Every finding on record at Oak Hill Rehabilitation & Healthcare Center

Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from accident hazards as possible for one of six residents reviewed (Resident 1) who used a shower chair that was not locked, resulting in a fall with a right hip fracture.Findings include: The facility's Shower/Tub policy, dated February 18, 2026, revealed that the steps in the procedure for a shower include; once the resident is taken into the shower room and placed under the shower, the shower chair is to be firmly positioned and locked. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 8, 2026, revealed that the resident was cognitively intact, was understood, could understand others, and had a diagnosis which included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). The resident's care plan, revised February 23, 2026, revealed that the resident was at risk for falls related to generalized weakness and staff was to ensure/provide a safe environment to minimize injury related to falls. A care plan, revised February 23, 2026, revealed that the resident had a self-care deficit related to her osteoarthritis of her bilateral knees, obesity and history of respiratory failure and staff was to provide assistance necessary to meet her needs of daily living. A nursing note for Resident 1, dated July 18, 2026, at 6:30 p.m. revealed that the licensed practical nurse informed the registered nurse that the resident had fallen in the central bath on the French Unit. The registered nurse entered the room, and the resident was observed lying facedown in the shower stall with her right leg extended out to her side laterally and her head up against the wall. The shower chair was behind her. She was assessed for injuries with no deformities or bleeding to the head noted. Neuro checks were unable to be completed due to her position and increased pain upon movement. Resident 1 appeared to be at her baseline mentally, her right leg and hip appeared aligned with no deformities. The resident stated her pain level was 10/10. She stated, I fell out of the shower chair. Vital signs were unable to be assessed due to the resident's position in the shower stall and her increased pain when attempting to assess her. The emergency personnel, physician and the Assistant Director of Nursing were notified. Resident 1 had no next of kin to notify. Interview with Resident 1 on August 12, 2026, at 1:02 p.m. revealed that on the day of the fall, that Nurse aide 2 and Nurse Aide 3 were in the shower room with her. She indicated that they were distracted and talking to each other. She asked Nurse aide 2 to place her right leg up on the bar so that she can wash herself properly. She stated that this is how she prefers to clean herself and she does it all the time. She went on to say that the two nurse aides left the shower room and she began to clean herself, and that as she leaned forward the shower chair flipped out over her head and she landed on the floor. She continued, saying that the fall happened right away, and that she usually says to the staff, did you lock my chair, but that she did not ask this time. She stated that a group of staff came in immediately and Nurse Aide 3 said out loud that she did not lock the chair. Resident 1 indicated that if she had known they did not lock the chair she would have called them back in to lock it, and that both staff were responsible because they were distracted and talking. She indicated that Nurse aide 2 has since come in to apologize but that Nurse aide 3 did not. Interview with Registered Nurse 1 on August 12, 2026, at 12:00 p.m. revealed that she was on duty the day Resident 1 fell and was transferred to the hospital. The hospital called her with report for Resident 1 and said they were sending her back to the facility. The hospital staff person communicated to Registered Nurse 1 that there were no injuries, then said that there was a fracture of the right hip, then stated that there was no fracture. Registered Nurse 1 said that she clarified with the hospital staff person that there was no fracture and the person's response was, correct no fracture. Registered Nurse 1 was present when EMS returned Resident 1 to the facility and EMS personnel told her the resident did not have a fracture. An interview with Director of Nursing on August 12, 2026, at 4:40 p.m. indicated that when Resident 1 returned from the hospital on July 18, 2026, the ADON called the hospital to confirm that there was no fracture. This was done because the facility was told by the hospital staff that there was no fracture, but, there was documentation on her paperwork that indicated a possible fracture. She was told there was no fracture. Nursing notes for Resident 1, dated July 18 through July 25, 2026, revealed that Resident 1 had pain in the right hip and was medicated with Tylenol and muscle relaxers repeatedly. On July 19, 2026, the nurse practitioner was called regarding her pain and ordered oxycodone (a narcotic pain reliever). On July 21, 2026, the nurse practitioner assessed the resident at the facility, noting that pain medication was somewhat effective, and that imaging showed no fractures. From July 21 to July 25, 2026, the resident continued to frequently use the narcotics and began to refuse bathing. On July 25, 2026, Resident 1 had increased pain and did not want to be rolled for morning care. The nurse practitioner was notified and ordered a mobile X-Ray which showed a right hip fracture. The resident was transported to the hospital, and admitted for surgery to repair the right hip. Interview with the Human Resource/scheduling director on August 12, 2026, at 2:57 p.m. indicated that she was the manager on duty that Saturday morning and she heard yelling for help coming from the bathroom on French unit. She immediately went to investigate and found the resident on the floor in the shower stall. She indicated that several staff were there and she asked out loud how did she fall and the resident said my wheels on the shower chair were not locked. The director went on to say that the two aides that had placed her in the shower began talking back and forth discussing whether the chair was locked or not. The director then stated to the aides that she could see that 3 out of 4 wheels were not locked. A witness statement from Registered Nurse 1 dated July 18, 2026, at 6:20 a.m. indicated that the occurrence required immediate staff education regarding the need for shower chair brakes to be in the locked positioned functioning properly. A witness statement from the Human Resource/Scheduling director, dated July 18, 2026, at 6:30 a.m. indicated that three out of four wheels on the shower chair were not locked properly, and that education was provided to the aides immediately after the fall. A witness statement from Nurse aide 2 dated July 18, 2026, at 6:30 a.m. revealed that there was no mention of the shower chair wheels being locked or unlocked. A witness statement from Nurse aide 3 dated July 18, 2026, with no time documented, indicated that the shower chair wheels were locked. The facility's investigation dated July 18, 2026, revealed that the shower chair breaks were not properly locked. Interview with the Director of Nursing on August 12, 2026, at 2:19 p.m. confirmed that staff did not lock Resident 1's shower chair properly, as per policy, which resulted in the chair flipping out from under her and her falling forward hitting her head on the wall and fracturing her right hip. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include: The facility's policy for dishwasher use, dated February 18, 2026, revealed that staff were to monitor the final rinse temperature during operation and were to record the temperature on the dishwasher temperature log.Observations on August 12, 2026, at 9:15 a.m. revealed that staff were running the dishwasher. Observations of the dishwasher temperature log, dated August 2026, revealed that the dishwasher wash temperatures and rinse temperatures were to be recorded every a.m. and p.m. The log did not include any dishwasher wash or rinse temperatures for August 11, 2026, or for the morning of August 12, 2026.Interview with the Dietary Manager on August 12, 2026, at 9:20 a.m. confirmed that staff were to document the dishwasher temperatures on the log each shift. The facility's policy for the three compartment sink, dated February 18, 2026, revealed that for the third compartment (sanitizer), staff were to prepare sanitizer according to the manufacturer's directions, use a quat test strip (used to test sanitizer strength) to verify the sanitizer concentration before use, and record or verify the concentration according to the facility's food-safety monitoring requirements. Observations of the three compartment sink on August 12, 2026, at 9:15 a.m. revealed that the sanitizer compartment was full of water and had two plates soaking in the compartment. The three compartment sink log for August 2026 indicated that sanitizer was to be checked at breakfast, lunch, and dinner; however, there was no documented quat test results for each meal August 1 through 11, 2026, and no documented quat test for breakfast on August 12, 2026. Interview with the Dietary Manager on August 12, 2026, at 9:26 a.m. confirmed that staff were to test the sanitizer with a quat test and record it on the log. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored and labeled in a medication cart. Findings include: The facility's policy for medication labeling and storage dated February 18, 2026, indicated that medications are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary method. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2 dated June 9, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs and had diagnoses that included diabetes and heart failure. Observations of the Colonial Hall medication cart on July 7, 2026, at 8:12 a.m. revealed a medicine cup in a drawer that contained coarse white powder. Interview with Registered Nurse 1 at the time of the observation revealed that the crushed powder was Resident 2's morning medications that were previously prepared to be administered after the resident was awake, and that it was acceptable to prepare/crush the resident's medications in advance to administering them. Interview with the Nursing Home Administrator and the Director of Nursing on July 7, 2026, at 8:24 a.m. revealed medications should not be taken out of the original labels and prepared in advance of administering the medications. Observations of the Colonial Hall medication cart on July 8, 2026, at 7:40 a.m. and 8:11 a.m. revealed that Registered Nurse 4 walked away from the medication cart, leaving the cart unlocked, unsupervised and out of her view. Interview with Registered Nurse 4 at the time of the observations revealed that she should lock the medication cart before leaving it unattended. Observations of the Colonial Hall medication cart on July 8, 2026, at 8:18 a.m. revealed six medicine cups in sections that were labeled with resident names in the second drawer in the cart. Two of the cups contained a course powder mixed with pudding and four of the cups contained medication tablets and capsules. Interview with Registered Nurse 4 at the time of the observation revealed that the medications were prepared earlier in the shift to save time. Registered Nurse 4 revealed that she should probably not prepare the medications early. An interview with the Nursing Home Administrator on July 8, 2026, at 9:10 a.m. confirmed that the medication cart should have been locked when unsupervised, and medications should not be prepared in advance of administering them. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing the regarding reason for transfer to the hospital for three of 27 residents reviewed (Residents 1, 5, 28). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1 dated May 5, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnoses that includes pneumonia and sepsis. A nursing note for Resident 1 dated April 16, 2026, at 2:28 a.m. revealed that the resident was admitted to the hospital with diagnoses of pneumonia and sepsis. Review of Resident 1's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer regarding her hospitalization on April 16, 2026. An admission MDS assessment for Resident 5 dated June 13, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnoses that includes acute myeloblastic leukemia (a fast-growing cancer of the blood and bone marrow). A nursing note for Resident 5 dated July 5, 2026, at 10:17 p.m. revealed that the resident was admitted to the hospital with diagnosis of leukocytosis (increased white blood count). Review of Resident 5's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer regarding his hospitalization on July 5, 2026. A quarterly MDS assessment for Resident 28 dated May 5, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnoses that includes urinary tract infection and sepsis. A nursing note for Resident 28 dated March 25, 2026, at 1:10 p.m. revealed that the resident was admitted to the hospital with diagnoses of urinary tract infection and tachycardia. Review of Resident 28's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer regarding her hospitalization on March 25, 2026. Interview with the Nursing Home Administrator on July 8, 2026, at 1:55 p.m. confirmed that there was no documented evidence that Residents 1, 5 and 28 or their representative were notified in writing of their transfer to the hospital. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required Non- Medical Coverage (NOMNC) notice to the resident or the resident's representative following the end of their Medicare A coverage for two of four residents reviewed (Residents 54 and 55). Findings include: A Skilled Nursing Facility Beneficiary Protection Notification Review form, completed by the facility and dated July 7, 2026, revealed that Medicare coverage for Resident 54 started on January 7, 2026, and that his last covered day was January 21, 2026. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The Non-Medical Coverage Notice for Medicare A for Resident 54 was not issued. A Skilled Nursing Facility Beneficiary Protection Notification form, completed by the facility and dated July 7, 2026, revealed that Medicare coverage for Resident 55 started on May 22, 2026, and that her last covered day was June 19, 2026. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The Non-Medical Coverage Notice for Medicare A for Resident 55 was not issued. Interview with the Nursing Home Administrator on July 7, 2026, at 3:15 p.m. confirmed that Residents 54 and 55 were not provided with the required notice of Non-Medical Coverage Notice for Medicare A as required when their Medicare coverage ended. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding Food Preparation, Service and Sanitation, dated February 18, 2026, revealed that food and nutrition service employees were to wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Observations during the lunch meal tray line on July 7, 2026, at 11:40 a.m. revealed that the Dietary Manager 5, [NAME] 6 and Dietary Aide 7 had a hair net on their heads that did not completely cover all of their hair. Interview with the Dietary Manager 5 on July 7, 2026, at 12:30 p.m. confirmed that the hair nets for her as well as [NAME] 6 and Dietary Aide 7 did not completely cover all of their hair and should have per policy. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending June 18, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 8, 2026, identified repeated deficiencies related to discharge process, professional standards, medication labeling and storage, sanitary food storage, preparation, and service, and infection prevention and control. The facility's plan of correction for a deficiency regarding discharge processes cited during the survey ending March 6, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F628, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance discharge processes requirements. The facility's plan of correction for a deficiency regarding staff meeting professional standards cited during the survey ending March 6, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with staff meeting professional standards requirements. The facility's plan of correction for a deficiency regarding medication labeling and storage, cited during the survey ending June 18, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with medication labeling and storage requirements. The facility's plan of correction for a deficiency regarding sanitary food storage, preparation, and service, cited during the survey ending June 18, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with providing sanitary food storage, preparation, and service requirements. The facility's plan of correction for a deficiency regarding infection prevention and control, cited during the survey ending June 18, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with infection prevention and control requirements. Refer to F628, F658, F761, F812, F880 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for two of 27 residents reviewed (Residents 17 and 44). Findings include: A facility policy for administering medications dated February 18, 2026, included that staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17 dated June 9, 2026, indicated that the resident was cognitively intact, required the assistance of staff for daily care needs, and had diagnoses that included diabetes. Observations made on July 8, 2026, at 7:19 a.m. revealed Registered Nurse 2 dropped a white tablet on top of the medication cart when opening the resident's medication package. She then picked the tablet up with her bare hands, added it in the medication cup with other medications, and administered it to the resident.Interview with Registered Nurse 2 on July 8, 2026, at 7:19 a.m. confirmed that she should not have touched Resident 17's medication with her bare hands and then administer it. Interview with the Nursing Home Administrator on July 8, 2026, at 9:16 a.m. confirmed that Registered Nurse 2 should not have touched Resident 17's medication with her bare hands and then administer it. A quarterly MDS assessment for Resident 44 dated May 22, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care needs, and had diagnoses that included diabetes. Observations made on July 8, 2026, at 7:55 a.m. revealed Registered Nurse 4 dropped a white capsule on top of the medication cart when pouring the medication from the medication bottle. She then picked the capsule up with her bare hands, added it in the medication cup with other medications, and administered it to the resident. Interview with Registered Nurse 4 on July 8, 2026, at 7:55 a.m. confirmed that she should not have touched Resident 44's medication with her bare hands and then administer it. Interview with the Nursing Home Administrator on July 8, 2026, at 9:10 a.m. confirmed that Registered Nurse 4 should not have touched Resident 44's medication with her bare hands and then administer it. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 27 residents reviewed (Residents 14 and 15). Findings include: A facility policy for administering medications dated February 18, 2026, revealed that medications are administered in accordance with prescriber orders, including any required time frame. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated May 13, 2026, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs and had diagnoses that included heart failure and hypertension (high blood pressure). Physician's orders for Resident 14 dated October 7, 2025, included an order for the resident to receive 25 milligrams (mg) of Metoprolol Succinate ER (used to treat high blood pressure, chest pain, and heart failure) two times a day for hypertension, hold if the residents heart rate is less than 60 beats per minute (bpm). Review of the Medication Administration Record (MAR) for Resident 14 dated April 2026 through July 2026 revealed that 25 mg of Metoprolol Succinate ER was administered on April 16 at 8:00 a.m. when the resident's heart rate was 43 bpm; on April 25 at 8:00 a.m. when the resident's heart rate was 50 bpm; on May 28 at 8:00 p.m. when the resident's heart rate was 57 bpm; on May 30 at 8:00 p.m. when the resident's heart rate was 50 bpm; on June 6 at 8:00 a.m. when the resident's heart rate was 57 bpm; on June 18 at 8:00 p.m. when the resident's heart rate was 50 bpm; on June 24 at 8:00 p.m. when the resident's heart rate was 54 bpm; on July 3 at 8:00 a.m. when the resident's heart rate was 52 bpm; and on July 4 at 8:00 p.m. when the resident's heart rate was 55 bpm. Interview with Director of Nursing on July 8, 2026, at 11:15 a.m. confirmed that Resident 14 was administered Metoprolol on the above-mentioned dates and times when it should not have been administered. An admission MDS assessment for Resident 15, dated June 15, 2026, indicated that the resident was cognitively intact, dependent on staff for her daily care needs and had diagnoses that included glaucoma (eye disease that damages the optic nerve). Physician's orders for Resident 15 dated June 12, 2026, included an order for the resident to receive one drop of 0.2-0.5 % Brimonidine Tartrate- Timolol Maleate (eye drops used to decrease eye pressure) in the right eye two times a day for glaucoma. Observations during medication administration on July 8, 2026, at 7:59 a.m. revealed that Registered Nurse 4 administered one drop of 0.2-0.5 % Brimonidine Tartrate- Timolol Maleate in Resident 15's left eye. Interview with Registered Nurse 4 on July 8, 2026, at 8:04 a.m. confirmed that she administered one drop of 0.2-0.5 % Brimonidine Tartrate- Timolol Maleate in Resident 15's left eye instead of her right eye as ordered. Interview with Nursing Home Administrator on July 8, 2026, at 9:10 a.m. confirmed that Resident 15's eye drops should have been administered as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 27 residents reviewed (Resident 6).Findings include: The facility's policy regarding comprehensive person-centered care plans, dated February 18, 2026, indicated that assessments of residents are ongoing and care plans are revised as information about the residents' condition changed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, revealed that the resident was cognitively impaired, had a history of wandering, wore a wander/elopement alarm daily, and had diagnoses that included dementia. Physician's orders for Resident 6, dated [DATE], included orders to observe the resident for wandering/elopement behavior, exit seeking, wandering every shift (Provide any additional details as needed in progress notes). Physician's orders dated [DATE], included orders that Resident 6 was DNR (Do Not Resuscitate-a formal medical order instructing healthcare providers not to attempt cardiopulmonary resuscitation-(CPR) if a patient's breathing stops or their heart ceases to beat); CMO (Comfort Measures Only - an end-of-life care plan in which focus shifts entirely to managing pain and maximizing the patient's physical, psychological, and spiritual comfort); determine use of antibiotics with comfort as goal; and no hydration or artificial nutrition by tube. An admission assessment for Resident 6 dated [DATE], revealed that the resident was an elopement risk and a wander guard (discreet wearable device primarily used in senior living, memory care, and hospital facilities to prevent wandering or elopement) was placed on the resident. Care Plan for Resident 6 dated [DATE], indicated that the resident had a POLST (Physician Orders for Life-Sustaining Treatment - specifies exactly what medical treatments a seriously ill or frail patient wants or does not want), and that CPR would be performed as ordered. There was no documented evidence that the resident's care plan was revised to reflect that he was a wanderer and elopement risk. Interview with the Licensed Practical Nurse Assessment Coordinator and the Nursing Home Administrator on [DATE], at 11:53 a.m. confirmed that Resident 6's care plan should have indicated that the resident was a DNR, and should have identified the problem and interventions related to the resident being an elopement risk, however it did not. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 27 residents reviewed (Resident 2).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A facility policy for administering medications dated February 18, 2026, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered and the signature and title of the person administering the drug. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2 dated June 9, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs and had diagnoses that included diabetes and heart failure. Review of Resident 2's MAR on July 7, 2026 at 7:55 a.m. as well as observations of the resident's room from 7:55 a.m. through 8:05 a.m. on July 7, 2026 revealed that her 8:00 a.m. medications were not documented as administered and no staff had entered the resident's room. However, at 8:05 a.m. on July 7, 2026 Resident 2's MAR revealed that her 8:00 a.m. medications were now documented as administered. Interview with Registered Nurse 1 on July 7, 2026, at 8:12 a.m. revealed that she documented that Resident 2's 8:00 a.m. medications were administered, however she had not yet administered the oral medications to Resident 2. Registered Nurse 1 reported that she did check Resident 2's blood sugar and administered her insulin but she could not recall the exact time it was administered. Interview with Resident 2 on July 7, 2026, at 8:22 a.m. revealed that she had not yet received her morning medications but did have her blood sugar checked and received her insulin. Review of the medication administration audit for Resident 2 dated July 7, 2026, revealed that Resident 2's 8:00 a.m. oral medications and insulin were documented as being administered at 8:04 a.m. Interview with the Nursing Home Administrator and the Director of Nursing on July 7, 2026, at 8:24 a.m. revealed that medications are to be documented as administered at the time they are administered, and that Registered Nurse 1 should not have documented that she administered Resident 2' s medications before she administered them. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and a facility investigation, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) in an emergency access box and failed to maintain a complete and accurate accounting of controlled medications for two of two residents reviewed (Resident 1 and Resident 2).Findings include:The facility's policy for the process to remove emergency medications from the narcotic E-box dated February 19, 2025, indicated that before removing any medication, the nurse must fully complete the emergency supply sign-out sheet and fax it to the pharmacy for an authorization code. Always remember to include quantity remaining so the pharmacy knows your quantity on hand and ensures that you never run out of a medication. Follow up by calling the pharmacy to notify them that you just faxed the sheet and need the authorization code to write on the sign out sheet and also to write on the emergency narcotics E-box access sheet. The nurse and witness must log the entry with signatures onto the emergency narcotic E-box Access sheet, cut the zip tie tag (way to lock the box), logging the tag numbers as requested. The nurse and the witness to remove the medication need to log the entry on the controlled substance record (tracks each dose of a controlled medication) or controlled patch record. Before locking the narcotic box, the nurse and witness must cycle count every item in the narcotic box, reconciling the quantity on the punch card item against the quantity written on the controlled substance record or controlled patch record. If there is a discrepancy, notify your Director of Nursing/management as soon as possible. Nurse and witness are to lock the narcotic box with zip tie tag numbers on the emergency narcotics E-box access sheet and file the narcotic supply sign-out sheet per the facility's process. The facility's policy for medication administration dated February 19, 2025, indicated that the individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1 dated July 24, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, had a diagnosis of cancer of the ovary (female reproductive organ), and was receiving hospice (end-of-life care) services. Physician's orders for Resident 1 dated July 26, 2025, included an order for the resident to receive one milliliter (ml) of Ativan Solution by mouth four times a day for seizure activity.Review of the MAR for Resident 1 dated July 2025 indicated that one ml of Ativan solution was administered on July 26 at 6:00 p.m. and July 27 at midnight. There was no documented evidence on any controlled substance record of this medication being administered. Review of an incident investigation provided by the facility dated August 28, 2025, indicated that Licensed Practical Nurse 1 and Licensed Practical Nurse 2 identified that on August 16, 2025, there was no Ativan solution available to be counted in the emergency narcotic E-box. There was no documented evidence that this was reported to the Director of Nursing, management, or pharmacy. The Assistant Director of Nursing reported that she found an empty pharmacy box that should have had Ativan solution in it on August 28, 2025, while cleaning the refrigerator. She reported this to the Director of Nursing and an investigation was initiated. A supervisor emergency medication supply form dated July 23, 2025, indicated that the emergency narcotic box did contain one 30 ml bottle of Ativan Intensol (concentrated liquid medication). Interview with Director of Nursing and Nursing Home Administrator on November 12, 2025, at 1:54 p.m. revealed that the facility completed an investigation regarding the missing Ativan solution and believed that the Ativan solution was removed from the E-box for a hospice resident identified as Resident 1 because two doses of the medication were documented as administered before the medication was received from the pharmacy. Staff were not following proper procedures for counting medications in the narcotic E-box when accessing it, therefore there was no way to identify exactly when it went missing. There was no documented evidence of the Ativan solution being removed from the narcotic E-box or being disposed of, and therefore they were unable to account for the missing Ativan solution. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2 dated August 19, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs and had a diagnosis of atrial fibrillation (a type of irregular heartbeat). Physician's orders for Resident 2 dated January 24, 20254, included for the resident to receive 50 milligrams (mg) of Tramadol (a narcotic pain medication) every eight hours as needed for shoulder pain. Review of Resident 2's controlled substance records dated September 23, 2025, and October 11, 2025, indicated that 50 mg of Tramadol was signed out on October 3, 2025, at 7:40 a.m.; October 5, 2025, at 9:00 p.m.; October 11, 2025, at 9:00 a.m.; October 14, 2025, at 8:00 p.m.; October 24, 2025, at 6:00 a.m. and 8:00 p.m.; October 25, 2025, at 2:00 p.m.; October 31, 2025, at 8:45 a.m. and 8:00 p.m.; November 7, 2025, at 8:00 p.m.; and November 10, 2025, at 8:13 p.m.Review of the Medication Administration Record (MAR) for Resident 2 dated October 2025 and November 2025, revealed no documented evidence that 50 mg of Tramadol was administered to Resident 2 on the above-mentioned dates and times. Interview with Nursing Home Administrator on November 12, 2025, at 1:50 p.m. confirmed that there was no documented evidence that the signed-out doses of Tramadol were administered to Resident 2 on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for nine of 26 residents reviewed (Residents 2, 3, 7, 13, 14, 18, 20, 40, 42). Findings include: The RAI User's Manual, dated October 2025, indicated that Section B0700 (make self-understood) should be coded with either clearly understood, usually understood, sometimes understood, or rarely/never understood. Section C0100 (should brief interview for mental status be conducted) should be completed if the resident is at least sometimes understood verbally, in writing, or using another method. Section C0100 was to be coded No (0) or Yes (1) to determine whether a Brief Interview for Mental Status (BIMS) (an assessment to determine a resident's cognitive status) should be attempted with the resident. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident and coded in Sections C0200 through C0500. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The instructions for determining a resident mental status Section D0100 was to be coded zero (0) No if a mood interview was not to be conducted with the resident because the resident was rarely/never understood and/or unable to respond, and one (1) Yes if a mood interview should be conducted with the resident. The RAI Manual indicated that a mood interview should be attempted with all residents. A quarterly MDS assessment for Resident 2, dated March 7, 2025, revealed that the resident is understood and understands, Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. Section D0150 was also coded Yes (1) that resident mood interview Section D0150 was to be conducted; however, the section was coded as not assessed. A quarterly MDS assessment for Resident 3, dated May 28, 2025, revealed that the resident is understood and understands, Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. Section D0150 was also coded Yes (1) that resident mood interview Section D0150 was to be conducted; however, the section was coded as not assessed. A quarterly MDS assessment for Resident 7. dated May 4, 2025, revealed that the resident was able to make herself understood and was able to understand others. Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. A quarterly MDS assessment for Resident 14, dated May 9, 2025, revealed that the resident was able to make himself understood and was able to understand others. Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. Section D0100 was also coded Yes (1) that a resident mood interview was to be conducted; however, the Section D0150 was coded as not assessed. A quarterly MDS assessment for Resident 18, dated May 16, 2025, revealed that the resident was able to make himself understood and was able to understand others. Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. Section D0100 was also coded Yes (1) that a resident mood interview was to be conducted; however, the Section D0150 was coded as not assessed. A quarterly MDS assessment for Resident 40, dated May 19, 2025, revealed that the resident is understood and understands, Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as not assessed. Section D0150 was also coded Yes (1) that resident mood interview Section D0150 was to be conducted; however, the section was coded as not assessed. Interview with the Nursing Home Administrator on June 17, 2025, at 2:21 p.m. confirmed that the above-mentioned MDS assessments for Residents 2, 3, 7, 14, and 40 were coded inaccurately and that Sections C0200-0500 and Section D0150 should have been completed per the RAI manual. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415F1 Antibiotic Medications (medication used to for infections) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 13, dated April 21, 2025, included an order for the resident to receive 1 gram of methenamine hippurate (an antibiotic) two times a day. The resident's Medication Administration Record (MAR) for May 2025 revealed that the resident received methergine Hippurate from May 1 through May 31, 2025. A quarterly MDS for Resident 13, dated May 2, 2025, revealed that Section N0401F1 was not coded, indicating that the resident did not receive antibiotic medication during the seven-day look-back assessment period. Interview with the Nursing Home Administrator on June 18, 2025, at 11:07 a.m. confirmed that Resident 13's quarterly MDS assessment was coded to indicate that the resident did not receive an antibiotic during the look-back period. Physician's orders for Resident 20, dated June 7, 2023, included an order for the resident to receive 1 gram of methenamine (an antibiotic) two times a day. The resident's Medication Administration Record (MAR) for March 2025 revealed that the resident received methenamine twice a day during the seven-day look-back assessment period. An annual MDS for Resident 20, dated March 7, 2025, revealed that Section N0401F was not coded, indicating that the resident did not receive antibiotic medication during the seven-day look-back assessment period. Interview with the Nursing Home Administrator on June 17, 2025, at 2:21 p.m. confirmed that Resident 20's MDS assessment was coded inaccurately, and that the resident did receive antibiotics during the look-back period. Physician's orders for Resident 42, dated April 29, 2025, included an order for the resident to have Magic Mix (1:1:1:1) of Silvadene (antibiotic), hydrocortisone (steroid medication), nystatin (antifungal medication), and zinc cream (used to prevent skin irritation) applied to his right buttocks daily. Resident 42's Treatment Administration Records (MAR's) for April and May 2025 revealed that the resident received Magic Mix to his right buttocks daily from April 30 through May 31, 2025. A quarterly MDS for Resident 42, dated May 2, 2025, revealed that Section N0401F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period. Interview with the Nursing Home Administrator on June 18, 2025, at 11:07 a.m. confirmed that Resident 42's quarterly MDS assessment was coded incorrectly, and did not indicate that the resident received an antibiotic during the look-back period. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure urinary output was monitored for three of 26 residents reviewed (Residents 39, 40, 45) who had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine), and failed to ensure that physician's orders were obtained for an indwelling urinary catheter for one of 26 residents reviewed (Resident 45). Findings include: A facility policy for urinary catheters care, dated February 19, 2025, indicated that staff were to review the resident's care plan to assess for any special needs of the resident and maintain an accurate level of the resident's daily output per facility policy and procedure. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated June 3, 2025, indicated that the resident had moderate cognitive impairment, had an indwelling urinary catheter, required assistance from staff for daily care needs, and had diagnoses that included an infection and inflammatory reaction due to an indwelling urethral catheter. A care plan for Resident 39, dated June 1, 2025, indicated that the resident required a foley catheter (type of indwelling catheter) and that staff were to report any changes in the amount, color, or odor of the resident's urine. Physician's orders for Resident 39, dated May 29, 2025, included for the resident to have a foley catheter for urinary retention. There was no documented evidence that staff were measuring the resident's urine output per facility policy. A quarterly MDS assessment for Resident 40, dated May 19, 2025, revealed that the resident was understood and understands, required assistance with daily care needs, had nephrostomy tube (a tube inserted into the kidney to excrete urine), and had medical diagnoses that included heart failure and high blood pressure. A care plan, dated May 24, 2024, revealed that staff were to monitor urinary output every shift per facility policy, Review of Resident 40's clinical record revealed no documented evidence that the resident's indwelling urinary catheter output was documented during the day shift on May 20, 23, 28, 31, and June 1, 6, 8, 10, 2025; during the evening shift on May 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, 31, 2025, and June 1, 4, 5, 6, 9, 10, 11, 15, 2025; and during the night shift on May 20, 22, 24, 25, 26, 29, and June 10, 15, 2025. Interview with the Director of Nursing on June 17, 2025, at 12:26 p.m. confirmed that there was no documented evidence that Resident 40's nephrostomy output was documented on the dates and times listed above. An admission MDS assessment for Resident 45, dated May 26, 2025, indicated that the resident had moderate cognitive impairment, had an indwelling urinary catheter, required assistance from staff for daily care needs, and had diagnoses that included neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of the clinical record for Resident 45, dated May 2025 and June 2025, revealed no documented evidence of a physician's order for an indwelling urinary catheter or for catheter care. Observations of Resident 45 on June 16, 2025, at 2:15 p.m. revealed the resident lying in his bed with his urinary catheter drainage bag containing urine hanging on his bed frame. There was no documented evidence that staff were measuring the resident's urinary output per facility policy. Interview with the Director of Nursing on June 17, 2025, a 12:34 p.m. confirmed that Resident 45 did not have a physician's order for the use or care of an indwelling urinary catheter, and also confirmed that there was no documented evidence that catheter care was being provided. Interview with the Director of Nursing on June 18, 2025, a 11:29 p.m. confirmed that there was no documented evidence that staff were measuring urine output per facility policy for Residents 39 and 45. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper ileostomy care for one of 26 residents reviewed (Resident 42). Findings include: The facility's policy regarding colostomy/ileostomy care (care for an artificial opening in the bowel), dated February 19, 2025, indicated that staff were to review the resident's care plan to assess for any special needs of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated May 2, 2025, indicated that the resident was cognitively intact, required assistance or total dependence on staff for daily care tasks, and had an ileostomy. A care plan, dated May 8, 2023, revealed that Resident 13 had an ileostomy, he wore products, and they were to be changed as needed. Physician's orders, dated April 22, 2025, included an order for the resident to have the barrier and pouch to his right abdominal ileostomy be changed every three days and as needed. The order indicated staff were to use a #6921 Coloplast Mio 55 millimeter(mm) light convex barrier (baseplate around stoma), a #18641 Coloplast Mio 60 mm high output pouch (collection bag), a #12035 brava 2 mm ring barrier (a moldable ring designed to create a seal between an ostomy baseplate and the skin, protecting against leakage and skin irritation), and a 120700 Brava elastic barrier extender c curved (elastic strip that helps secure the ostomy barrier to the skin and prevents it from lifting or rolling up). Observations of Resident 42 on June 18, 2025, at 11:55 a.m. revealed that the resident had an ileostomy bag in place and it was leaking. He stated his pouch did not leak in the hospital, but since his return from the hospital his ileostomy pouch has been leaking. He stated that it leaked all of the time and it had recently been changed three times in one day. Observations on June 18, 2025, at 11:56 a.m. revealed that the facility's ileostomy supplies included a [NAME] 8531 premier flextend lock and roll 2 1/2 64 mm drain pouch. Interview with Registered Nurse 3 at that time revealed that the facility used the same colostomy/ileostomy supplies for all residents who required colostomy/ileostomy products and was the only product they had in the building. Interview with the Director of Nursing on June 18, 2025, at 12:36 p.m. confirmed that staff should have been using the ileostomy supplies ordered by the physician. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 26 residents reviewed (Residents 7, 36, 40). Findings include: A facility policy regarding medication administration, dated February 19, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. A facility policy regarding controlled substances, dated February 19, 2025, indicated that waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 4, 2025, indicated that the resident was able to make herself understood and could understand others, required assistance with care needs, was taking an opioid medication (a controlled medications used to treat pain), was receiving hospice services, and had diagnoses that included dementia. Physician's orders for Resident 7, dated April 19, 2025, included an order for the resident to receive a 12 microgram per hour (mcg/hr) Fentanyl (opioid medication) transdermal patch (delivers a specific dose of medication through the skin) every three days for pain management, removing it per schedule. Review of the Medication Administration Record, as well as the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 7 for April 2025, May 2025, and June 2025 revealed that a 12 mcg/hr Fentanyl patch was removed from Resident 7 on April 22, 25, 28; May 1, 4, 13, 16, 19, 22, 25, 28; and June 3, 6, 9, and 12. There was no documented evidence that the Fentanyl transdermal patch that was removed was disposed of in the presence of the nurse and a witness per facility policy. Interview with the Director of Nursing on June 17, 2025, at 2:47 p.m. confirmed that there was no documented evidence that the Fentanyl transdermal patches removed from Resident 7 on the above-mentioned dates and times were disposed of in the presence of the nurse and a witness per the facility's policy. A quarterly MDS assessment for Resident 36, dated May 7, 2025, revealed that the resident was cognitively intact, had occasional pain, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders for Resident 36, dated March 24 and May 1, 2025, included orders for the resident to receive 50 milligrams (mg) of Tramadol (opioid medication) every four hours as needed. A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 36's Tramadol revealed that one tablet was signed out on the controlled drug log on April 19 at 3:00 p.m.; April 22 (no time listed); April 24 at 7:00 a.m.; May 9 at 8:00 a.m.; May 10 at 3:00 a.m.; June 3 at 8:00 p.m.; June 10 at 8:45 a.m.; and June 12, 2025, at 7:36 a.m. There was no documented evidence in the clinical record to indicate that the signed-out doses of Tramadol were administered to Resident 36 on the above dates and times. Interview with the Director of Nursing on June 18, 2025, at 12:07 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 36 on the dates and times mentioned above. A quarterly MDS assessment for Resident 40, dated May 19, 2025, revealed that the resident was understood and could understand, required assistance with daily care needs, and has medical diagnoses that include heart failure and high blood pressure. Physician's orders for Resident 40, dated January 24, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (opioid medication) every eight hours for pain. Review of Resident 40's MAR for March 2025, April 2025, May 2025, and June 2025 revealed that one 50 mg tablet of Tramadol was signed-out for administration to the resident on March 17, 2025, at 10:08 a.m.; March 18, 2025, at 9:00 p.m.; March 23, 2025, at 7:09 a.m.; March 27, 2025, at 6:40 a.m.; April 2, 2025, at 8:00 p.m.; April 4, 2025, at 7:24 p.m.; April 6, 2025, at 8:25 p.m.; April 13, 2025, at 7:15 a.m.; April 14, 2025, at 7:00 a.m.; April 25, 2025, at 5:50 p.m.; May 10, 2025, at 11:40 p.m.; May 15, 2025, at 9:20 a.m.; May 23, 2025, at 9:00 p.m.; June 2, 2025, at 6:45 a.m.; and June 11, 2025, at 7:00 a.m. However, the resident's clinical record contained no documented evidence that the signed-out tablets of Tramadol were administered to the resident on these dates. Interview with the Director of Nursing on June 17, 2025, confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 40 on the dates mentioned above. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 26 residents reviewed (Resident 7). Findings include: The facility policy for administering medications, dated February 19, 2025, indicated that medications are administered in accordance with prescriber orders, and that the individual administering medications checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 4, 2025, indicated that the resident was able to make herself understood and could understand others, required assistance with care needs, was receiving hospice services, and had diagnoses that included dementia. Physician's orders for Resident 7, dated April 16, 2025, indicated for the resident to receive 10 milligrams (mg) of diazepam (controlled drug medication used to treat anxiety) gel every two hours as needed for agitation. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug), dated May 7, 2025, indicated that the diazepam delivered to the facility was provided in 0.5 milliliter (ml) syringes and that two 0.5 ml syringes were to be administered per dose. However, on May 16 at 10:34 p.m.; June 4 at 12:00 a.m., 12:00 p.m., 2:00 p.m. and 5:00 p.m.; June 5 at 12:35 a.m., and 7:49 p.m.; June 7 at 11:38 p.m.; June 8 at 6:40 a.m. and 10:00 p.m.; and June 11 at 9:30 p.m., only one 0.5 ml syringe of diazepam was signed out on the controlled drug record as administered. Interview with the Nursing Home Administrator on June 18, 2025, at 12:37 p.m. confirmed that staff were signing out and administering only one 0.5 ml syringe of diazepam on the above-mentioned dates and times when they should have been administering two 0.5 ml syringes. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of planned, written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu. Findings included: An interview with a group of residents on June 16, 2025, at 11:12 a.m. revealed that they did not always get what was on the menu. Review of the posted menus for the lunch meal on Monday, June 16, 2025, revealed that residents were to receive honey pot roast, fried potatoes, seasoned red cabbage, bread pudding, dinner roll with margarine, and a beverage. Observations in the main dining room on June 16, 2025, at 12:35 p.m. during the lunch meal revealed that there was no dinner roll or margarine provided to the residents. Observations on June 16, 2025, at 12:38 p.m. revealed that Resident 42 did not receive a dinner roll with margarine with his lunch meal. Interview with the Dietary Manager on June 16, 2025, at 12:45 p.m. confirmed that the dinner roll and margarine were not provided to the residents and he was unaware that they were to get a dinner roll with the lunch meal. 28 Pa. Code 211.6(a) Dietary Services.

Based on observations and staff interviews, it was determined that the facility failed to serve food that was palatable. Findings include: Review of the posted menus for the lunch meal on Tuesday, June 17, 2025, revealed that residents were to receive a smothered pork chop, mashed potatoes, steamed broccoli, pineapple delight cake, dinner roll with margarine, and a beverage. A test tray for the lunch meal on the French Hall on June 17, 2025, revealed that the cart left the kitchen at 11:53 a.m., arrived on the nursing unit at 11:54 a.m., and the last resident was served at 12:14 p.m. The test tray was tasted at 12:14 p.m. and the broccoli was mushy and not palatable. Interview with the Dietary Manager on June 17, 2025, at 12:14 p.m. confirmed that the broccoli was overcooked and was mushy. 28 Pa. Code 211.6(b) Dietary services.

Based on review of facility cleaning records, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of one ice machines (pantry room) and failed to store and serve food under sanitary conditions. Findings include: The facility's cleaning records for the ice machine, dated May 20, 2025, revealed that the interior was sanitized and the outside of the ice machine was cleaned on this date. Observations of the pantry on June 18, 2025, at 9:18 a.m. revealed that the ice machine had a build up of a white, slimy substance on the plastic dispenser that the ice came out of and on the black metal screen that the leftover ice fell onto. Observations of the pantry refrigerator revealed three small containers of fresh blue berries that were not dated or labeled. Interview with the Dietary Manager on June 18, 2025, at 9:21 a.m. confirmed that the ice machine needed cleaned and the containers of fresh blueberries should have been labeled and dated. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for four of four residents identified at risk for elopement. The facility further relied on it's alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. (Residents 1, 2, 3,4). Findings include: The facility policy for wanderguards (a bracelet that triggers an alarm and can lock monitored doors to prevent the resident from leaving unattended) and elopements, dated February 2022, indicated that if a resident was identified to be at risk of wandering, elopement or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. If the resident presents with increased unsuccessful elopement attempts or increased verbalizations to elope, the interdisciplinary team (IDT) would re-evaluate the resident and the current plan of care. When a wanderguard is in use, nursing staff are to check placement each shift and check the function daily. A diagnosis record for Resident 2, dated August 28, 2021, revealed diagnoses that included [CONDITION(S)] (mood disorder with mood swings), high blood pressure, depressive disorder, traumatic brain disorder, seizures, history of falls, and lack of coordination. A nursing note for Resident 2, dated December 20, 2021, indicated that the resident got his coat from his closet. The resident stated, I am going to [NAME]. The nurse asked the resident how he was getting there and resident stated he was going to walk. He was able to be redirected to his wheelchair outside of his room but he would not let the nurse hang up his coat. An elopement assessment for Resident 2, completed on December 20, 2021, indicated that he was at risk for elopement and a wanderguard was placed at that time. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 1, 2022, indicated that he was alert and oriented, able to make his needs known and ambulated independently with supervision. The elopement care plan for Resident 2, dated January 16, 2022, indicated that staff were to allow the resident to express his feelings or frustration as needed. When exhibiting exit seeking behaviors, redirect to an appropriate area and provide supervision. An update, dated February 9, 2022, indicated that staff were to encourage socialization and provide recreational programing. A nursing note for Resident 2, dated February 2, 2022, indicated that at 8:00 p.m. the resident waited until staff were out of site and exited through the front door. The nurse came out of another resident's room and noted that the resident was not sitting in his chair. The nurse checked the resident's room and other rooms on the hall. The nurse informed the registered nurse that she was not able to locate the resident. Staff checked all rooms and a nurse aide was sent outside to check for Resident 2. The nurse aide found the resident in a parking lot and when the staff asked how he exited the building, he stated I cut off my bracelet with fingernail clippers. The facility investigation report indicated that he was found in the parking lot of a car dealership located beside the facility, toward the main highway. The facility's investigation report, dated February 2, 2022, indicated that after the incident, Resident 2's medications were reviewed by the Certified Registered Nurse Practitioner's (CRNP - a registered nurse (RN) who has advanced education and clinical training in a health care specialty area) and all resident rooms were checked for cutting devices. An elopement risk asessment for Resident 2, dated February 8, 2022, indicated that he had a history of leaving the facility without supervision or informing staff, and that he verbally expressed his desire to go home. The resident was educated on the facility's leave of absence and patio usage procedures after indicating to staff that he wanted to go and see his old house. It was also documented that the resident understood the leave of absence (LOA) and patio usage procedures. The assessment further indicated that he was not an elopement risk. A physician's order for Resident 2, dated February 8, 2022, included an order to discontinue the wanderguard on his right ankle. A CRNP's order for Resident 2, dated March 9, 2022, included an order to place the wanderguard on the resident. A CRNP note for Resident 2, dated March 10, 2022, indicated that he needed a wanderguard to be applied for exit-seeking behaviors. The resident told the CRNP while pointing to his right ankle this keeps me from leaving. He indicated that he wanted to leave to go to [NAME] and see his old home and cat, and that he wanted to smoke. A nursing note for Resident 2, dated March 12, 2022 at 9:08 p.m., documented by Licensed Practical Nurse 1, indicated that the resident was using his actual fingernail and cutting at the wanderguard stating, I'm getting out of here when I get this thing off. The nurse tried to redirect him, but was unsuccessful. The note further indicated that the resident was to be monitored every hour for placement of the wanderguard. A nursing note for Resident 2, dated March 13, 2022, at 3:33 p.m., documented by Licensed Practical Nurse 1, indicated that at 2:30 p.m. the resident was looking out from the doorway of his room, up and down the hall, like he was checking to see where staff were. The nurse asked the resident if he needed anything and the resident asked if the front door was open. He was told that it locks automatically. The nurse checked for the resident's wanderguard and it was off. The resident said that he put it in the drawer. Licensed Practical Nurse 1 got the wanderguard out of the drawer and placed it back on the resident. The resident was noted to be unhappy about the wanderguard. The note further indicated that the resident would be monitored throughout the shift for placement of the wanderguard. There was no documented evidence in Resident 2's plan of care to indicate that it was updated related to his safety after repeated ideations of elopement on March 12 and 13, 2022. Additionally, there was no documented evidence to indicate that Resident 2 was monitored every hour throughout the shift and no documented evidence to indicate that the registered nurse and physician were notified of his increased elopement ideations. Observations during an interview with Resident 2, on March 25, 2022, at 11:53 a.m. revealed that he was in his room eating his lunch and he had been given a metal spoon, fork and knife to use. The resident indicated that he was not allowed to leave the building and that they put a thing on him to make sure he did not leave. Interview with the Nursing Home Administrator on March 25, 2022, at 1:46 p.m. revealed that Resident 2's elopement ideations should have gone up the chain of command to the registered nurse, the Director of Nursing, and the physician and confirmed that they were not notified. He further confirmed that the resident's plan of care should have been updated, and that there was no documented evidence of hourly checks or frequent monitoring and no documentation of why the nurse determined him to be not to be at risk on February 8, 2022. Interview with the Regional Director of Clinical Operations on March 25, 2022, at 4:49 p.m. confirmed that there was no documented evidence in Resident 2's clinical record to indicate that daily monitoring and functional checks of the elopement bracelet were done as per facility policy from March 9, 2022 through March 25, 2022. An admission MDS assessment for Resident 1, dated January 8, 2022, revealed that the resident had diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and required extensive assistance from staff for her ambulation (walking). An admission evaluation for Resident 1, dated Janaury 3, 2022, revealed that the resident was not at risk for elopement at this time. A nursing note for Resident 1, dated January 30, 2022, at 1:50 p.m. revealed that the resident had closed herself in the closet in her room and had her winter coat on, stating that she was going to her nephew's wedding. Wanderguard placed at this time. A nursing note for Resident 1, dated January 30, 2022, at 3:42 p.m revealed that at 2:45 p.m. an employee was outside on her break and saw the resident outside at the back of the building. She had a winter coat and slipper socks on, but no shoes. Resident 1 had a wanderguard on her right ankle. She was safely redirected back into the building by the registered nurse and a skin assessment was done. Resident does have two small open areas on her right shin which were cleaned. The resident was last seen in the building at 2:15 p.m. Resident denied any pain. One on one care was started right away, 15 minute checks were initiated and will continue for 24 hours. A witness statement from Registered Nurse 2, dated January 30, 2022, revealed that she was outside smoking when she heard yelling. Resident 1 was in the back of the building by the maintenance office with a coat on. Registered Nurse 2 redirected the resident back in and asked how she got out. Resident stated, I jumped out of a window. Registered Nurse 2, a nurse aide, and a licensed practical nurse walked around to all windows. The Director of Nurse's (DON) office was shut and locked but had been open earlier. The resident stated that she had to climb on a desk. Registered Nurse 2 then went to the DON's office and looked through the door. The window was open and the screen was knocked out. Registered Nurse 2 last saw the resident at 2:00 p.m. A witness statement from Licensed Practical Nurse 1, dated January 30, 2022, revealed that she was in another resident's room doing a treatment and the registered nurse supervisor came in and said she brought in Resident 1 from outside and when the resident was asked how she got out, she said through a window. Staff went and checked doors to make sure they were alarmed and also checked Resident 1's wanderguard and it was working. Room windows were checked and they were all closed. The resident was asked what she saw in the room she went out of, and she stated, There were a lot of desks and stuff in the room and in front of the window I climbed up to. Offices were checked and it was noted that a window was open in an office and the screen was out. A witness statement from Nurse Aide 3, dated January 30, 2022, revealed that she was in another resident's room and when she walked out of the room she heard someone yelling and went to see what was going on. The nurse said that she was out on her break and saw Resident 1 back by the shed and that she got the resident back in the building. When the resident was asked how she got out, she stated that she went out the window. A witness statement from Nurse Aide 4, dated January 30, 2022, revealed that she was changing a resident when the registered nurse came to the door telling her that Resident 1 had climbed out the window in the DON's office and was found outside. Interview with the Nursing Home Administrator on March 25, 2022, at 1:43 p.m. confirmed that Resident 1 eloped through a window in the Director of Nursing's office. A quarterly MDS assessment for Resident 3, dated February 8, 2022, indicated that she was confused and ambulated independently. An elopement risk assessment for Resident 3, dated August 3, 2021, and February 8, 2022, identified her to be at risk for elopement. A physician's order for Resident 3, dated November 6, 2021, indicated that she was to have a wanderguard to her right ankle and that placement was to be checked every shift. There was no documented evidence that nursing checked the function of the elopement bracelet daily as per the facility policy. An admission MDS assessment for Resident 4, dated February 2, 2022, revealed that the resident required extensive assistance from staff for his daily care needs, including with ambulation, and had diagnoses that included Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). A care plan for the resident, dated February 12, 2022, revealed that he was an elopement risk related to his cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and that he was to have a wanderguard/alarming bracelet. A nursing note for Resident 4, dated February 12, 2022, at 8:36 p.m. revealed that the resident expressed multiple times that he wanted to go home to family. A wanderguard was placed on the resident's left ankle. Physician's orders for Resident 4, dated February 12, 2022, included an order for the resident to have a wanderguard. A nursing note for Resident 4, dated February 12, 2022, at 8:43 p.m. revealed that the resident's son was called and agreed to the placement of the wanderguard. Review of Resident 4's Medication Administration Record (MARs), Treatment Administration Record (TARS), and clinical record revealed no documented evidence that the resident's wanderguard was routinely checked for the function and/or placement daily as per the facility's policy. Interview with the Director of Clinical Operations on March 25, 2022, at 4:49 p.m. indicated that Residents 3 and 4 did not have documentation regarding the routine monitoring of the function and/or placement of the elopement device as per the facility's policy. On March 25, 2022, at 1:55 p.m. the Nursing Home Administrator was given the IJ template and informed that the health and safety of the residents was placed in Immediate Jeopardy due to the failure to develop and implement new interventions to ensure residents were properly supervised to prevent elopements. The facility submitted and implemented an immediate action plan that included completing elopement evaluations on all current residents, and any resident identified as an elopement risk would have a wanderguard applied and their care plan would be updated as well as the facility's elopement book. The education included re-education of the facility's policy process and procedures for wanderguards and elopements. The Immediate Jeopardy was lifted on March 26, 2022, at 10:09 a.m. when it was confirmed that the facility had completed elopement evaluations on all current residents in the facility and ensured that the facility's elopement book was accurate, educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, clinical records and facility investigation information, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed (Resident R3), resulting in a fractured ankle for the resident. Findings include: The facility's policy regarding gait belts (belt placed around the resident's waist for staff to hold onto while transferring the resident), dated May 18, 2017, indicated that patient care providers would use a gait belt when ambulating or transferring residents who were unsafe to ambulate or transfer independently. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated August 2, 2017, revealed that the resident required the extensive assistance of two persons for transfers. Review of the Kardex (document that contains information related to the resident's care, including the transfer status, number of staff, and devices required to transfer the resident) for Resident R3, dated November 12, 2016, revealed that the resident was to be transferred with the assistance of two staff members using a gait belt. A physical therapy discharge summary for Resident R3, dated February 13, 2017, revealed that the resident was to be transferred to/from the bed and wheelchair with moderate assistance from two staff members. Resident R3's care plan, dated June 1, 2017, and updated August 1, 2017, revealed that the resident was at risk for falls and was to be transferred with the assistance of two staff members. Facility investigation information revealed that Resident R3 was noted to have a bruised and swollen left ankle on August 7, 2017, at 5:20 a.m. A written statement submitted by Nurse Aide 1, dated August 6, 2017, at 3:30 p.m., revealed that the nurse aide attempted to transfer Resident R3 from her bed to her wheelchair, which was alongside the bed. The statement indicated that Nurse Aide 1 had to lower the resident to the floor, at which point she requested assistance from Nurse Aide 2 to get the resident back into her bed. Nurse Aide 2 called Licensed Practical Nurse 3, who came into the room to assess the resident. The statement indicated that at that time, Nurse Aides 1 and 2 left the room to assist another resident to transfer. A written statement from Nurse Aide 2, dated August 7, 2017, at 4:15 p.m. revealed that she was on the hall telephone with a family member when Nurse Aide 1 came out of Resident R3's room and requested assistance immediately. She indicated that when she entered the room, the resident was sitting on the floor and Nurse Aide 1 told her that she had to lower the resident to the floor because she would not turn after Nurse Aide 1 stood her up. Nurse Aide 2's statement indicated that she and Nurse Aide 1 then put the resident back into bed and she notified Licensed Practical Nurse 3 about the incident. Licensed Practical Nurse 3 checked the Kardex and told her that the resident required two staff to assist her for transfers. A written statement from Licensed Practical Nurse 3, dated August 8, 2017, confirmed that she was notified by Nurse Aide 2 that Resident R3 was lowered to the floor by Nurse Aide 1. She indicated in her statement that when she arrived in the room, the resident had already been placed back into bed by Nurse Aides 1 and 2. There was no documented evidence that any staff members notified the registered nurse about the incident until the following morning. Review of an SBAR communication form (form used to document a situation, and the assessment of an incident), dated August 7, 2017, revealed that Resident R3's left ankle/foot was swelling and had bruising, and the resident displayed signs of pain when moved, as evidenced by grimacing and yelling. physician's orders [REDACTED]. An X-ray report for Resident R3, dated August 8, 2017, revealed that the resident had fractures to the malleolus (bony bumps at the side of the ankle), and an orthopedic consultation, dated August 10, 2017, confirmed the fractures. Interview with Physical Therapist 4 on August 11, 2017, at 2:25 p.m. confirmed that Resident R3 required the assistance of two nursing staff for transfers, and an attempt to transfer the resident with the assistance of only one staff member was not correct. Interview with Nurse Aide 2 on August 11, 2017, at 2:40 p.m. confirmed that Nurse Aide 1 was the only staff member in Resident R3's room at the time of the attempted transfer on August 6, 2017. She confirmed that Nurse Aide 1 told her that she had to lower the resident to the floor, and that she (Nurse Aide 2) assisted Nurse Aide 1 with placing the resident back into her bed before the unit nurse was notified about the incident. Interviews with the Director of Nursing on August 11, 2017, at 2:53 p.m., 3:05 p.m., and 4:05 p.m. confirmed that Nurse Aide 1 attempted to transfer Resident R3 without the assistance of any other staff. She confirmed that nursing staff have been instructed to read the Kardex to ensure that they were aware of the residents' care needs, and that a sign was posted at both nursing stations to remind staff to read the Kardex before each shift. She confirmed that the facility had no policy related to transfers, but the recommendations from therapy related to transfers were placed on the Kardex for each resident. Interview with Nurse Aide 1 on August 16, 2017, at 9:25 a.m. confirmed that she attempted to transfer Resident R3 from the bed to the wheelchair without the required assistance of another staff member. She stated that another nurse aide at the facility told her that it was all right to transfer the resident by herself, but she did not verify this information. She also confirmed that she did not use a gait belt, as directed by the Kardex, but supported the resident by holding onto her hand and the back of her pants. Following the incident, she and Nurse Aide 2 assisted the resident off the floor and placed her back in bed prior to notifying Licensed Practical Nurse 3. Nurse Aide 1 stated that she felt that the Kardex was not always up-to-date, and that the resident did not require the assistance of two for transfers. She stated that, for example, there was another resident at the facility whose Kardex stated she required the assistance of two for everything, but everyone knew that the resident only required the assistance of two to use the bathroom, and for everything else it was okay to use the assistance of one. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/5/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/5/16. 28 Pa. Code 201.29(j) Resident rights. Previously cited 10/5/16, 8/20/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/1/17, 10/5/16, 8/20/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/8/17, 6/27/17, 6/1/17, 10/5/16, 8/20/15.