidence to support that any practitioner was promptly notified of Resident 1's AMA discharge, that staff accurately documented on the re-evaluation of the resident's decision-making capacity, or that any interventions were attempted to ensure the safety of a resident with unconfirmed decision-making capacity who had left the building without any means of transportation, social support, medical supplies, or resources. On October 2, 2025, at 4:55 p.m., the Administrator was notified that the failure to notify a provider of a resident who left the facility AMA and failure to ensure that a resident was capable of safely making the decision to independently discharge from the facility without interventions or services constituted an Immediate Jeopardy situation at F628-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. The facility policy, Discharging a Resident Without a Physician's Approval, was updated on October 2, 2025, and compliance with the updated policy will be implemented. The updates included that when a resident desires to leave AMA, staff will reference the resident's capacity in the medical record for consideration with management of the discharge and any AMA discharge will now require an incident report that will prompt staff to contact the provider. Physicians will be notified of AMA discharges immediately. The incident reports are audited by the risk management nurse. Compliance with the policy will be audited through High Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings. 2. Nursing staff onsite were re-educated on the updated policy, and notification to the Pennsylvania Department of Health and the local Area Agency on Aging at the time of an AMA discharge. The remainder of nursing staff will be educated by October 6, 2025. 3. A new physician's order set was implemented on October 2, 2025, to clearly communicate to the interdisciplinary team when a resident lacks capacity, has capacity, or if capacity is to be determined. Resident capacity will be documented with the order set. Nursing supervisors will audit new admissions for implementation of the order set. 4. The interdisciplinary team will be educated by October 6, 2025, on the new order set, and to document resident capacity based only on physician documentation. Compliance will be reviewed at QAPI meetings. The survey team validated that the Immediate Jeopardy was removed on October 2, 2025, at 9:58 p.m., through review of facility procedures and training, and interviews with staff following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of ten sampled residents at risk for elopement. (Resident 2) In addition, the facility failed to provide required education to staff related to elopement prevention on nursing unit Tower 3, affecting 29 residents assessed as at risk for elopement. This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed September 19, 2025, revealed that staff were to assure the safety and security of all residents. Review of the facility policy entitled, One to one (1:1), Behavioral Intervention, last reviewed September 19, 2025, revealed that staff would remain within arm's length or within visual sight of the resident at all times when receiving 1:1 intervention. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included dementia, insomnia (difficulty falling or staying asleep), wandering, restlessness, and agitation. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated September 5, 2025, the resident had memory impairment and could walk without assistance. An elopement assessment dated [DATE], revealed Resident 2 was at risk for elopement. Review of Resident 2's care plan revealed he was at risk for elopement with interventions for 1:1 observation and a roam alert bracelet (an electronic device that prevents doors from opening and/or sounds an alarm). On September 17, 2025, the physician ordered for staff to provide 1:1 supervision due to the resident being an elopement risk. On September 2, 2025, social services documented that the resident spends his day wandering around the unit and that his family stated he had a history of elopement and eloped via the window from his previous facility. On September 9, 2025, the physician documented that he discussed his concerns with risk management regarding the resident's high risk for elopement and to consider 1:1 if his behaviors persisted. On September 12, 2025, at 1:49 p.m., a nurse documented that Resident 2 was actively exit seeking, attempting to get on the elevators, and that he was on every 15 minute checks. At 2:49 p.m., it was documented that the resident was able to get on the elevator. On September 13, 2025, staff documented that Resident 2 was continuously standing by the elevator. On September 14, 2025 at 4:15 p.m., the resident was again on the elevator and when staff removed him he punched a window multiple times. At 10:16 p.m., the resident expressed that he needed to leave. On September 15, 2025, the psychology consultant recommended 1:1 supervision instead of every 15 minute checks. On September 16, 2025, Resident 2 was again noted to be hovering around the elevator and needed to be removed from the elevator multiple times by staff. On September 17, 2025, the resident was found with the elevator/door codes written on a piece of paper in his sock. He was then placed on 1:1 observation. On September 19 2025, staff documented that the resident was pacing between stairwells and elevators with the assigned 1:1 staff member following. On September 20, 2025, at 11:21 p.m., the nursing supervisor (RN 4) observed from her office on a different floor that the resident's alert bracelet was alarming and contacted the unit to locate the resident. He could not be located on the unit or on the facility grounds. Resident 2 was located by police on September 21, 2025 at 6:52 a.m., at a convenience store approximately two miles from the facility, and was taken to the emergency room for evaluation. He was returned to the facility at 9:30 a.m. Review of facility documentation, dated September 21, 2025, revealed that the resident's assigned 1:1 staff member left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced. The resident was left unsupervised and did not have 1:1 observation, per his physician's order and care plan, and eloped from nursing unit Tower 3 and the building unwitnessed. Further review of facility documentation revealed that Resident 2 was later observed on camera footage exiting through a stairwell door on Tower 3 after using the code to open the door. There was no documented evidence that the nurse aide (NA 1) and nurse (LPN 1) assigned to Resident 2 on Tower 3 on September 20, 2025, at the time of the elopement, had received the required training prior to the start of their shifts as indicated in the facility's Immediate Jeopardy action plan dated September 19, 2025. Review of additional facility documentation revealed that 29 residents on Tower 3 were assessed to have been at risk for elopement on September 20, 2025. There was no documented evidence that the facility implemented or evaluated the psychology consultant's recommendation for 1:1 supervision until September 17, 2025. There was no documented evidence that the door codes where changed on September 17, 2025, after the resident was found with the codes, or on September 20, 2025, when the resident used the code to exit the facility. In an interview on September 23, 2025, at 11:30 a.m., the Risk Management Nurse confirmed that the door codes were not changed until September 22, 2025. On September 23, 2025, at 11:43 a.m., the Administrator was notified that the failure to provide adequate interventions and supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 2's room was changed to a secure unit.2. The facility changed all the door and elevator codes on September 22, 2025.3. The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.4. The facility educated all staff regarding the new 1:1 policy and not sharing door codes beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.5. The facility educated staff that a search should occur immediately if a door alarm is sounding beginning on September 21, 2025. The remainder of staff will be educated by September 24, 2025.6. The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.7. The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events. 8. The Nursing Home Administrator will update the pre-admission review of elopement risk by September 24, 2025, to ensure the facility can safely manage a resident at risk of elopement. 9. Monthly department head meetings will be held for the leadership team to discuss elopement events beginning September 25, 2025.10. Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action. The survey team validated that the Immediate Jeopardy was removed on September 23, 2025, at 4:05 p.m., through review of the facility training, and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 483.25(d) Accidents.Previously cited 9/19/25 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Based on review of facility job descriptions, clinical record review, and review of facility documentation, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure that adequate interventions and supervision were provided to prevent the elopement of two of 10 sampled residents. (Residents 1 and 2) In addition, the NHA and DON failed to ensure staff education was completed as indicated in their Immediate Jeopardy Action Plan on nursing unit Tower 3, affecting 29 residents at risk for elopement. Findings include:Review of the NHA's job description revealed that the Administrator was responsible to plan, direct, and control the organization and management of administrative, patient care, ancillary, and service functions, and was to ensure the facility's compliance with State, Federal, and other regulations governing facility licensing. Review of the DON's job description revealed that the Director of Nursing was responsible for the planning, coordination, and control of all services provided through the Nursing department. Work included the development and implementation of nursing services, standards, staffing, and provision of overall administrative management functions.Clinical record review revealed that Resident 1 eloped from the facility on September 17, 2025, after self-removing his roam alert bracelet (an electronic device that prevents doors from opening and/or sounds an alarm). This resulted in an Immediate Jeopardy Situation. The facility's action plan, dated September 19, 2025, indicated that each nurse would receive education related to elopement prevention prior to the start of their next scheduled work shift and that all staff would receive the education by September 22, 2025.Clinical record review revealed that Resident 2 had a physician's order for staff to provide one to one supervision due to exit seeking behavior . Further review of the clinical record revealed that the resident had eloped from the facility on September 20, 2025, after being left unsupervised by the staff assigned to provide 1:1 supervision. This resulted in a second Immediate Jeopardy situation. There was no documented evidence that the nurse aide (NA 1) assigned to provide the 1:1 supervision had received elopement training before September 22, 2025, and that the nurse (LPN 1) assigned to oversee the nurse aide and the resident on September 20, 2025, at the time of the elopement, had received the required training prior to the start of the shift as indicated in the facility's Immediate Jeopardy action plan dated September 19, 2025. Review of additional facility documentation revealed that 29 residents on Tower 3 were assessed to have been at risk for elopement on September 20, 2025.The NHA and DON failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the two Immediate Jeopardy situations.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and a review of facility documentation, it was determined that the facility failed to provide sufficient and competent staff needed to implement a resident's care plan interventions. (Resident 2)Findings include:Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included dementia, insomnia, wandering, restlessness, and agitation. According to the Minimum Data Set assessment dated [DATE], the resident had memory impairment and could walk without assistance. Review of Resident 2's care plan revealed that he was at risk for elopement with interventions for one to one (1:1) observation. On September 17, 2025, the physician ordered for staff to provide 1:1 supervision due to the resident being an elopement risk. Review of facility documentation dated September 21, 2025, revealed that the staff member assigned to provide 1:1 supervision for Resident 2 left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced by another staff member. Resident 2 was then left without 1:1 supervision which resulted in him eloping from the facility on September 20, 2025, at 11:21 p.m.Review of the facility staffing documentation for Saturday, September 20, 2025, revealed that the facility failed to meet the state required Nurse Aide ratios and minimum direct care hours per resident.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(4)(5) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of ten sampled residents. (Residents 1, 2)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to the Minimum Data Set (MDS) assessment, dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE], revealed that the resident wandered and was at risk for elopement. On August 20, 2025, a nurse noted that an alert bracelet was applied to the resident's leg. There was no documented evidence that the facility included interventions on the care plan to monitor the resident's risk for elopement, wandering behavior and the use of this device. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included dementia, insomnia (difficulty falling or staying asleep), wandering, restlessness, and agitation. According to the MDS assessment, dated September 5, 2025, the resident was Spanish speaking and rarely understood others when spoken to in English. The MDS Care Area Assessment summary noted that the resident's communication was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 2's communication barrier were included in the care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed March 25, 2025, revealed that staff were to assure the safety and security of all residents and that facility staff were to list prevention strategies on residents' care plans. The policy further indicated that residents capable of removing their alert bracelets (an electronic device that prevents doors from opening and/or sounds an alarm) were to be issued a stronger tamper resistant band. If the resident was able to remove the stronger band and was independently ambulatory (walked without assistance), the resident would require a one to one (1:1) observation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, syncope and collapse (fainting), and cerebral infarction (stroke). According to the Minimum Data Set assessment (a periodic evaluation of resident care needs) dated August 27, 2025, the resident had memory impairment and could walk without assistance. Review of the elopement assessment dated [DATE], revealed the resident wandered and was at risk for elopement. On August 20, 2025, a nurse noted that an alert bracelet was applied to the resident's leg. On September 13, 2025, a nurse noted that he had self-removed his alert bracelet and the nurse questioned if the unlocked unit was appropriate for the resident. On September 17, 2025, at 2:20 p.m., a nurse noted that Resident 1 was observed on the first floor. The resident was returned to the second-floor unit where he resided, and a new alert bracelet was applied. On September 17, 2025, at 2:54 p.m., another nurse noted that Resident 1's alert bracelet could not be located, and another new one was applied. At 4:11 p.m., a nurse noted that the physician group ordered for Resident 1 to be on every 15 minute checks due to wandering and removing his alert bracelet. Review of the facility documentation dated September 17, 2025, revealed that Resident 1 could not be located on the unit at 4:30 p.m., and the facility began a search. When Resident 1 could not be located on the facility grounds, the police were contacted. The police observed the resident walking along a road one mile from the facility. He was returned to the facility by the police on September 17, 2025, at 8:10 p.m. There was no documented evidence that Resident 1 was provided a stronger alert bracelet band or placed on 1:1 observation after removing his alert bracelet on September 13 and 17, 2025, as per facility policy. There was no documented evidence that Resident 1 had care plan interventions developed to address his elopement risk, wandering behavior, and alert bracelet use. In an interview on September 19, 2025, at 11:55 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1 was issued a stronger alert bracelet band per policy and that no care plan interventions were developed to address his elopement risk, wandering behavior, and alert bracelet. On September 19, 2025, at 1:28 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.2. The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.3. The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.4. The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.5. The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.6. The facility will update the template for 1:1 orders in the electronic health record on September 22, 2025.7. The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available on September 19, 2025, were immediately educated. Other staff will be re-educated prior to the start of their next shift. 8. Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee. 9. Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit. The survey team validated that the Immediate Jeopardy was removed on September 19, 2025, at 7:00 p.m., through review of the facility training and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to ensure that residents were free from physical and/or mental abuse for three of 10 sampled residents. (Residents 1, 2, 3) Findings include: Review of the facility policy entitled, Abuse Prevention Program/Abuse Free Environment, last reviewed March 24, 2025, revealed that residents had the right to be free from abuse. Clinical record review revealed that Resident 1 had diagnoses that included anxiety, depression, and mild intellectual disabilities. Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated May 28, 2025, revealed that the resident had cognitive impairment. Clinical record review revealed that Resident 2 had diagnoses that included diabetes (disease that affects the way the body uses blood sugar) and chronic obstructive pulmonary disease (lung condition). Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment. Clinical record review revealed that Resident 3 had diagnoses that included hemiplegia and hemiparesis (paralysis), insomnia (difficulty sleeping) and palpitations (irregular heart beats). Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment. Review of facility documentation dated June 23, 2025, revealed that the facility received a phone call from 911 (emergency call center designed to provide immediate assistance in emergencies) around 3:00 a.m. and alerted staff to go to room A3 on the Tower 7 nursing unit. In written statements dated June 23, 2025, Registered Nurses 1, 2, and 3 noted that upon opening the door to the room, License Practical Nurse (LPN) 1 was observed in full personal protective equipment (PPE) standing near Resident 1, tapping the resident on the chest and back, and sticking her fingers in the resident's mouth. There were blood stained wash cloths on the floor. Residents 2 and 3 were present in the room and shouting for help. In a written statement dated June 23, 2025, Nurse Aide (NA) 2 stated that LPN 1 entered Resident 1's room (A3, Tower 7) at approximately 1:00 a.m. to provide care to Resident 1 while NA 2 was attending to other residents in the room. LPN 1 remained in the room after NA 2 left. NA 2 also stated that around 2:45 a.m., the call bell to the room was activated and when she went to respond, LPN 1 slammed the door in her face and told her to get out. There was no evidence that NA 2 reported the incident or that staff intervened until approximately 15 minutes later when a call was received from the 911 call center. In a verbal statement dated June 23, 2025, Resident 2 stated that LPN 1 woke her and told her to put on a PPE gown to protect her from the demons. Resident 2 stated that LPN 1 would not allow her to leave the room or go to the bathroom. She then watched LPN 1 hit Resident 1 on the chest and back and shove wash cloths and towels down her throat. Resident 2 called 911 from her personal cell phone at that time. In a verbal statement dated June 23, 2025, Resident 3 stated that LPN 1 gave her a PPE gown to put on and a wet wash cloth to clean her hands. Resident 3 could see LPN 1 hitting Resident 1 on the chest and back and sticking her fingers into Resident 1's mouth. Resident 3 also stated that LPN 1 sprinkled water on her numerous times. Resident 1 was transferred to the emergency room (ER) for evaluation and found to have had petechial hemorrhages (tiny spots of bleeding) to the hard palate (roof of the mouth) and periorbital (around the eyes) edema (swelling). Her upper and lower lip were noted to have been swollen and a slit was noted to her lower lip. She was observed having some difficulty closing her mouth. Nursing documentation dated June 24, 2025, at 12:00 a.m., upon the resident's return from the ER, noted that Resident 1 stated, I was so scared. I thought I was going to die. In an interview on June 25, 2025, at 10:30 a.m., Resident 3 stated that the incident was horrific and that she had been scared. Based on the findings, the facility failed to ensure that Residents 1, 2, and 3 were free from physical and/or mental abuse, resulting in actual physical harm to Resident 1. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered treatments for one of five sampled residents with pressure ulcers. (Resident 308) Findings include: Clinical record review revealed that Resident 308 had diagnoses that included diabetes mellitus and hidradenitis suppurativa (a chronic condition where skin lesions develop as a result of inflammation and infection of sweat glands). Review of the wound consultant notes revealed that the resident had a stage 4 pressure sore (full-thickness skin and tissue loss, exposing muscle, tendon, or bone) on the sacrum (lower back). On February 21, 2025, the physician ordered for staff to cleanse the wound with wound cleanser, apply a collagen sheet to the wound bed, gently fill the rest of the wound with silver alginate, and cover with an Optifoam gentle dressing every shift. Review of Resident 308's March 2025 treatment administration record revealed a lack of documentation to support that the treatment to her sacrum had been completed on March 1, 3, 4, 7, 10, and 11, 2025. In an interview on April 16, 2025, at 9:47 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 308's wound treatments had been completed as ordered on the above dates. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 36 sampled residents. (Resident 322) Findings include: Clinical record review revealed that Resident 322 had diagnoses that included severe protein calorie malnutrition, bipolar disorder, and dementia. Review of Resident 322's MDS assessment dated [DATE], indicated that Resident 322 utilized an antipsychotic medication. Review of Resident 322's clinical record revealed no orders for or evidence that the resident received an antipsychotic medication. In an interview on April 15, 2025, at 12:57 p.m., the Administrator confirmed Resident 322's MDS was inaccurate.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner on two of 12 nursing units. (Northwest 1 and Northwest 2) In addition, the facility failed to distribute resident meal trays in a sanitary manner on one of 12 nursing units. (Northeast 1) Findings include: A review of the facility policy entitled, Foods Brought by Family/Visitors, dated [DATE], revealed that perishable food items were to be labeled with the resident's name, the item, and the use-by date. Expired food items were to be discarded. Observation of the nourishment room refrigerator on the Northwest 1 unit on [DATE], at 9:25 a.m., revealed there was a package each of strawberries and blueberries, two packages of shrimp, a package of crawfish tail meat, an opened package of pepperoni, and an opened bottle of chili sauce. These items were not dated or labeled with a name on them. There was a container of vegetable soup that was dated [DATE], an opened container of lobster bisque dated [DATE], and a container of black bean salad that was labeled with a use-by date of [DATE]. In the cabinets, there were two bulk containers of cookies that were not dated. In an interview on [DATE], at 9:34 a.m., Registered Nurse (RN) 1 stated the nourishment room was only used for the residents. Observation of the nourishment room refrigerator on the Northwest 2 unit on [DATE], at 9:55 a.m., revealed there was a container of blueberries and strawberries, a container of meat sauce, a cup of peaches, and an opened bottle of orange soda. These items were not dated or labeled with a name on them. There was a packaged salad that was labeled use-by [DATE]. Review of the facility policy entitled, Standard Precautions, Contact Precautions, Droplet Precautions, Airborne Precautions, Enhanced Barrier Precautions, last reviewed February 20, 2025, revealed that staff were to change gloves between tasks, and wash their hands between resident contacts. During observations of the lunch meal service on the Northeast 1 unit on [DATE], from 11:50 a.m. through 12:11 p.m., Licensed Practical Nurse (LPN) 1 was observed passing trays from the meal cart. LPN 1 was observed leaving the tray line area, opening doors to the medication room and other storage rooms, and adjusting her jacket. LPN 1 returned to tray line to continue serving food, including touching rolls, with her hands, wearing the same gloves, after touching the door knobs, keypads, and jacket, without changing her gloves. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy and observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication or treatment cart on one of 12 nursing units. (Tower 5) Findings include: Review of the facility policy entitled, Storage of Medications, last reviewed February 20, 2025, revealed that the compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were to be locked when not in use. Unlocked medication carts were not to be left unattended. Observations on April 14, 2025, on Tower 5, from 11:20 a.m. through 11:36 a.m., revealed the medication cart in the common area was unlocked, unattended, and accessible to anyone in the vicinity. Observation from 11:55 a.m. through 12:26 p.m., revealed the same medication cart in the common area was unlocked, unattended, and accessible to anyone in the vicinity. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement treatment and services to prevent a further decrease in range of motion for two of eight sampled residents with limited range of motion. (Residents 21 and 380) Findings include: Clinical record review revealed that Resident 21 had diagnoses that included monoplegia (paralysis of one limb) of upper limbs, muscle weakness, and lack of coordination. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, dependent on staff for activities of daily living, and had a limitation in range of motion on one side of the upper extremities. On April 4, 2025, the occupational therapist (OT) recommended a restorative nursing program (RNP) for range of motion for active assisted range of motion for the right and left upper extremities in all available planes as tolerated. A physician's order dated April 4, 2025, directed staff to provide the RNP and passive range of motion for the left upper extremities in all available planes five to seven times a week for 15 minutes as tolerated. There was no evidence that staff had implemented the RNP. In an interview conducted on April 16, 2025, at 9:41 a.m., the Director of Nursing confirmed there was no evidence that the RNP was provided for Resident 21. In an interview conducted on April 16, 2025, at 10:21 a.m., the Program Director of Rehabilitation stated that Resident 21 required the RNP as recommended for the right and left upper extremities to prevent further contracture of her left hand and to maintain range of motion. Clinical record review revealed that Resident 380 had diagnoses that included atrial fibrillation and cauda equina syndrome (a condition that occurs when the bundle of nerves below the end of the spinal cord are damaged). The MDS assessment dated [DATE], indicated that the resident was not cognitively impaired and required staff assistance for activities of daily living. Review of Resident 380's current care plan revealed that he had limited physical mobility related to weakness and that staff was to provide a restorative nursing program for passive range of motion exercises to his lower extremities 15 minutes per day. In an interview on April 14, 2025, at 12:31 p.m., Resident 380 stated that staff did not complete exercises to his lower extremities and that he would not refuse if offered. Review of Resident 380's RNP task flowsheet from March 15 through April 13, 2025, revealed that the resident was not offered restorative range of motion on 19 of 30 days. In an interview on April 16, 2025, at 9:47 a.m. the Director of Nursing confirmed that there was no documented evidence that the restorative nursing program was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, review of facility documentation, and staff interview, it was determined that the facility failed to provide nail care to promote foot health for one of 36 sampled residents. (Resident 397) Findings include: Clinical record review revealed that Resident 397 had diagnoses that included encephalopathy (damage or disease that affects the brain) and ischemic cardiomyopathy (a condition when your heart muscle is weakened as a result of a heart attack or coronary artery disease). Review of the Minimum Data Set assessment, dated March 21, 2025, revealed that the resident had mild cognitive impairment and was dependent on staff for care. On March 15, 2025, the physician ordered that nursing staff schedule the resident with the podiatry clinic for mycotic toenails (a fungal infection of the toenails that can cause discoloration, thickening, and separation from the nail bed). On April 13, at 11:42 a.m., the resident was observed in bed with toenails that were discolored, thick, long, and jagged. There was no documented evidence that the resident was seen by a podiatrist or provided with foot care. In an interview on April 16, 2025, at 9:50 a.m., the Director of Nursing stated that the podiatrist was at the facility weekly and that the resident should have been scheduled with the podiatry clinic and was not. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy review, review of other facility documentation and staff interview, it was determined that the facility failed to assess and provide adequate safety and supervision to prevent self harm for one of five residents reviewed (Resident R370). The facility also failed to thoroughly investigate the circumstances of an incident of self harm for one resident (Resident R370). Findings include: Review of facility policy entitled, Increased Observation dated [DATE] and an interview on [DATE], at 3:50 p.m. with Registered Nurse (RN) 1, revealed that the licensed nurses were to determine the need for increased observation when a resident's behavior warrants such increased observation. The staff were to initiate a form entitled, Increased Observation that included the reason for the increased observation. The staff were to document, on every shift, that they had verified the resident's whereabouts and safety. The staff were also to update the care plan (an assessment of resident needs with instructions on how the staff were to respond to those needs) to include increased supervision. Clinical record review revealed that Resident R370 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. rational reason), and newly diagnosed major neuro-cognitive disorder vascular dementia (vascular dementia is a progressive form of dementia caused by blockage or reduced blood flow to the brain and dementia is a disease that causes progressive cognitive impairment that includes memory loss and personality changes.) Prior to admission, Resident R370 had been treated in the hospital following an attempted suicide where she had taken medication with the intention of overdose. According to the hospital records, the resident had a history of [REDACTED]. The corresponding care plan identified that the resident had experienced hearing voices talking to her and had excessive mood swings. Interventions included that the staff were to observe for changes in behavior, altered mental status, sudden changes in cognitive function, suicidal ideation (the thought to hurt one's self), self harming threats or behaviors of threats of harm to others. Any abnormal findings, including those aforementioned, were to be reported to the physician. Clinical record review revealed that on [DATE], at 10:15 a.m. Resident R370 was crying hysterically saying both her daughters were dead. The Certified Registered Nurse Practitioner was on the unit and ordered a medication change and a referral for psychiatric services. Later that day at 5:00 p.m., the staff documented that the resident stated, she wants to die. On [DATE], at 9:49 p.m. the resident was crying and stated she was sad because her daughter died . On [DATE], at 10:00 a.m. the resident was crying and stated, I'm going to get a gun and kill myself. At 10:30 a.m., a staff noted two open areas on the resident's forearm. The supervisor was notified. Review of facility documentation revealed that the resident was placed on increased observation by the supervisor for 24 hours for suicidal ideation; however, there was a lack of documented evidence to support that the staff actually provided the increased observation in accordance with the facility policy. In an interview on [DATE], at 3:45 p.m. RN1 stated that there was no documented evidence that increased observation was completed for those 24 hours. The staff did not notify the physician of the incident until almost 24 hours later on [DATE], at 8:45 a.m. From [DATE] through [DATE], nursing documented that the resident continued with delusions and hallucinations that related to someone's death. The staff also documented that the resident had called 911 claiming her daughter was in danger on [DATE]. There was no documentation that the staff notified the physician of the resident's continued delusions and hallucinations (hearing voices that are not real). On [DATE], the facility's Psychiatrist assessed the resident for the first time and determined that based on the evaluation, the resident required in-patient hospitalization for unspecified psychosis. The resident was admitted that day for a three day stay and returned to the facility with some medication changes. On [DATE], at 10:25 p.m. the staff documented that the resident stated to a nurse aide that, she will break TV, so that she can hurt herself. There was no documented evidence that any increased supervision was provided at that time to ensure the resident's safety. The resident continued to express statements of delusions and hallucinations throughout the following days. Again, statements were related to the death of children or herself, and Satan coming to harm her and her expressed fear of such encounter. According to the nurses' notes and review of facility documentation, on [DATE], at 2:30 p.m. there was a reported incident that the Resident R370 hit another resident. The Certified Registered Nurse Practitioner was notified and the staff were told, to observe; however, there was no specific documentation to support that staff did in fact observe the resident at an increased level. On [DATE] and 11, 2016, the resident became verbally abusive and threatening to the staff. On [DATE], 2016, the staff documented that the resident continued to hear voices, was restless and tearful at times. The resident was assessed by the Psychiatrist on [DATE], (second psychiatric assessment) and found to be anxious, tearful and had persecutory delusions (thoughts that someone or something was going to harm them). Medication changes were ordered by the physician. The resident continued with behaviors from [DATE] through [DATE], of hearing voices, delusional statements of being pregnant with dead baby, and going to the electric chair, to name a few. The resident expressed fear of unknown entities, anxiousness, tearfulness and increased restlessness as evidenced by wandering into other residents' rooms. There was a lack of evidence to support that the staff notified the physician or that any increased level of supervision was provided to the resident during this time. On [DATE], at 6:00 p.m. a nurse documented that Resident R370 was at the nursing station, crying and asking for her husband and kids. At 7:30 p.m., the nurse documented that the resident was at the nursing station visibility upset, making statements of, I'm not going on Channel 3 TV tomorrow morning to be made a fool of. The nurse attempted to reassure the resident and offered medications but the resident refused and accused the nurse of trying to poison her. The nurse also documented that the resident stated three times that, she is not going on channel 3. I will kill myself tonight and no one knows how I will do it except me or else I will have the cops shoot me on live TV. The nurse documented, will observe closely. There was a lack of evidence as to the level of supervision that the resident was provided following these threats of self harm. At 8:05 p.m., the nurse documented again that she offered the resident medication which was refused. At 8:10 p.m., the nursing supervisor arrived on the unit to check the resident's status after receiving a call from the nurse on the unit regarding the resident's statements of self harm. The resident was found seated on the side of her bed leaning forward with blood on the floor. Review of documentation dated [DATE], submitted by the facility revealed that the resident was found with a three inch laceration between the wrist and elbow, and that there was blood on the floor of approximately one foot by six inches in size, and large shards of glass on the bedside table and floor from a broken magnifying glass. The resident was transferred to the hospital for the laceration repair and subsequently transferred to an in-patient psychiatric treatment facility. Review of documentation dated [DATE], submitted by the facility regarding this resident's attempt of self harm revealed that the nurse documented that the resident had stated three times that she would commit suicide and was paranoid throughout the shift. There was no further investigation as to the times of these statements, whether they were made concurrently or on three different occasions during the first few hours of the shift. Facility documentation indicated that the staff had notified the nursing supervisor and the staff were told, to keep a close watch until she could get there. The supervisor arrived on the unit approximately 30 minutes after being made aware of the resident's statements of intent of self harm. There was no supportive documentation in the clinical record that the staff supervised the resident. Review of the time of the nursing documentation revealed that the nurse documented at 7:30 p.m. and at 8:00 p.m. and 8:05 p.m., that there was some contact with the resident. There was no documentation that any staff had checked on the resident for at least a 30 minute period from 7:30 p.m. to 8:00 p.m. There was no further investigation to explain or support how the staff supervised the resident from the time of the resident's statements of intent to harm herself until she was found with blood on her and the floor. Review of documentation dated [DATE], submitted by the facility regarding the event indicated that the magnifying glass may have been brought into the facility by the family. There was no further investigation into how the resident obtained the magnifying glass, no documentation that the family were questioned about the magnifying glass or other residents questioned as to whether they had a magnifying glass that was missing. In an interview with RN3 on [DATE], at 9:45 a.m. she stated that she had never observed the resident reading with a magnifying glass. In an interview on [DATE], at 1:00 p.m. RN2 verified that the facility had not investigated the circumstances regarding how the resident got access to a magnifying glass. 42 CFR 483.25(h) Accidents Previously cited [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE]