Every finding on record at Parkhouse Rehabilitation and Nursing Center

Based on observations and staff interviews, it was determined that the facility failed to ensure the resident environment remained as free of accident hazards as possible by failing to ensure that the door leading to the trash chute on the memory care unit remained locked at all times.Findings include:Observations conducted on the memory care unit located on the 8th floor on June 9, 2026, at approximately 7:47 a.m. revealed a sign affixed to a door stating, TRASH CHUTE - This door must be kept locked at all times. THANK YOU. Further observation revealed the door was unlocked and located out of view of the nurses' station. A laundry cart had been placed in front of the trash chute, requiring the cart to be moved in order to gain access to the chute.Subsequent observations conducted on June 10 and June 11, 2026, revealed the door leading to the trash chute remained unlocked. The laundry cart remained positioned in front of the trash chute; however, the chute remained accessible once the cart was moved.An interview conducted with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA) on June 11, 2026, at approximately 11:38 a.m. confirmed that the door leading to the trash chute is required to remain locked at all times. 28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services28 PA, Code 201.18(b)(1)(3)(e)(1) Management

Based on interview, observation, and facility policy review, it was determined the facility failed to implement enhanced barrier precautions (an infection control strategy to prevent the spread of multi-drug-resistant organisms in long term care facilities) for two out of four hallways reviewed on Unit 2 West. Findings include: A review of facility policy titled, Isolation Steps: Categories of Transmission-Based Precautions, reviewed August 2025 revealed: All residents with any of the following should use enhanced barrier precautions.open wounds, and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy) . wear a gown and gloves for all interactions that may involve contact with a resident or the resident's environment. Donning PPE (personal protective equipment) upon room entry and properly discarding before exiting the patient room is done to contain pathogens (germs that cause disease). Observation of room [ROOM NUMBER] on June 9, 2026, at approximately 6:58 a.m. revealed a urinary drainage bag hanging from the bed frame and no sign on the door for enhanced barrier precautions. Further observation of room [ROOM NUMBER], revealed a sign for enhanced barrier precautions for residents in bed 2 and bed 4, however there was no PPE bin in the hallway for two out of the 3 rooms where enhanced barrier precautions were in place. Subsequent observations on June 10, 2026, at approximately 1:39 pm and June 11, 2026, at approximately 8:43 a.m. revealed there was no sign on the door of room [ROOM NUMBER] for enhanced barrier precautions and no bin containing PPE for that hallway. Observation of rooms 211, 214, 215, and 217 on the 2 [NAME] hallway on June 11, 2026 at approximately 9:00 a.m., revealed signs for enhanced barrier precautions, but no bin for PPE for any room on this hallway. Interview with nursing employee E5 on June 11, 2026 at approximately 9:30 a.m. revealed that E5 did not know what enhanced barrier precautions were, What is that? I've never heard of that. Interview with nursing employee E4 on June 12, 2026 at approximately 9:45 a.m. revealed that there should have been a sign on the door of room [ROOM NUMBER] and that there were not enough bins for all the rooms that were on enhanced barrier precautions, but they were on order. Interview with nursing employee E3 on June 12, 2026 at approximately 3:00 p.m. revealed that the facility struggled with having PPE binds outside each room because of clutter in the hallway, but that there should be bins for PPE that are convenient for staff to use. Review of Resident 9's care plan revealed a care plan for Enhanced Barrier Precautions (EBP) r/t (related to) (Contained RLE (right lower extremity- the right leg) wound. Observations of Resident 9's room on June 10, 2026, at 11:57 am; on June 11, 2026, at 10:56am and June 12, 2026, at 8:22am revealed no EBP sign on door and no PPE (personal protective equipment) outside door. Interview with Employee E7 on June 12, 2026, at 8:24am confirmed the above findings. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to protect the residents' rights for one of thirty-five residents reviewed (Resident 99)Findings include:Resident 99 was admitted to the facility on [DATE], with medical diagnoses that include Parkinsons's Disease (movement disorder of the nervous system), difficulty walking, need for assistance with personal care, unsteadiness on feet, and abnormality of gait (deviation from normal walking pattern.)A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated May 14, 2026, revealed that the resident utilizes a wheelchair, requires partial to moderate assistance with toileting hygiene, and substantial to maximum assistance with sit to stand and toilet transfers. Review of Resident 99's care plan revealed a focus dated November 11, 2025, noting the resident exhibits toileting deficits, putting them at risk for reduced independence with activities of daily living (adls). Further review of Resident 99's care plan revealed a focus dated November 24, 2025, noting the resident has an ADL self-care performance deficit related to depression, Parkinson's Disease, and asthma. Interventions included Resident 99 requires the assistance of one staff for personal hygiene, transfers and toilet use.Observations made on June 9, 2026, at 6:30 a.m. revealed Nurse Aide Employee E9, and Unit Manager Licensed Practical Nurse Employee E10 sitting behind the nurses station with Resident 93. Observations made on June 9, 2026, at 6:50 a.m., revealed Resident 99 sitting in his/her room, in their wheelchair, a clear liquid was observed pooling on the floor. Closer observation revealed the resident's clothes and wheelchair were wet. Resident 99 stated he/she needed assistance with continence care, and no staff came to assist him/her during the entire night shift. Observation was made of Resident 99 activating his/her call bell at 6:52a.m.At 6:54 a.m., Employee E9 was observed leaving the nurses' station and walking towards Resident 99's room. Employee E9 immediately returned to the nurses' station. At 6:55 a.m. Resident 99's call bell was observed to be turned off. During interview Resident 99 stated Employee E9 came in the room, turned the call bell off, and told Resident 99 he/she had to wait for assistance with continence care.During interview at 6:58 a.m. Employee E9 confirmed he/she went into Resident 99's room, observed the resident required continence care, turned the call bell off, and told the resident he/she had to wait for assistance. Employee E9 stated he/she could not leave Resident 93 because he/she was a fall risk. Employee E10 was observed sitting behind the nurses' station with Employee E9 since this Surveyor's 6:30 a.m. arrival on the unit. During interview conducted at 10:15 a.m. Resident 99 confirmed that Employee E9 never returned to assistant the resident. Resident 99 stated he/she did not receive continence care until the dayshift started. During interview with Resident 99 on June 10, 2026, at 12:10 p.m. the resident stated he/she did not receive continence care during the entire night shift again.Review of resident 99's 30-day toileting task form revealed no documentation of the resident receiving overnight toileting care for June 9, 2026, and June 10, 2026. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., when the above information was presented, the NHA and DON stated they would investigate the matter.Employee E9 turning off Resident 99's call bell, telling him/her they had to wait for care, and not providing continence care when required violated Resident 99's right to dignified treatment.28 Pa. Code 201.29(j) Resident Rights.

Based on record review and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for one out of one residents reviewed (Resident #335).Findings include:Review of Resident 335's medical record revealed a Notice of Medicare Non-Coverage (NOMNC) indicating Medicare-covered skilled services were ending on May 14, 2026. The notice was signed and dated by the resident on May 13, 2026, at 9:00 a.m., which was 1 day prior to the end of Medicare-covered services.An Interview conducted on June 12, 2025, at 12:05 p.m., with the Nursing Home Administrator (NHA) confirmed the NOMNC was not provided within the required 2-day (48-hour) timeframe.The facility failed to provide the NOMNC within the required 2-day advance timeframe from which it should have been provided.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a) Resident Rights

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor the resident's behaviors, and medication side effects, for residents receiving a psychotropic medication for three of the five residents reviewed (Resident 15, 17, and 327). Findings: A review of the facility's policy titled Antipsychotic/Anxiolytic Utilization, last review in April 2025, revealed that documentation is necessary to assist in assessing whether the resident's behavioral symptom needs some form of intervention, determining whether the behavioral symptom is transitory or permanent. A review of Resident 15's physician order dated June 2, 2026, revealed an order Quetiapine Fumarate (Atypical anti-psychotic) Oral Tablet 25 mg 1 tablet by mouth at bedtime for anxiety A review of Resident 15's Medication Administration Records and progress notes medication revealed side effects were not monitored since the Quetiapine Fumarate medication started on March 12, 2026. A review of Resident 17's physician order dated August 28, 2025, revealed an order Risperdal (atypical antipsychotic) Oral Tablet 1 MG Give 1 tablet by mouth at bedtime related to psychotic disorder with delusions due to known physiological condition A review of Resident 17's Medication Administration Records and progress notes medication revealed side effects were not monitored since the Quetiapine Fumarate medication started on August 28, 2025. An interview with the Director of Nursing on June 12, 2025, at 10:10am confirmed the above findings. A review of Resident 327's physician order dated March 12, 2026, revealed an order Seroquel (Anti-psychotic medication) oral tablet 25 mg Give 25mgby mouth two times a day for psychotic disorder with delusion (A mental health condition where a person experiences persistent, fixed false beliefs that are unshakeable even when presented with factual evidence), please monitor for sedation and increase in falls. A review of Resident 327's Medication Administration Records and progress notes revealed the resident's behaviors and medication side effects were not monitored since the Seroquel medication started on March 12, 2026. An interview with the Director of Nursing on June 12, 2026, at 10:00 a.m., confirmed that Resident 327's behavior and medication side effects were not monitored. The facility failed to ensure Residents 15, 17, and 327's behaviors and medication side effects were monitored. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(1)(3)(5) Nursing services 28 Pa Code 211.5 (f) Clinical records

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of the 35 residents reviewed (Residents 2,3, and 283). Findings Include: Review of Resident 2 progress note on 4/15/2026 at 12:47 nursing note stated Resident 2 sustained a witnessed fall after breakfast at 9:2am. [NAME] did strike her head, and she landed on her L hip after the fall. Further review of Resident 2 progress note on 4/18/2026 at 11:38 nurses note stated: Resident Xray results received after rereading DX:Acute left sub capital femur fracture with impaction (broken left side of your thighbone). Md notified and recommended for resident to be sent to hospital. Resident sent to Phoenixville Hospital. Daughter contacted but no answer. Brother contacted and aware of situation. A review of Resident 2's Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) MDS is dated 5/18/2026 revealed that under section J1900-Number of Falls Since Admission/Entry or Reentry or Prior Assessment did not indicate that residents had a fall with major injury. Interview with Employee E6 on June 11, 2026, at 12:07pm confirmed the above findings. A review of Resident 3's nursing progress notes dated December 6, 2025, at 7:43 a.m., revealed the resident was observed on the floor next to the bed. The resident denied pain. The family and the physician were notified. A review of Resident 3's nursing progress notes dated December 8, 2026, at 1:46 p.m., revealed new order for Xray three views left foot regarding s/p (status post) fall. A review of the Xray report dated December 8, 2026, revealed Acute fracture at base of 1st metatarsal (A break on the shortest, thickest, and strongest bone in the human foot) noted. A review of Resident 3's Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 26, 2025, did not indicate that resident had a fall with major injury. A review of Resident 283's nursing progress notes dated May 3, 2026, at 12:35 p.m., revealed an x ray was done post unwitnessed fall on May 1, 2026. The Xray result was nondisplaced fracture of the nasal bone (A break in the nasal bone but stays aligned without moving). The physician and the guardian were notified. A review of Resident 283's Quarterly MDS dated [DATE], did not indicate that residents had a fall with major injury. An interview with licensed nurse Employee E6 was conducted on June 11, 2026, at 12:23 p.m. Employee E6 confirmed that Resident 3 and 283's falls with major injury were not accurately reflected on their MDS' The facility failed to ensure Resident 3 and 283's falls with major injury were not accurately reflected on their MDS assessments. 28 Pa Code 211.5 (f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, resident and staff interviews and review of resident clinical records it was determined that the facility failed to provide assistance with activities of daily living for 1 of thirty-five residents reviewed (Resident 99).Findings include:Facility policy titled Activities of Daily Living (ADLs), last reviewed December 2024, notes it is the policy of the facility to understand the principals of quality of life, and honor and support these principals for each resident, and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will provide care and services for hygiene-bathing, and toileting care.Resident 99 was admitted to the facility on [DATE], with medical diagnoses that include Parkinsons's Disease (movement disorder of the nervous system), difficulty walking, need for assistance with personal care, unsteadiness on feet, and abnormality of gait (deviation from normal walking pattern.)A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated May 14, 2026, revealed that the resident utilizes a wheelchair, requires partial to moderate assistance with toileting hygiene, and substantial to maximum assistance with sit to stand and toilet transfers. Review of Resident 99's care plan revealed a focus dated November 11, 2025, noting the resident exhibits toileting deficits, putting them at risk for reduced independence with activities of daily living (adls). Further review of Resident 99's care plan revealed a focus dated November 24, 2025, noting the resident has an ADL self-care performance deficit related to depression, Parkinson's Disease, and asthma. Interventions included Resident 99 requires the assistance of 1 staff for personal hygiene, transfers and toilet use.Observations made on June 9, 2026, at 6:30 a.m. revealed Nurse Aide Employee E9, and Unit Manager Licensed Practical Nurse Employee E10 sitting behind the nurses station with Resident 93. Observations made on June 9, 2026, at 6:50 a.m., revealed Resident 99 sitting in his/her room, in their wheelchair, a clear liquid was observed pooling on the floor. Closer observation revealed the resident's clothes and wheelchair were wet. Resident 99 stated he/she needed assistance with continence care and no staff came to assist him/her during the entire night shift. Observation was made of Resident 99 activating his/her call bell at 6:52a.m.At 6:54 a.m., Employee E9 was observed leaving the nurses' station and walking towards Resident 99's room. Employee E9 immediately returned to the nurses' station. At 6:55 a.m. Resident 99's call bell was observed to be turned off. During interview Resident 99 stated Employee E9 came in the room, turned the call bell off, and told Resident 99 he/she had to wait for assistance with continence care.During interview at 6:58 a.m. Employee E9 confirmed he/she went into Resident 99's room, observed the resident required continence care, turned the call bell off, and told the resident he/she had to wait for assistance. Employee E9 stated he/she could not leave Resident 93 because he/she was a fall risk. Unit Manager Licensed Practical Nurse Employee E10 was observed sitting behind the nurses' station with Employee E9 since this Surveyor's 6:30 a.m. arrival on the unit. During interview conducted at 10:15 a.m. Resident 99 confirmed that Employee E9 never returned to assistant the resident. Resident 99 stated he/she did not receive continence care until the dayshift started. During interview with Resident 99 on June 10, 2026, at 12:10 p.m. the resident stated he/she did not receive continence care during the entire night shift again.Review of resident 99's 30-day toileting task form revealed no documentation of the resident receiving overnight toileting care for June 9, 2026, and June 10, 2026. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., when the above information was presented, the NHA and DON stated they would investigate the matter.Quality of Care 483.24(b)(1)28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to implement physicians' orders for three of 24 sampled residents (Residents R1, R16, R56 and R262). Findings include: Review of Resident R1's clinical record revealed an admission date of April 27, 2026. Clinical record review revealed that Resident R1's had diagnoses that included chronic obstructive pulmonary disease, unspecified (COPD, a condition caused by damage to the lungs resulting in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs), dependence on supplemental oxygen, psychosis (collection of symptoms that disrupt a person's thoughts and perceptions, making it difficult to distinguish what is real from what is not), and major depressive disorder, recurrent, moderate (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R1's clinical record revealed a physician order stating, Ear mates to oxygen tubing at all times to help relieve pressure, with a start date of June 1, 2026. Observations conducted on June 10, 2026, at approximately 1:17 p.m. revealed Resident R1 resting in bed while receiving supplemental oxygen via nasal cannula (a device used to deliver oxygen through two small prongs inserted into the nostrils). Further observation revealed the oxygen tubing was not fitted with ear mates (foam protectors) as ordered. An interview conducted with Resident R1 on June 10, 2026, at approximately 1:20 p.m. revealed he/she could not recall the last time ear mates had been attached to the oxygen tubing. An interview conducted with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA) on June 11, 2026, at approximately 11:38 a.m. confirmed the above findings. A review of Resident 16's diagnosis list includes End Stage Renal Disease (ESRD – the final, permanent stage of chronic kidney disease where kidneys have lost most of their function, making them unable to sustain life), Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally), and hypertension (high blood pressure). An interview was conducted with Resident 16 on June 10, 2026, at 9:30 a.m., while on dialysis. The residents reported that their dialysis days are Mondays, Wednesdays, and Friday's morning. A review of Resident 16's physician order dated March 30, 2026, revealed an order for Hydralazine (A medication to lower blood pressure), HCL 25 mg tablet. Give one tablet by mouth every 12 hours for hypertension, hold for SBP (Systolic Blood Pressure) below 120mm Hg. The medication was scheduled at 9:00 a.m. and 9:00 p.m. A review of Resident16's April 2026, Medication Administration Record (MAR) revealed Hydralazine was not administered on the following days: April 1, 3, 6, 8, 10, 13, 15, 17, 202, 22, 24, and 27. The record indicated that medication was not administered because the resident was on dialysis. Further review revealed that from April 1, 2026, until April 30, 2026, the medication Hydralazine was administered to the resident five times with systolic blood pressure below 120 mm Hg (out of ordered parameters). Resident 56 was admitted into the facility on February 9, 2026, with medical diagnoses that include encounter for attention to colostomy (a surgical procedure that creates an opening in the abdomen to allow stool to exit the body) Review of Resident 56's physician orders revealed an order dated February 9, 2026, for colostomy care every shift, empty and document changes. Further review of Resident 56's physician orders revealed an order dated April 21, 2026, for Enhanced Barrier Precautions for Colostomy every shift for infection control. Review of Resident 56's care plan revealed a focus noting the resident is on Enhanced Barrier Precautions (EBP) related to colostomy. Review of Resident 56's May and June 2026 Medication Administration Reports revealed documentation of EBP being followed related to colostomy care but no documentation of colostomy care being provided. Resident 56's 14-day bowel continence task form notes the resident did not have a bowel movement for 14 of the 14 days. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., when the above information was presented, the NHA and DON confirmed that the resident utilizes a colostomy, The DON stated Resident 56 had a follow up visit with a Gastrointestinal physician who recommended they wait until the resident's colonoscopy, scheduled for July 7, 2026, to determine whether the colostomy can be reversed or not. The DON and NHA confirmed there were no documentation of colostomy care being provided. A review of Resident 262's diagnosis list includes ESRD, Hemodialysis, and Hypertension. A review of Resident 262's physician order dated April 18, 2026, revealed Dialysis Care: Receives Dialysis at bedside on Monday, Wednesday, and Friday. An observation on June 10, 2026, at 9:30 a.m., revealed the resident was receiving Dialysis on the facility's dialysis rooms. A review of Resident 262's physician order dated April 24, 2026, revealed an order for Sevelamar Carbonate 0.8 packet GM. Give one packet by mouth three times daily for ESRD. The medication administration was scheduled at 9:00 a.m., 2:00 p.m., and 9:00 p.m. A review of Resident 262's physician order dated April 19, 2026, revealed an order for Lisinopril (A medication to lower blood pressure). Give 1 tablet by mouth one time a day for hypertension. The medication administration was scheduled for 9:00 a.m. An additional order was Hydralazine (A medication to lower blood pressure) HCL 50 mg, one tablet by mouth every eight hours. The medication administration was scheduled for 12:00 a.m., 8:00 a.m., and 4:00 p.m. A review of Resident 262's June 2026 MAR revealed Sevelamer, and Lisinopril were not administered at 9:00 a.m. on June 3, 5, 8, and 10, 2026. Hydralazine was not administered at 8:00 on June 3, 5, 8, and 10, 2026. The records indicated medications were not administered because the resident was on dialysis. An interview with the Director of Nursing (DON) on June 12, 2026, at 10:00 a.m., confirmed Resident 16, and medications were not administered due to residents being on dialysis. A review of Resident 262's physician order dated April 19, 2026, revealed an order Clonidine (A medication used to treat high blood pressure) HCL Give 1 tablet by mouth every 6 hours for hypertension for systolic BP (blood pressure) greater than 180, or hold if HR (heart rate) less than 50. A review of Resident 262 May 2026, MAR revealed that from May 1, 2026, until May 28, 2026, Clonidine medication was administered to the resident 86 times with a blood pressure below 180 (outside the ordered parameter). The above was confirmed with the DON on June 12, 2026, at 2:00 p.m. The facility failed to ensure Resident 16 and 262's medication orders were followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records

Based on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a wound treatment order correctly and in a timely manner for one of ten residents reviewed (Resident 259).Findings: A review of Resident 259's active care plan revealed the resident was at risk for skin integrity impairment related to immobility and incontinence. The interventions, including an air mattress, repositioning, and treatment as ordered, were put in place. Additional interventions include applying Calamine-Zinc Oxide External Lotion, applied to the buttocks topically every day and evening shift for protectant (Dermaseptin ointment- A soothing skin protectant used to treat and prevent minor skin irritations by creating a protective, moisture-repelling barrier). A review of the nursing progress notes dated April 1, 2026, at 2:32 p.m., revealed the resident was observed with a new skin area of concern to the sacrum a large, (triangular bone located at the base of the spine, just below the lumbar vertebrae and between the hip bones), a DTI (Deep Tissue Injury - Persistent non-blanchable deep red, maroon or purple discoloration) to the sacrum (The triangular bone just below the lumbar vertebrae), dry, with a measurement of 2.8 x 2.0 x 0 cm. The area was deep purple. Wedge pillows are used for positioning and out of bed restrictions to four hours three times a week. A review of the wound consult dated April 7, 2026, revealed that the sacral wound progressed to a Stage II (Partial-thickness skin loss with exposed dermis). A Triade Hydrophilic wound dressing (A zinc oxide-based, containing petrolatum, carboxymethylcellulose, and dimethicone paste that manages light-to moderate wound drainage) to the sacrum was recommended. A review of Resident 259's physician's order revealed that the wound specialist recommendations on April 7, 2026, for the Triade treatment were not put in as an order and therefore was not followed. A review of the wound consult dated April 14, 2026, revealed the resident's sacral wound remained a stage II, continue Triade Hydrophilic treatment. A review of Resident 259's physician's order revealed that the wound specialist recommendations on April 14, 2026, to continue the Triade treatment to the resident's' sacral wound was not followed. A review of the wound consult dated April 21, 2026, revealed sacral wound stage III (full-thickness skin loss) measuring 1.0 x 0.5 x 0.1 cm. dry with 70% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. A wound treatment of honey hydrogel was recommended. A review of Resident 259's April 2026 Treatment Administration Record (TAR) revealed that recommended wound treatment for honey hydrogel was not started until April 23, 2026, two days after the sacral wound was identified as stage III. An interview was conducted with the Assistant Director of Nursing (ADON) on June 11, 2026, at 1:00 p.m. The ADON confirmed that the Triade Hydrophilic paste recommendation was not followed, and the honey hydrogel wound treatment was not followed in a timely manner. The facility failed to ensure that Resident 259's wound treatment, as recommended by the wound specialist, was followed correctly and in a timely manner. 28 Pa Code 211.5 (f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring of fluid restrictions for two of three residents reviewed for nutrition/hydration needs (Resident 108, and Resident 259). Findings: Review of facility policy, titled Restricting Fluids last revised November 11, 2025, documents the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. A review of the facility's policy titled Weight Assessment and Intervention, last revised on March 11, 2025, revealed that weights will be measured monthly unless discontinued by the physician. Significant weight changes are defined as more or less than 5% within 30 days; more or less than 7.5% over 3 months, and more or less than 10% within 6 months. I the weight change meets the definition of Significant, the Dietitian should discuss with the IDCP team and make recommendations. The resident's physician will be made aware of the weight loss. Review of Resident 108's medical diagnoses revealed diagnoses that included mild protein-calorie malnutrition (insufficient intake of protein and calories), atherosclerotic heart disease of native coronary artery (plaque buildup in coronary arteries), end stage renal disease (chronic kidney disease where kidneys no longer function adequately to sustain life without treatment), hypertensive heart and chronic kidney disease with heart failure (when high blood pressure cause damage to both the heart and kidneys) stage 5 chronic kidney disease or end stage renal disease, (kidney failure requiring dialysis), and fluid overload (too much water, blood or lymphatic fluid in the body). Review of Resident 108's physician orders revealed an order dated May 28, 2026, for 1500 milliliters (ml) fluid restriction: nursing staff to provide a total of 540 ml per day, 180 ml during day shift, 180 ml during evening shift, and 180 ml during night shift. Dietary staff provide a total of 960 ml per day, 360 ml with breakfast, 240 ml with lunch, and 360 ml with dinner. Review of Resident 108's May and June 2026, Medication Administration Reports (MAR) and 30-day task documentation for amount of fluid intake obtained from nursing staff for the past 30 days, in addition to the amount of fluids provided with meals, revealed that the combined fluid intake either exceeded the ordered amount or failed to document the resident's fluid intake amounts. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., the DON confirmed that staff was not accurately documenting the resident's fluid intake. A review of Resident 259's weights and vitals revealed a weight of 123.2 pounds on December 2, 2025, and a weight of 110.6 pounds on April 23, 2026, a 10.23% significant weight loss in four months. Further review revealed the resident's weight was not taken in March 2026. The significant weight loss identified on April 23, 2026, was not addressed, and physicians were not notified until May 15, 2026. An interview was conducted with the Registered Dietitian Employee E13 on June 12, 2026, at 1:55 p.m. The RD reported that their company just started seeing residents in the facility on May 4, 2026, and therefore cannot provide an explanation why the resident's weight was not monitored in March 2026, and why significant weight loss identified on April 23, 2026, was not addressed until May 15, 2026. An interview with the Nursing Home Administrator conducted on June 12, 2026, at 1:56 p.m., confirmed that Resident 259's March 2026 weight was not monitored, and significant weight loss identified on April 23, 2026, was not timely addressed. The facility failed to ensure Resident 259's weight was consistently monitored and that significant weight loss was addressed and communicated with the physician in a timely manner. 201.18(b)(1) Management 211.10(c) Resident care policies 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of one resident reviewed enteral feeding care. (Resident 14)Findings include: Review of facility policy and guidelines titled Enteral Feeding last revised April 15, 2024, documents the licensed nurse is responsible to assure patency of the feeding tube, administration of nutritional products and medications per physician orders, assessment of the tube and skin site and documentation of the enteral feeding process. Per the policy, documentation of the enteral feeding orders, volume, amounts, and care will be completed on the Medication Administration Record. Review of Resident 14's medical diagnoses revealed the resident admitted from the hospital on November 17, 2025, with medical diagnoses that include Traumatic Subarachnoid Hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering it, caused by physical head injury), Diffuse Traumatic Brain Injury (a disruption in normal brain function caused by a bump, blow, jolt to the head, or penetrating head injury), Mild Protein Malnutrition, and Dysphagia (difficulty swallowing), Review of Resident 14's weights revealed Resident 14 lost 23 pounds between November 19, 2025, and June 12, 2026. Review of Resident 14's physician orders revealed an order dated March 5, 2026, for every evening shift give Glucerna 1.5 at 80 milliliters (ml) per hour for 12 hours via PEG tube up at 7pm and down at 7am or once total volume (TV) of 960 ml is infused and every day-shift document TV infused daily once feeding completed. Review of resident 14's Medication Administration Record (MAR) for the month of June 2026, revealed documentation of total infusions ranging between 0 ml and 960 ml. Review of resident 14's physician orders revealed an order dated March 5, 2026, for Enteral Feed every day-shift document TV infused daily once feeding is completed. Review of Resident 14's May and June 2026, MAR revealed 15 days when staff documented a total volume of NA. Total volume was noted as 0 ml for 5 days, 300 ml for one day, 100 ml for one day, and 712 ml for one day. Observations made on June 12, 2026, at 11:50 a.m. revealed Resident 14's was still connected to his/her feeding pump. The pump was flashing inactive for 10 minutes. The Glucerna bag was dated June 11, 2026. 200 ml of the 1000 ml bag remained on the pump. Interview with Unit Manager Registered Nurse Employee E8 on June 12, 2026, at 11:57, when observations were made of Resident 14's feed pump and MARS, Employee E8 confirmed Resident 14's feed pump orders weren't being followed and/or documented as prescribed. Interview with the Nursing Home Administrator and Director of Nursing on June 12, 2026, at 2:00 p.m. when the above was presented, the DON confirmed the resident's enteral feed orders were not being followed and/or documented properly. 28 Pa Code: 211.5(f) Clinical records 28 Pa code: 211.12(d)(1)(3)(5) Nursing services

Based on review of the facility's policy and medication manufacturer's guidelines, observations, and interview with staff and resident, it was determined that the facility failed to secure a treatment cart for one out of two units reviewed (Two West) and failed to secure and control vials of homeopathic remedies for one out of seven residents reviewed (Resident 12), and failed to ensure medications were properly stored and labeled on two of six medication carts observed (second-floor medication cart B and third-floor medication cart A Findings: A review of the facility's policy titled Medication Storage, last reviewed on [DATE], revealed, Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of Health guidelines. The same policy revealed, Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of manufacturers' storage guidelines for Lantus Insulin (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Humalog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturers' guidelines for Novolin N 10 ml vial (An intermediate-acting insulin), revealed that the medication must be discarded 31 days after opening (refrigerated/room temperature). An observation of the second-floor medication cart B was conducted in the presence of licensed nurse Employee E11 on [DATE], at 7:00 a.m. The following were observed: One vial of Lantus insulin, opened and undated; two Lispro pen insulin, opened and undated, and one Lantus pen insulin, opened and undated. An interview with Employee E11 on [DATE], at 7:06 a.m. was conducted. Employee E11 does not know when the above-mentioned insulin was opened. Employee E11 confirmed that the insulins should have been dated when opened. An observation of the third-floor medication cart A was conducted in the presence of licensed nurse Employee E12 on [DATE], at 7:10 a.m. The following were observed: One Novolog insulin vial, opened and undated, One Lantus vial opened on [DATE], one Humalog vial opened on [DATE], one Novolog pen opened on [DATE], one Novolin vial opened on [DATE], one Lantus vial opened on [DATE], one Lispro vial opened on [DATE], and one Lantus pen opened and undated. The above observations were conveyed to the Director of Nursing on [DATE], at 11:00 a.m. The facility failed to ensure medications on the second-floor Medication Cart B, and third-floor medication Cart A were properly stored and labeled. Observation of unit Two [NAME] on [DATE] at approximately 6:30 a.m. revealed a treatment cart standing in the 2 [NAME] hallway that was unlocked. Observation of unit Two [NAME] on [DATE] at approximately 9:30 a.m. revealed the same treatment cart in standing in the 2 [NAME] hallway that was unlocked. This observation was confirmed with Nursing Employee E4 on [DATE] at approximately 9:45 a.m. Review of facility policy entitled Self-Administration of Drugs, reviewed [DATE] revealed: If the resident is able and willing to take responsibility for documenting their self administration of medications, the resident is asked to complete a bedside record indicating the administration of the medication (if beside storage is to be used and Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Review of Resident 12's quarterly Minimum Data Set (MDS – a mandatory assessment of a residents condition and care needs) dated [DATE] revealed Resident 12 was cognitively in-tact and independent to complete activities of daily living and mobility tasks. Resident 12 had diagnoses that included: anxiety disorder, major depressive disorder, psychotic disorder with delusions, and chronic obstructive pulmonary disease. Resident 12 received antianxiety medications (for the treatment of the mental disorder anxiety), anticoagulant medications (for the treatment of irregular heartbeat), and opioid medications (controlled substance for the treatment of moderate to severe pain). Review of Resident 12's care plan revealed Resident 12 wishes to self-medicate with homeopathic treatments (essential oils) and wishes to keep her own homeopathic treatments at the bedside. Resident 12 will safely administer homeopathic remedies and keep them locked in bedside table safely. Observation of Resident 12's room on [DATE], at approximately 9:30 a.m. revealed multiple brown dropper bottles stored on a shelf under Resident 12's television. Subsequent interview with Resident 12 revealed the bottles contain my oils. Resident 12 shares a room with a roommate. Review of Resident 12's orders revealed: May self-administer medications dated [DATE]. Review of Resident 12's medication administration record for [DATE] revealed no homeopathic remedies documented in the medication administration record. Review of provider notes dated [DATE] revealed a complaint from Resident 12 related to dry skin dermatitis; resident is using her body soap and herbal essential oil. Review of invoices from the company that provides Resident 12's homeopathic remedies revealed: 20 units of homeopathic remedies order February 9, 2026 and two additional homeopathic remedies ordered [DATE]; 14 homeopathic remedies ordered [DATE]; and nine units of homeopathic remedies ordered [DATE]. Interview with nursing employee E4 on [DATE], at approximately 9:45 revealed that nursing does not track of what homeopathic remedies Resident 12 has, what they are for, or when they are taken. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(d) Pharmacy Services 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on observations, clinical record review and staff interviews, it was determined the facility failed to ensure that rehabilitation services were provided one of three residents reviewed. (Resident R12) Findings include Review of Resident R12's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident 12's diagnosis's list includes unspecified dementia (general loss of cognitive abilities, including memory, unspecified severity, with mood disturbance) and pain in left shoulder. Observations made on April 16, 2026, at 11:45 am revealed Resident 12 had significant left-hand contracture (a shortening and stiffening of muscles that limits joint movement) Review of Resident 12's occupational therapy (OT) notes revealed Resident 12 evaluation and plan of treatment for left hand contracture was conducted on August 22, 2025. Review of Resident 12's OT short term goal(stg) revealed Patient will achieve normal anatomical alignment of the left fingers for 3 hours in order to facilitate joint mobility and in order to prevent contractures. Target date of 9/4/2025 Further review of Resident 12's OT long term goal (ltg) revealed Patient will achieve normal anatomical alignment of the left fingers for 6 hours in order to facilitate joint mobility and in order to prevent contractures. Target date of 10/20/2025 Review of Resident 12's OT Treatment Encounter Notes revealed on August 28, 2025 Pt tolerated wearing left hand roll for 3.5 hours on this date to prevent contracture and maintain skin integrity. Skin checked pre and post application with no signs of redness or irritation present Review of Resident 12's OT Treatment Encounter Notes revealed on September 3, 2025 .Patient tolerating 4 hours with skin check performed with no skin breakdown or redness observed. Pain description/Type: hurts Review of Resident 12's OT Treatment Encounter Notes revealed on September 4, 2025, and September 5, 2025, Resident 12 did not receive treatment for left hand. Review of Resident 12's OT Treatment Encounter Notes revealed on September 8, 2025 Response to session Interventions: Patient is showing decline in cognition and sequencing to participate in ADL. She was unable to use utensil appropriately. Patient is refusing L hand splint/L hand hygiene Review of Resident 12's OT Discharge summary revealed that on September 12, 2025, STG and LTG were discharged for Resident 12's left hand. Review of Resident 12's clinical record reveals no evidence of further attempts made on left hand treatment before Resident 12's discharge on [DATE]. Interview with Rehabilitation Director confirmed that Resident 12 did have therapy on September 4, 2025, and September 5, 2025, but the therapy did not address the treatment for Resident 12's left hand. Interview with Nursing Home Administrator on April 16, 2026, at 1:15pm confirmed the above findings. 28 Pa. code 211.12(a)(c)(d)(3) Nursing services 28 Pa. Code 201.18 (b)(1) Management

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of nine residents observed. (Resident 13). Findings include: Review of Resident 13's clinical record revealed resident was admitted to the facility on [DATE].Further review of Resident 13's admission assessment dated [DATE], revealed resident had a BIMS 15 (brief interview for mental status) indicating resident was cognitively intact.Review Resident 13 diagnosis list revealed schizoaffective disorder, bipolar type (characterized by symptoms of both schizophrenia (mental illness that affects how people think and behave) and bipolar disorder (mental condition that causes extreme mood swings)). Observation of seventh floor during complaint survey on April 16, 2026, at approximately 11:09 a.m. revealed Resident 13 was sitting on bedside with no call bell to alert staff for assistance if necessary. Upon checking the room for the call bell cord, it was observed that there was no call bell plugged into the wall for Resident 13 and no call bell observed in the room. Interview with Employee 5 on April 16, 2026, at 11:11am, confirmed that there was no call bell for Resident 13.Review of facility records for nonclinical rounds revealed that on April 13, 2026, there was a call bell in Resident 13's room.Interview with Nursing Home Administrator on April 16, 2026, at 1:15pm confirmed the above findings. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on observation and staff interview, it was determined that the facility failed to ensure a safe, clean, comfortable, and homelike environment for one of two units (North building Floor 8)Findings include:Observations on March 16, 2026, between 10:00 - 10:30 a.m. of the North building 8th floor (N8) revealed that the floor in front of the nursing station and the hallway was sticky. A visible spill was observed in the lounge area and in the doorway of room [ROOM NUMBER].Multiple scraps of paper were observed on the floor in the lounge area and in the hallways. A sugar packet was observed on the floor in room [ROOM NUMBER] and a plastic lid and straw were on the floor in room [ROOM NUMBER]. A plastic glove was observed on the floor in the hallway.A dried, brown substance was observed on the floor in the room and bathroom of room [ROOM NUMBER]. Additionally, a dried, brown substance was observed on the toilet.A dried food substance was observed on the floor in rooms [ROOM NUMBERS].A thermostat was observed in room [ROOM NUMBER] without a cover, with exposed wires visible.This information was presented to the Nursing Home Administrator and Director of Nursing on March 16, 2026, at 12:30 p.m.483.10 Resident rightsPreviously cited 1/30/26, 7/28/2528 Pa. Code 201.18(e)(1)

Based on policy review, resident and staff interviews and review of resident records it was determined that the facility failed to provide assistance with activities of daily living for 1 of seventeen residents reviewed (Resident 1).Findings include:Facility policy titled Activities of Daily Living (ADLs), last reviewed December 2024, notes it is the policy of the facility to understand the principals of quality of life, and honor and support these principals for each resident, and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will provide care and services for hygiene-bathing, dressing, grooming and oral care.Review of Resident 1's February 20, 2026, Activities of Daily Living (ADLs), admission Minimum Data Set (MDS), revealed the resident utilizes a wheelchair and requires supervision or touching assistance with showering/bathing, and requires supervision and touching assistance with tub/shower transfers.Interview with Resident 1 on March 3, 2026, at 2:30 p.m., when the resident stated he/she had not received his/her scheduled shower on Monday March 2, 2026, or Tuesday March 3, 2026, because staff told him/her there were not enough staff scheduled on the unit to provide the care. During the interview Resident 1 stated that he/she would like to have a shower and requested the staff be made aware. Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 12:55 p.m., when the above information was presented the NHA and DON stated residents often refuse showers, prefer bed baths instead, and some are care planned for bed baths only. They did not confirm Resident 1 preferred or was care planned for bed baths only.Quality of Care 483.24(b)(1)28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on policy review, interviews and record reviews it was determined that the facility failed to properly administer medications for 1 out of five residents reviewed (Resident 5). Findings include: Review of facility policy and guidelines titled Administering Medications, last revised on April 17, 2024, documents medications shall be administered in a safe and timely manner and as prescribed.Per the policy, if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or medical director to discuss concerns.Additionally, the individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method of administration before giving the medication.Review of Resident 5's care plan revealed medical diagnosis' that included Metabolic Encephalopathy (a change in how the brain works due to an underlying condition causing memory loss or confusion), Hypertension (high blood pressure), Hyperlipidemia (high level of fats in blood), Paroxysmal Atrial Fibrillation (sudden irregular heart rhythm), and Neurocognitive Disorder with Lewy Bodies (progressive brain disorder characterized by cognitive decline, movement difficulty and visual hallucinations).Review of Resident 5's census form revealed an admission date of December 31, 2025.Review of Resdient 5's progress notes revealed a nursing note on January 1, 2026 at 2:38 a.m. stating this nurse notified the RN Supervisor of resident receiving insulin. New orders received to monitor blood sugars.Review of Resident 5's medication error report revealed Resident 5 was given Humalog (fast acting insulin) instead of tuberculin solution (used to test for tuberculosis).Review of Resdient 5's physician orders revealed there was no order for Humalog insulin.Interview with the Director of Nursing on March 4, 2026, at 12:55 p.m., confirmed Resident 5 received Humalog insulin instead of tuberculin solution in error on January 1, 2026. 28 PA Code 109.65 (b) Recording of drug administration28 PA Code 211.12. (d)(1) Nursing services.28 Pa. Code 211.5(f) Clinical Records

Based on observations it was revealed that the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public 2 of 8 units observed. (north building floor 7 and 8) Findings include:Observations made on March 3, 2026, at 2:15 p.m., of the North Building 8th floor (N8) bathroom revealed used briefs on the trash can, paper towels, used gloves, and empty bottles of body wash and shampoo in the sinks.Observations of the N8 trash chute closet revealed trash overflowing in the bin with papers, used gloves, paper towels, and food on the floor.Observations of the North Building stairwell revealed used gloves on the landing between floors North Building 7th floor (N7) and N8.Observations made on March 4, 2025, at 10:05 a.m., of trash chute rooms on all floors of the North Building revealed food, used gloves and papers and paper towels on the floor on N8.Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 12:55 p.m., when the above information was presented the NHA and DON stated they would investigate the matter.

Based on observation, it was determined that the facility failed to ensure a safe, clean, homelike, comfortable environment for one of twenty-seven rooms observed (room [ROOM NUMBER]).Findings include: Observations made on September 7, 2025, at 12:15 p.m., of 27 rooms on the 8th floor, revealed that one wall in room [ROOM NUMBER] had paint that was bubbled and peeling. Further observations revealed drywall that was cracked with pieces of drywall sitting on the windowsill. Observations were made of fraying fall mats on the 6th floor in rooms 601, 615, 616, 625, and 627. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON), on January 30, 2026, at 2:20 p.m. when the above was presented, the NHA stated she would investigate the matter. Resident Rights 483.10(i)(1)-(7)

Based on observation, it was determined that the facility failed to ensure food was stored in a clean, sanitary environment in the pantry of one of three floors observed (floor 8).Findings include: Observations of the 8th floor pantry revealed rust and brown stains on the outside and inside of the cabinets, brown stains on the countertop, and red and brown stains inside of the refrigerator and freezer. Observations revealed a coffee carafe with dried coffee at the bottom, a water-stained ice bucket and ice scoop was observed on the counter. Further review revealed rust on the coffee and ice machines, and calcium build-up on the ice machine, sink fixtures and inside the sink. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON), on January 30, 2026, at 2:20 p.m., when the above was presented, the NHA stated it was the responsibility of both dietary and housekeeping staff to clean the pantry. The NHA stated she would investigate the matter. Food and Nutrition Services 483.60(i)(1)(2)

Based on a review of the facility's policy, clinical records, and staff interviews, it was determined the facility failed to timely and comprehensively assess a pressure ulcer wound resulting in actual harm to one resident (Resident 2) and failed to follow physician's wound treatment orders for three of the 11 residents reviewed (Residents 2, 62, and 225). Findings include: Review of the facility's policy titled Skin Integrity, dated April 1, 2022, revealed documentation and care interventions for skin integrity including assessment/observation to be completed within the first twenty-four hours of admission/quarterly/significant change in condition using admission Nursing Evaluation. Review of Resident 2's diagnosis list revealed diagnoses including Quadriplegia (paralysis of all four extremities), Epilepsy (seizures), protein calorie malnutrition, Bipolar Disorder (psychiatric disorder) and Major Depressive Disorder (mental disorder characterized by persistent and debilitating feelings of sadness, loss of interest in activities, and other symptoms that interfere with daily life). Review of Resident 2's care plan revealed Resident 2 had a goal of Activities of Daily Living (basic, routine tasks necessary for personal care and independence) performance deficit related to functional decline and Quadriplegia. Interventions included requiring assistance of two staff persons for repositioning and turning in bed. Further review of the care plan revealed Resident 2 was totally dependent on staff for toilet use, with an intervention to check and change every two hours. Further review of the care plan revealed potential for impairment to skin integrity related to fragile skin, immobility, and incontinence. Interventions included monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD (physician). Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's weekly skin check assessment dated [DATE], revealed no new skin issues. Review of Resident 2's progress notes dated February 17, 2025, revealed during care, this nurse was notified that the resident had a skin tear (type of traumatic wound caused by mechanical forces like friction, blunt force trauma, or falls, resulting in the separation of skin layers) on sacrum (large, triangular bone at the base of the spine) and an abrasion (superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn) right posterior (back) thigh. Review of Resident 2's second skin check assessment dated [DATE], revealed Stage 3 (serious wound that penetrates through the skin layers into the subcutaneous tissue, revealing the underlying fat) sacral/buttocks 5.0 x 10 x 2 cm (centimeters) moderate serosanguinous (type of wound drainage that contains both serous fluid [the clear, thin liquid part of blood] and blood cells) drainage, 40% slough (dead tissue that separates from the living tissue), 60% granulation tissue (fleshy, pink or red, moist tissue that forms on the surface of a wound as it heals) appears as a blister that popped. Review of Resident 2's clinical record failed to reveal documented evidence that Resident 2 had a blister on the sacrum. Interview with Licensed Employee E3 on May 29, 2025, at 11:00 a.m. revealed Resident 2 appeared to have had a blister on sacrum, however, no clinical documentation was provided to support a blister was present. This interview further revealed, Resident 2 experienced a delay in treatment by the wound consultant until March 6, 2025 as a result of the resident being out of bed or unavailable when the wound consultant was available. Interview with Director of Nursing on May 30, 2025, at 10:00 a.m. revealed Resident 2 had a history of a prior sacral wound and that a blister was present on the sacrum. No clinical documentation was provided to support either a prior sacral wound history or the presence of a blister on the sacrum. Review of Resident 2's initial wound consultation dated March 6, 2025, revealed Resident 2 had a significant past medical history of quadriplegia, mild protein-calorie malnutrition. Further review of same consultation revealed patient presents for initial evaluation of a new Stage 3 pressure ulcer of sacrum. Area has 20% slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material). Further review of the same wound consultation revealed Sacral wound is a Stage 3 pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 3.5 cm length x 8 cm width x 0.1 cm depth with an area of 28 square centimeters. Assessment of exposed structures limited to the breakdown of skin. No tunneling (type of wound that extends deeper into the tissue than its surface, creating a narrow channel or tunnel-like passageway) has been noted. No sinus tract (type of wound characterized by a narrow channel or passageway that extends from the surface of the skin into deeper tissues) has been noted. No undermining (wound where the edges are not attached to the underlying tissue, creating a pocket or shelf beneath the skin at the wound's edge) has been noted. There is a light amount of sero-sanguineous drainage noted which has no odor. Wound bed has 80% granulation, 20% slough; no eschar (dead tissue) and no epithelialization (process of the epidermis regenerating over a wound surface, essentially covering the wound with new skin tissue) present. Interview with Director of Nursing on May 30, 2025, at 12:00 p.m. confirmed no clinical documentation was available to support that Resident 2 had a blister on the sacrum prior to the discovery of the Stage III pressure ulcer and that no treatments were in place to treat a blister. This interview also confirmed Resident 2's pressure ulcer was discovered at the level of Stage III. The facility failed to timely identify a pressure ulcer prior to the progression to a Stage III causing actual harm to Resident 2. Clinical records review revealed Resident 62 was admitted to the facility on [DATE], with a diagnosis of Acute Respiratory Failure (life-threatening condition where the lungs are unable to adequately exchange gases [oxygen and carbon dioxide] in the blood, leading to insufficient oxygen delivery to the body and potentially harmful levels of carbon dioxide). Review of Resident 62's admission skin assessment failed to reveal a skin impairment to the sacrum and or the buttock area. Review of Resident 62's skin care plan developed on May 2, 2025, revealed: [Resident] has potential for impairment to skin integrity r/t (related to) muscle weakness. Stage 3 (Full thickness skin loss) left buttock. Review of Resident 62's physician's orders dated May 2, 2025, revealed an order to cleanse the wound with normal saline solution, pat dry, and cover with silicone border gauze every day shift every Tuesday, Thursday, and Saturday. Review of Resident 62's nursing skin/wound note dated May 8, 2025, at 11:29 a.m., revealed Skin assessment of buttocks. The resident states he/she had the wound for a long time. Stage 3 left buttock. 0.3 x 0.2 x 0.1 cm. Small serosanguinous (type of wound drainage that is a combination of blood and serum). 20% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). 80% granulation. Clinical record review revealed Resident 62's Stage 3 left buttock/sacral pressure ulcer was not comprehensively assessed (size, condition) until May 8, 2025, six days after it was identified upon admission on [DATE]. Interview with the Director of Nursing conducted on May 30, 2025, at 10:00 a.m., confirmed Resident 62's identified on admission pressure ulcer was not comprehensively assessed until May 8, 2025. Clinical records review revealed Resident 225 was admitted to the facility on [DATE], with a Stage 4 (full-thickness skin and tissue loss) pressure ulcer to the sacrum (triangular bone just below the lumbar vertebrae) measuring 8.5 x 10 x 0.2 cm. with heavy serosanguinous drainage with 50% slough and 50% granulation. A wound treatment was ordered. Review of Resident 225's wound physician's consult report dated March 27, 2025, revealed a Stage 4 sacral wound, measuring 7.0 x 10 x 0.2 cm. with 40% slough. A wound care order to cleanse with wound cleanser, apply Hydrogel (water-rich dressing that maintains a moist wound environment, promoting healing and potentially reducing pain), and cover with bordered gauze (bandage with adhesive tape that holds the dressing in place) daily. Review of Resident 225's Treatment Administration Record (TAR) revealed the wound physician's treatment order for the sacrum initiated March 27, 2025 was not implemented until March 31, 2025, four days after it was ordered. Interview with licensed nurse Employee E3 was conducted on May 29, 2025, at 1:00 p.m. Employee E3 reported that she/he does weekly rounds with the wound physician. Employee E3 reported, after the wound report was reviewed by the Interdisciplinary Team, she/he was responsible for entering it as an order on the resident's electronic medical records. Employee E3 reported the order was not implemented because it was not placed as an order until March 31, 2025, because he/she just did not get to it. The above information was conveyed to the Director of Nursing on May 30, 2025, at 10:00 a.m. 28 Pa. 211.10(c) Resident care policies Previously cited 6/7/24 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 6/7/24

Based on a review of the facility's policy, clinical records, facility documentation, observation, and staff interviews, it was determined that the facility failed to comprehensively assess, monitor, provide additional interventions, and timely follow a physician's order for a wound consult of an identified skin impairment to the left heel resulting into the harm of a declined unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left heel for one of two residents reviewed (Resident 1). Findings include: Review of the facility's policy titled Skin Integrity, dated April 1, 2022, revealed that the facility develops a routine to review residents with wounds or at-risk weekly. The DON (Director of Nursing) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored weekly. Further review of the same policy revealed, if there is a decline in skin integrity, pressure redistribution surfaces will be reviewed, and interventions/plans of care will be updated as appropriate. The same policy revealed that the assessment/observations are to be completed within the first 24 hours of admission/quarterly/significant change of condition using the Admission Nursing evaluation/Braden Scale. Review of Resident 1's diagnosis list revealed Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side (paralysis of one side of the body following a stroke), and weakness. Review of Resident 1's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated December 18, 2022, revealed the resident required extensive two-person assistance with bed mobility. The resident had an indwelling catheter (flexible tube that is used to drain urine from your bladder into a bag outside your body) and was always incontinent of bowel. The same MDS assessment revealed the resident's skin was intact but was at risk for developing a pressure ulcer/injury. Review of the Braden Scale (tool used to identify patients at risk for developing a pressure ulcer) dated December 14, 2022, revealed Resident 1 was moderately at risk for developing a pressure ulcer. Review of Resident 1's potential for impairment to skin integrity care plan developed on December 13, 2022, revealed the following interventions: Avoid scratching and keep hands and body parts from excessive moisture; Encourage good nutrition and hydration; Identify/document potential causative factors and resolve where possible; Monitor/document location, size and treatment of skin injury; Use caution during transfer and bed mobility; Incontinence care and preventative skin care; Keep skin dry and clean; Monitor labs; Pressure reduction mattress; Treatment as ordered, and Use draw sheet or lifting device to move the resident. Review of the nursing progress notes dated February 23, 2023, at 7:39 a.m., revealed: Left heel pressure ulcer/, boggy heel. The supervisor was made aware and will place a consult for foot care, with a bilateral heel protector in place, complained of pain/discomfort, and was placed on the 24-hour report to continue to monitor. Review of Resident R1's clinical record revealed a wound care consult for the left heel was ordered by the physician on February 23, 2023. Review of Resident R1's clinical record failed to reveal a comprehensive skin assessment completed for the skin impairment identified on the left heel. Nursing assessment failed to reveal size, appearance, color, and stage (if applicable) of the left heel pressure ulcer. Clinical records revealed the intervention documented in the progress note of February 23, 2023, a bilateral heel protector, was not applied. The facility was unable to provide documented evidence that the heel protector was placed on resident's heel after the wound was identified. Clinical records review also revealed that Resident 1's skin care plan was not updated with the interventions. Clinical records review revealed that the wound care consult ordered on February 23, 2023, was not done until March 20, 2023, which was 25 days after the consult was ordered by the physician. Clinical records review failed to reveal the identified left heel skin impairment was monitored or checked weekly. Review of the physician's order dated March 16, 2023, revealed an order for a Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) to the left heel then cover with bordered gauze. Review of the care plan developed on March 16, 2023, revealed Resident has an unstageable pressure ulcer to the left heel due to immobility. Clinical records review failed to reveal an assessment of the identified unstageable pressure ulcer to the left heel. Observation of the wound was conducted on March 20, 2023, at 11:00 a.m., with licensed nurse Employee E3. Resident 1 was laying in bed, with both heels touching the pillow placed under the legs. Employee E3 reported that the wound doctor saw the resident earlier that morning (unable to indicate exact time). Observation revealed left heel wound did not have a dressing, the wound was covered with 100% black necrotic eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). Employee E3 reported the wound was unstageable and measured 2.2 x 2.0 cm (centimeter) in size. Interview was conducted with the Director of Nursing, and the Regional Clinical Director Employee E4 on March 20, 2023, at 11:52 a.m. The Director of Nursing indicated any identified skin impairment should be assessed and documented with the following: measurement, stage, color, area, and drainage. The Director of Nursing stated, she/he identified Resident 1's left heel unstageable ulcer when she/he provided a shower/bath to the resident on March 16, 2023. Review of the facility's documentation, Resident Concern Report dated March 16, 2023, revealed a family's concern regarding the resident's hygiene and skin integrity. Findings and disposition revealed: Shower was provided to the resident, left heel wound was identified. Treatment placed with heel protection. Air mattress applied, wedge protection to the left side. Interview conducted with the Director of Nursing and Employee E4 on March 20, 2023, at 1:00 p.m. confirmed the left heel skin impairment initially identified on February 23, 2023, as pressure ulcer/, boggy heel was not comprehensively assessed, interventions were not implemented, order for a wound care consult was not completed until March 20, 2023, and failed to provide reason for the delay. The Director of Nursing confirmed the left heel skin impairment identified on February 23, 2023, was not routinely monitored or assessed and the resident skin care plan was not updated. The Director of Nursing reported a shower and a skin check were performed on March 16, 2023, after receiving a concern from the resident's family. The Director of the Nursing indicated the unstageable wound observed during the shower was covered with 90% black eschar, with slight bleeding, and measured approximately 3 x 3 cm in size. Treatment was ordered, and a care plan was updated on March 16, 2023. Late documentation of the left heel unstageable wound assessment was done on March 20, 2023. The facility failed to comprehensively assess, implement interventions, follow a physician's order for a wound consult timely, and monitor the left heel ulcer/, boggy heel initially identified on February 23, 2023, resulted in harm of a declined pressure ulcer to the left heel after addressing a family's skin integrity concern on March 16, 2023. 28 Pa Code 201.18 (b)(1) Management Previously cited 9/21/22, 10/12/22, 2/6/23 28 Pa Code 211.10 (d) Resident care policies Previously cited 2/6/23 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 9/21/22, 10/12/22, 2/6/23 28 Pa. Code: 211.5(f) Clinical records Previously cited 9/21/22, 2/6/23

Based on observation, review of clinical records, review of facility documents and interviews with staff, it was determined that the facility failed to provide supervision and monitoring to Resident R1, which resulted in Resident R1 performing nonconsensual sexual acts on Resident R2. This deficiency was cited as past non-compliance. (Resident R2) Findings include: Review of facility policy, Freedom from abuse, neglect, and exploitation, dated June 12, 2020, revealed that the policy included that the facility would provide a safe resident environment and protect residents from abuse. This included freedom from verbal, mental, sexual, or physical abuse. The guidelines included: that staff will be trained in the types of abuse and neglect; for allegations of abuse, the facility will immediately implement safeguards to prevent further potential abuse; resident to resident abuse - the facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g. physical, sexual or verbal aggression). Review of online literature from the Pennsylvania Department of Aging regarding the Pennsylvania Empowered Expert Residents Program, dated 2020, revealed the following: Pennsylvania Empowered Expert Residents (PEERs) are individuals living in long-term care settings who have been trained to advocate to improve the quality of life in their homes. After graduating from a Long-Term Care Ombudsman five-part empowerment training, PEERs are equipped to help their fell ow residents improve day-to-day life in long-term care facilities. PEERs also advise the Office of State Long-Term Care Ombudsman on the issues affecting all of Pennsylvania's long-term care residents. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], from a short-term Physical Rehabilitation Center. The resident's diagnosis included a complete lesion at C5 level of the cervical spinal cord (trauma to the spinal cord, where body movement is impaired) and delusional disorder (person cannot tell what is real from what is imagined). Review of the resident's care plan revised September 19, 2019, revealed the resident utilized an electric wheelchair for mobility. Review of Resident R1's quarterly Minimum Data Set assessment (MDS-a periodic assessment of needs) dated August 27, 2020, revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15 indicating that he was cognitively intact. Review of Resident R1's nursing note dated March 3, 2019, revealed that the resident in room 609 complained of Resident R1 coming into his room mainly at night to visit his roommate and bumping into everything and moving his curtain and telling him his curtain needs to be in the middle and not where he likes it. The resident in room 609-1 stated I told him not to come in my room and he said I can go in any room I want to. The resident in room 609-1 stated He comes in and turns on my roommate's TV and he does not even watch TV, he covers his head with a blanket. Review of Resident R1's social service note dated March 18, 2019, revealed that resident rights were reviewed with the resident related to room visitation and to being invited by a resident before entering a personal space/room on any unit. Resident R1 indicated he is a PEER and at times he is helping. Social Services communicated to the resident that it is appropriate as a PEER to advocate for a resident and to inform staff of the request so that staff may deliver the specific service or need. Resident R1 indicated he understood. Review of Resident R1's care plan initiated on July 22, 2016, revealed a focus area that Resident R1 had a history of behaviors with manipulation and accusations related to personality disorder. An intervention related to this focus area was for the resident to be educated on not entering other resident's rooms without consent. This intervention was developed August 13, 2019. Review of a resident contract dated August 14, 2019, revealed I, (Resident R1), agree to stay out of all resident personal rooms and not to involve myself in their care being provide. I understand that I am not to enter into a room of a resident that cannot give permission to me to be present in the room . (Resident R1) refused to sign . Review of Resident R1's Behavior Note dated November 24, 2019, revealed, Observed patient in the doorway of rm (Room) 211 on West 2 [Nursing Unit]. Advised (Resident R1) per (Resident R4's) family request he is not allowed in his room or in patient's personal space. (Resident R1) became upset and stated he was never told that. It isn't true. Nursing supervisor notified. Referred (Resident R1) to nursing supervisor if he had any further questions or concerns. Review of Resident R1's social service note dated August 27, 2019, revealed that on August 26, 2019, social services had met with Resident R1 to address the proper procedure in using the correct gender bathroom. Review of Resident R1's social service note dated January 8, 2020, revealed that social services met with Resident R1 related to arriving on a locked unit. Resident R1 indicated he pushed the elevator button for his floor with a male staff from the facility and the elevator went to the locked unit and he had no intention for a visit. Review of Resident R1's nursing note dated January 8, 2020, by the Director of Nursing (DON) revealed that Resident R1 was noted going in and out of the locked unit. This was brought to my attention and administration. At 1215 hrs. (12:15pm.) we the DON, ADON (Assistant Director of Nursing) and myself met with (Resident R1). The DON reminded (Resident R1) that he was not allowed on N8 (locked unit) because of the nature of the unit. The residents on N8 are not able to make their own decisions. Review of Resident R1's activity note dated March 12, 2020, revealed (Resident R1) is doing activity he will use his computer, phone for games, and reading or keeping with the news. (Resident R1) go and visiting other floor to see his peers (Resident R1) will make him self-known throughout the building. Review of Resident R1's social service note dated August 13, 2020, revealed that resident rights were reviewed with the resident related to personal space and to refrain from touching peers and their personal DME [Durable Medical Equipment]. The resident was to contact staff for assistance in aiding a peer. Resident R1 understood and apologized for his impulsiveness. Review of the facility's documentation submitted to the State agency revealed that on September 11, 2020, at approximately 12:20 p.m. Licensed Practical Nurse (LPN), Employee E3, notified management of an allegation of sexual abuse that occurred between Resident R1 and Resident R2. During the interview conducted by the facility with Employee E3, the employee reported that while walking past Resident R1's private room, the employee noticed that the curtain was pulled shut and identified two shadows. The larger shadow was leaning over the smaller shadow. Employee E3 could identify that there was movement with a person's upper extremity moving quickly upward and downward in a fast motion. As Employee E3 approached the door and knocked to enter the room the larger shadow moved back quickly. Employee E3, identified that the larger shadow appeared to have let go of clothing to the smaller shadow in the waist area. When Employee E3 pulled the curtain back and entered the room the employee identified the larger shadow as Resident R1, and the smaller shadow as Resident R2. Employee E3, identified that Resident R2's pant area was disheveled. Employee E3, immediately removed Resident R2 from Resident R1's room and took him to an area of privacy and Resident R2 was asked as to what had occurred in Resident R1's room. Resident R2 stated to Employee E3, that He was fixing my pee pee like this demonstrating to [Employee E3] him touching him on his penis. Employee E3 asked Resident R2 if Resident R1 touched his penis when they were in his room. Resident R2 replied yes. Employee E3, immediately reported the incident to the Assisting Director of Nursing (ADON), who went to assess and speak to Resident R1 and Resident R2. Facility documentation indicated that Resident R2 confirmed during an interview with the ADON the incident as it was described to Employee E3. When Resident R1 was interviewed he reported to the ADON, that Resident R2 was in his room and Resident R2 just pulled out his penis and began touching himself. He reported that he told him to put it away but he kept scratching it. He reported that he did not know what to do so he just let him stay in his room. Then he stated that Employee E3, entered and took him out of the room. Upon assessment there was no signs of injury or scratches noted on his genital area. Resident R2's clinical record revealed the diagnoses of [CONDITION(S)] (group of disorders that affect movement and muscle tone or posture, lack of coordination), mood disorder, muscle weakness, anxiety disorder, and major depressive disorder (major loss of interesting pleasurable activities). Review Resident R2's quarterly MDS dated [DATE], revealed that the resident used a wheelchair for mobility and had a BIMS (Brief Interview for Mental Status, score of 15 indicating that he was cognitively intact. Review of Resident R2's psychologist consult dated September 11, 2020, revealed that the resident was willing to discuss the incident that occurred on September 11, 2020, between him and Resident R1. It was documented that there were concerns regarding Resident R2 ability to differentiate between what was appropriate touch versus inappropriate touch. Interview with Resident R2 on September 21, 2020, at 1:00 p.m. revealed the following: (Resident R1) had noticed my brief wasn't right and morning shift shouldn't have done it that way. (Resident R1) was fondling playing with my penis. [Employee E3] saw it. He was moving it back and forth. I should have realized what he was doing. Everyone was singing in the solarium and he asked me to go to his room to his computer. He told me to deny what happened. He showed me pictures on his computer. He was trying to get me on Facebook (a social media account). He never touched me like that before. He tried to make me change my story. I didn't realize what he was doing. He was a classmate of my older sister. He used to help with stuff. I thought he was a friend. He asked me to be his roommate, but I wouldn't feel comfortable with that. Makes me feel upset that someone was a friend did that and told me to lie about what [Employee E3] saw. Resident R2 would continually ask this writer if he should remove Resident R1 as a contact on his phone or on Facebook. Interview on September 20, 2020, at 1:30 p.m. with Employee E3, revealed that she has worked at the facility for [AGE] years. Employee E3, stated the following: My assignment included taking care of (Resident R1) for [AGE] years. Around 12:15 p.m., I was walking past (Resident R1's) room. I noticed curtains pulled and the curtains are very see-through. I saw two shadows. A smaller one and a larger one and I observed an arm going back and forth. [nurse was moving her hand in a jerking fashion]. My sneakers squeaked and I heard jogging pants snap. I knocked and said (Resident R2) it's time for lunch. (Resident R1) had to move for (Resident R2) to get out. I knew what I saw. I took (Resident R2) down to the bathroom to make sure he was ok. I called bigger peeps (administration). (Resident R2) told me, yes (Resident R1) was fixing my brief and trying to make my private part like his. Now (Resident R1) is circling the desk I'm trying to dial any number I can. I'm texting the DON (Director of Nursing). Now (Resident R1) is peeking in (Resident R2's) room with his head. Then, I was trying to get (Resident R1) away from (Resident R2). I told the supervisor and she came up. (Resident R1) is AAO (alert and oriented) x3 (person, place, and time) and is very aware and (Resident R2) is like talking to a 10-[AGE] year-old child . (Resident R2) said that (Resident R1) pleaded with me to not say anything which concerns me because there both on the same unit .I knew what I saw my stomach dropped. I got blurry and light. I know (Resident R2) is innocent. He truly thought that (Resident R1) was fixing his brief. Interview with Employee E5, Nurse Manager, on September 20, 2020, at 3:00 p.m. revealed that she has been a nurse manager for [AGE] years and she has worked at the facility for [AGE] years. She stated that she is the nurse manager of the 2 West nursing unit, and she is covering for the 6 North Nursing Unit. Employee E5, revealed the following: Yes, I worked on the West 2 Nursing Unit. (Resident R1) would come and drop the newspaper he is very sociable. He was told he had to stay in the hallway on West 2. I think he gets a little too involved. (Resident R1) believes he can direct people's care. He would say I'm a PEER and this person's not getting this or that. He felt like he could be on the units because he is a PEER support and I do remember them saying that PEERS have certain units . (Resident R1) would talk to the guys on the unit. We would just tell him there would be no reason to go into resident's rooms and just stay in the hallway. I'm not sure why he's still on the 6 North Nursing Unit. Interview with Employee E7, Director of Social Services, on September 21, 2020, at 1:20 p.m. revealed that she has been employed by the facility for [AGE] years. Employee E7, Director of Social Services, stated that the facility was actively trying to discharge (Resident R1). We have been working with him on nursing home transition prior to the recent incident. (Resident R1) is a PEER (Pennsylvania Empowered Expert Residents) . (Resident R1) is good at a PEER, but he would overstep his boundaries and interfere with the residents. (Resident R1) would be told you shouldn't be behind resident's curtain and he would say I know. I wish I had something more on that, but I don't . A psychologist evaluated him, and he had personality (disorder) traits and we were told to have boundaries with him and don't go on a social conversations with him .He would go towards people who had intellectual disabilities saying I just want to help them. I had interviewed (Resident R2) who said he was just trying to help me. Many people with intellectual disabilities don't question people's intent, they think why would anyone want to hurt me? I didn't do anything to them? This deficiency was cited as past non-compliance. On September 11, 2020, the facility initiated a plan of correction to address the action of a non- consensual sexual act performed to a resident. The facility immediately implemented their abuse policy as follows: -The employee who believe might have observed sexual abuse immediately removed the victim (Resident R2) from the perpetrator's room (Resident R1) -The sexual abuse incident was immediately reported to the Assistant Director of Nursing. -The facility immediately conducted an investigation into the allegation of sexual abuse involving Resident R2. -Resident R2 was immediately removed form the situation and taken to his room for assessment. -Resident R1 was placed on 1:1 supervision to ensure the safety of residents and remained on a 1:1 supervision pending a possible discharge from the facility and as of the date of the survey by the State agency Resident R1 remained on a 1:1 supervision. -The policy was notified the same day of the incident and a report was filed. -On September 19, 2020 the facility began a staff wide training on the facility's abuse policy and on the facility's 1:1 supervision policy. -Alert and oriented resident were provided a questionnaire to identify any other areas of concerns or cases of abuse. Interviews conducted with facility staff on September 23, 24 and 25, 2020 reported they had all been in-serviced on recognizing signs of sexual abuse and on safety surveillance. The staff confirmed the seven types of abuse, physical signs of sexual abuse, mental signs of abuse, resident behaviors who had been abused, characteristics or staffing or a perpetrator that could be targeting a possible victim for usual abuse, to whom to immediately report an allegation of abuse and one to one monitoring. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(1) Nursing services 28 Pa. Code 211.12(c)(3) Nursing services 28 Pa. Code 211.12(c)(5) Nursing services

Based on observation, review of clinical records, review of facility documents and interviews with staff, it was determined that the facility neglected to ensure residents were free from abuse from Resident R1, which resulted in actual harm to Resident R1 performing nonconsensual sexual acts on Resident R2. This deficiency was cited as past non-compliance. (Resident R2) Findings include: Review of facility policy, Freedom from abuse, neglect, and exploitation, dated June 12, 2020, revealed that the policy included that the facility would provide a safe resident environment and protect residents from abuse. This included freedom from verbal, mental, sexual, or physical abuse. The guidelines included: that staff will be trained in the types of abuse and neglect; for allegations of abuse, the facility will immediately implement safeguards to prevent further potential abuse; resident to resident abuse - the facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g. physical, sexual or verbal aggression). Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], from a short-term Physical Rehabilitation Center. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan revised September 19, 2019, revealed the resident utilized an electric wheelchair for mobility. Review of Resident R1's quarterly Minimum Data Set assessment (MDS-a periodic assessment of needs) dated August 27, 2020, revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15 indicating that he was cognitively intact. Review of Resident R1's care plan initiated on July 22, 2016, and revised on September 4, 2020, revealed a focus area that Resident R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to provide 1 to 1 attention until behavior passed. This intervention was developed on 7/22/2016. To monitor behavior, location, time of day and person involved in the behavior and potetial causes. This intervention was developed 10/26/2020. On August 13, 2019 an intervention of providing education to the resident on not entering other resident's rooms without consent was added to the resident's care plan. Review of Resident R1's nursing note dated January 8, 2020, by the Director of Nursing (DON) revealed that Resident R1 was noted going in and out of the locked unit. This was brought to my attention and administration. At 1215 hrs. (12:15pm.) we the DON, ADON (Assistant Director of Nursing) and myself met with (Resident R1). The DON reminded (Resident R1) that he was not allowed on N8 (locked unit) because of the nature of the unit. The residents on N8 are not able to make their own decisions. Review of the facility's documentation submitted to the State agency revealed that on September 11, 2020, at approximately 12:20 p.m. Licensed Practical Nurse (LPN), Employee E3, notified management of an allegation of sexual abuse that occurred between Resident R1 and Resident R2. During the interview conducted by the facility with Employee E3, the employee reported that while walking past Resident R1's private room, the employee noticed that the curtain was pulled shut and identified two shadows. The larger shadow was leaning over the smaller shadow. Employee E3 could identify that there was movement with a person's upper extremity moving quickly upward and downward in a fast motion. As Employee E3 approached the door and knocked to enter the room the larger shadow moved back quickly. Employee E3, identified that the larger shadow appeared to have let go of clothing to the smaller shadow in the waist area. When Employee E3 pulled the curtain back and entered the room the employee identified the larger shadow as Resident R1, and the smaller shadow as Resident R2. Employee E3, identified that Resident R2's pant area was disheveled. Employee E3, immediately removed Resident R2 from Resident R1's room and took him to an area of privacy and Resident R2 was asked as to what had occurred in Resident R1's room. Resident R2 stated to Employee E3, that He was fixing my pee pee like this demonstrating to [Employee E3] him touching him on his penis. Employee E3 asked Resident R2 if Resident R1 touched his penis when they were in his room. Resident R2 replied yes. Employee E3, immediately reported the incident to the Assisting Director of Nursing (ADON), who went to assess and speak to Resident R1 and Resident R2. Facility documentation indicated that Resident R2 confirmed during an interview with the ADON the incident as it was described to Employee E3. When Resident R1 was interviewed he reported to the ADON, that Resident R2 was in his room and Resident R2 just pulled out his penis and began touching himself. He reported that he told him to put it away but he kept scratching it. He reported that he did not know what to do so he just let him stay in his room. Then he stated that Employee E3, entered and took him out of the room. Upon assessment there was no signs of injury or scratches noted on his genital area. Resident R2's clinical record revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Resident R2's quarterly MDS dated [DATE], revealed that the resident used a wheelchair for mobility and had a BIMS (Brief Interview for Mental Status), score of 15 indicating that he was cognitively intact. Review of Resident R2's psychologist consult dated September 11, 2020, revealed that the resident was willing to discuss the incident that occurred on September 11, 2020, between him and Resident R1. It was documented that there were concerns regarding Resident R2 ability to differentiate between what was appropriate touch versus inappropriate touch. Interview with Resident R2 on September 21, 2020, at 1:00 p.m. revealed the following: (Resident R1) had noticed my brief wasn't right and morning shift shouldn't have done it that way. (Resident R1) was fondling playing with my penis. [Employee E3] saw it. He was moving it back and forth. I should have realized what he was doing. Everyone was singing in the solarium and he asked me to go to his room to his computer. He told me to deny what happened. He showed me pictures on his computer. He was trying to get me on Facebook (a social media account). He never touched me like that before. He tried to make me change my story. I didn't realize what he was doing. He was a classmate of my older sister. He used to help with stuff. I thought he was a friend. He asked me to be his roommate, but I wouldn't feel comfortable with that. Makes me feel upset that someone was a friend did that and told me to lie about what [Employee E3] saw. Resident R2 would continually ask this writer if he should remove Resident R1 as a contact on his phone or on Facebook. Interview on September 20, 2020, at 1:30 p.m. with Employee E3, revealed that she has worked at the facility for [AGE] years. Employee E3, stated the following: My assignment included taking care of (Resident R1) for [AGE] years. Around 12:15 p.m. I was walking past (Resident R1's) room. I noticed curtains pulled and the curtains are very see-through. I saw two shadows. A smaller one and a larger one and I observed an arm going back and forth. [nurse was moving her hand in a jerking fashion]. My sneakers squeaked and I heard jogging pants snap. I knocked and said (Resident R2) it's time for lunch. (Resident R1) had to move for (Resident R2) to get out. I knew what I saw. I took (Resident R2) down to the bathroom to make sure he was ok. I called bigger peeps (administration). (Resident R2) told me, yes (Resident R1) was fixing my brief and trying to make my private part like his. Now (Resident R1) is circling the desk I'm trying to dial any number I can. I'm texting the DON (Director of Nursing). Now (Resident R1) is peeking in (Resident R2's) room with his head. Then, I was trying to get (Resident R1) away from (Resident R2). I told the supervisor and she came up. (Resident R1) is AAO (alert and oriented) x3 (person, place, and time) and is very aware and (Resident R2) is like talking to a 10-[AGE] year-old child . (Resident R2) said that (Resident R1) pleaded with me to not say anything which concerns me because there both on the same unit .I knew what I saw my stomach dropped. I got blurry and light. I know (Resident R2) is innocent. He truly thought that (Resident R1) was fixing his brief. Interview with Employee E5, Nurse Manager, on September 20, 2020, at 3:00 p.m. revealed that she has been a nurse manager for [AGE] years and she has worked at the facility for [AGE] years. She stated that she is the nurse manager of the 2 West nursing unit, and she is covering for the 6 North Nursing Unit. Employee E5, revealed the following: Yes, I worked on the West 2 Nursing Unit. (Resident R1) would come and drop the newspaper he is very sociable. He was told he had to stay in the hallway on West 2. I think he gets a little too involved. (Resident R1) believes he can direct people's care. He would say I'm a PEER and this person's not getting this or that. He felt like he could be on the units because he is a PEER support and I do remember them saying that PEERS have certain units . (Resident R1) would talk to the guys on the unit. We would just tell him there would be no reason to go into resident's rooms and just stay in the hallway. I'm not sure why he's still on the 6 North Nursing Unit. Interview with Employee E7, Director of Social Services, on September 21, 2020, at 1:20 p.m. revealed that she has been employed by the facility for [AGE] years. Employee E7, Director of Social Services, stated that the facility was actively trying to discharge (Resident R1). We have been working with him on nursing home transition prior to the recent incident . (Resident R1) would be told you shouldn't be behind resident's curtain and he would say I know. I wish I had something more on that, but I don't . A psychologist evaluated him, and he had personality (disorder) traits and we were told to have boundaries with him and don't go on a social conversations with him .He would go towards people who had intellectual disabilities saying I just want to help them. I had interviewed (Resident R2) who said he was just trying to help me. Many people with intellectual disabilities don't question people's intent, they think why would anyone want to hurt me? I didn't do anything to them? This deficiency was cited as past non-compliance. On September 11, 2020, the facility initiated a plan of correction to address the action of a non- consensual sexual act performed to a resident. The facility immediately implemented their abuse policy as follows: -The employee who believe might have observed sexual abuse immediately removed the victim (Resident R2) from the perpetrator's room (Resident R1) -The sexual abuse incident was immediately reported to the Assistant Director of Nursing. -The facility immediately conducted an investigation into the allegation of sexual abuse involving Resident R2. -Resident R2 was immediately removed form the situation and taken to his room for assessment. -Resident R1 was placed on 1:1 supervision to ensure the safety of residents and remained on a 1:1 supervision pending a possible discharge from the facility and as of the date of the survey by the State agency Resident R1 remained on a 1:1 supervision. -The policy was notified the same day of the incident and a report was filed. -On September 19, 2020 the facility began a staff wide training on the facility's abuse policy and on the facility's 1:1 supervision policy. -Alert and oriented resident were provided a questionnaire to identify any other areas of concerns or cases of abuse. Interviews conducted with facility staff on September 23, 24 and 25, 2020 reported they had all been in-serviced on recognizing signs of sexual abuse and on safety surveillance. The staff confirmed the seven types of abuse, physical signs of sexual abuse, mental signs of abuse, resident behaviors who had been abused, characteristics or staffing or a perpetrator that could be targeting a possible victim for usual abuse, to whom to immediately report an allegation of abuse and one to one monitoring. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(c)(1) Nursing services 28 Pa. Code 211.12(c)(3) Nursing services 28 Pa. Code 211.12(c)(5) Nursing services

Based on a review of clinical records, facility policies and procedures, and facility documentation, and interviews with residents and staff, it was determined that the facility failed to maintain a safe environment related to fire drills and failed to ensure that adequate fire safety training was provided to agency nursing staff. This failure of not training agency nursing staff on fire safety placed a threat to the health and safety of all residents at the facility related to a lack of knowledge on emergency procedures if a fire or a related disaster occurred at the facility. These conditions resulted in an Immediate Jeopardy situation. In addition, the facility failed to provide adequate supervision for a resident who eloped and sustained an injury which resulted in actual harm to the resident who sustained a [MEDICAL CONDITION] (Resident R441). Findings Include: Review of facility policy titled Emergency Procedure - Fire dated (MONTH) 4, (YEAR), revealed that the facility had a designated procedure for fires and explosions that shall be followed if such an emergency arises. Staff receive training at least annually on fire procedures and the use of fire extinguishers. A request was made to the Nursing Home Administrator (NHA) on (MONTH) 4, 2019, for a list of agency personnel who worked in the facility in the past four months as well as evidence of their education on hire. The list provided by the NHA on (MONTH) 7, 2019, included 73 agency personnel, which included nursing assistants, registered nurses and licensed practical nurses. A review of the personnel files for the agency personnel revealed no facility fire safety training. Interview on (MONTH) 6, 2019, at 9:40 a.m. with Employee E7, Registered Nurse (RN), who is an outside agency personnel, stated that she did not receive facility fire safety training prior to her first day of providing care to residents. Interview on (MONTH) 6, 2019, at 9:50 a.m. with Employee E6, Licensed Practical Nurse, who is an outside agency personnel, stated that she wasn't sure/couldn't recall if she received facility fire safety training prior to her first day of providing care to residents. Review of the facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 22, (YEAR), revealed very poor staff performance. Doors shut to rooms without checking for fire. Review of the facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 22, (YEAR), very weak supervised staff needs to talk to their staff. Review of the facility's Safety Committee Meeting dated (MONTH) 25, (YEAR), revealed Must work better on fire drills - fire safety in-service and education facility wide. Employee E8, Security Supervisor/Fire Safety Educator - follow up. Review of the facility's Safety Committee Meeting dated (MONTH) 8, (YEAR), revealed Fire Drills/Disaster Drills: True with no other documented evidence for mention of the fire drills. Review of the facility's Safety Committee Meeting dated (MONTH) 28, (YEAR), revealed . Fire Drills - spoke w/security and was informed that if a fire drill is done and if it doesn't go well security wants to educate unit and redo fire drill within days to see if there is a better outcome. The obstacle comes with revolving staff (agency) and, at the present time, they are unable to move forward with this plan. Security stated that each month before a drill, they inform the unit that a drill is coming up, but even doing this, the staff are still confused about what they should do. (Further review of the document revealed the following information) - Fire Drills - Training. - Develop a one page training for what to do during a fire drill. - How do we educate agency staff on fire drill process? - Post something at nurses' station - Increase info during safety fair - follow up 30/60/90 - for new hires - Go back to old fire drill model - - monthly unit based. Review of the facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 29, (YEAR), revealed that the Supervisor did education with nursing concerning using proper entry to assist with fire/emergencies. Review of the facility's Safety Committee Meeting dated (MONTH) 26, (YEAR), revealed Fire Drills/Disaster Drills: True with no other mention of fire drills. Review of the facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 9, (YEAR), revealed that unit staff need to work on an effective routine for fire drills. This drill was very unorganized on the unit. Review of the facility's Safety Committee Meeting dated (MONTH) 22, (YEAR), revealed Fire Drills Disaster Drills: True with no other mention of fire drills. Review of the facility's Safety Committee Meeting dated (MONTH) 29, (YEAR), revealed Fire Drills/Disaster Drills: True with no other mention of fire drills. Review of the facility's Safety Committee Meeting dated (MONTH) 28, (YEAR), revealed Fire Drills/Disaster Drills: True with no other mention of fire drills. Review of the facility's Safety Committee Meeting dated (MONTH) 19, (YEAR), revealed that Security and Maintenance are working on fire drill response training and disaster training for managing staff. Roll out 2-1-19. Review of the facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 20, (YEAR), revealed Wheelchair blocking fire door, slow response by 8 North Nursing unit staff. Review of facility document Parkhouse Fire Alarm/Drill Summary dated (MONTH) 9, 2019, revealed . Unit response was slow. Review of the facility's Safety Committee Meeting dated (MONTH) 16, 2019, revealed the fire department is supposed to come awaiting completion and roll out of fire drill training roll out was supposed to be 1/1/19 new date - 2-1-19. Interview on (MONTH) 6, 2019, at 11:00 a.m. with Employee E8, Security Supervisor/Fire Safety Educator, where he acknowledged the above mentioned fire drill deficient areas. Employee E8, Security Supervisor/Fire Safety Educator, attributed the fire drill deficiencies on agency staff and their lack of knowledge regarding the facility's fire safety program. Employee E8, Security Supervisor/Fire Safety Educator, stated part of his responsibilities include in-servicing new hires, that are not agency personnel, on the facility fire safety plan. Employee E8, Security Supervisor/Fire Safety Educator, stated that he was under the impression that the facility's educator was responsible for orientating new agency hires. Interview with the NHA on (MONTH) 7, 2019, at 1:30 p.m. where she confirmed that agency personnel are not oriented on hire regarding the facility's fire safety program. The NHA stated that regular non-agency staff do receive fire safety training on hire, but agency staff do not receive training. An Immediate Jeopardy situation was identified to the NHA and the Director of Nursing (DON) on (MONTH) 7, 2019, at 6:04 p.m. related to the facility not ensuing that a safe environment was maintained regarding fire drills related to a lack of fire safety training for agency nursing staff. This failure of not training agency nursing staff on fire safety placed a threat to the health and safety of all residents at the facility related to the facility's agency staff lack of knowledge on emergency procedures if a fire or a related disaster occurred at the facility. The corrective action plan included the following interventions: 1. Parkhouse provided fire safety education to 43 agency staff that were in the building the past 24 hours. March 7, 2019 - 3:00 p.m. - 11:00 p.m. shift and 11:00 p.m. - 7:00 a.m. shift March 8, 2019 - 7:00 a.m. - 3:00 shift was completed on this date. March 8, 2019 - 3:00 p.m. - 11:00 p.m. shift 2. 21 Agency staff are scheduled: 4 RN's, 10 LPN's, 7 CNA's. 16 of the above referenced agency staff have worked within the past 24 hrs. and have received the fire safety training, the remaining 5 will receive training upon arrival to the facility before being assigned to a unit. 3. All contracted agencies were contacted on (MONTH) 7, 2019, and advised that their assigned staff reporting to Parkhouse must complete fire safety education prior to being assigned to a unit. 4. Parkhouse staffing coordinator reached out to the five agency staff scheduled for 3:00 p.m. - 11:00 p.m. on (MONTH) 8, 2019, to reiterate they must arrive prior to their scheduled shift to take part in fire safety education and will then be assigned a unit. 5. Unit Managers/ADON will conduct the fire safety education with agency upon arrival on (MONTH) 8, 2019. 6. They will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office. 7. Process will continue for proceeding shifts throughout the weekend, and thereafter. 8. Staffing Coordinator will identify first time agency staff, provide a list to Nursing Supervisor or designee, they will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office. Monitoring visits were conducted on (MONTH) 7, 2019, and (MONTH) 8, 2019, to verify the implementation of the immediate action plan and to review staff re-education documentation. On (MONTH) 8, 2019, 43 agency staff that were in the building in the past 24 hours received fire safety education. All contracted agencies were contacted and advised that they would need fire safety training prior to being assigned a unit. Fire safety education is completed and documented in log/binder. Staffing coordinator will identify first time agency staff, provide a list to Nursing Supervisor/designee, they will ensure fire safety education is completed and documented in log/binder. The Immediate Jeopardy was lifted on (MONTH) 8, 2019, at 1:06 p.m. Review of the clinical record for Resident R441 revealed that the resident was admitted to the facility from an acute care hospital on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. Review of a nursing admission Nursing Evaluation, dated (MONTH) 15, 2019, indicated that the resident was oriented to self and time of day, and that the resident was not ambulatory or self mobile in wheelchair and therefore not an elopement risk. Further review of the same assessment indicated that the resident was disoriented times one, had a history of [REDACTED]. Review of the Interdisciplinary Team discussion of resident's functional abilities on (MONTH) 18, 2019, at 12:46 p.m. indicated that Resident R441's functional abilities and goals were discussed and the performance codes for self-care indicated that Resident R441 required partial or moderate assistance of staff person for personal hygiene, lower body dressing and putting on footwear, and transfers including chair/bed to chair and toileting; supervision only for oral hygiene and upper body dressing; and set-up only for eating. The Interdisciplinary Team discussion also indicated that performance codes for walking were not attempted, due to medical condition or safety concern, and also noted that the resident does not use a manual wheelchair as a mode of transportation. Review of the nursing progress notes for Resident R441 on (MONTH) 16, 2019, at 5:29 a.m. revealed that the resident woke up confused and disoriented looking to call sister. The same note of (MONTH) 16, 2019, stated that the resident was reoriented to room and that safety was to be maintained at all times. Further review of the nursing progress notes indicated that on (MONTH) 16, 2019, at 12:11 p.m. resident was alert with confusion, and non-compliant with transfers. Review of nursing note of (MONTH) 17, 2019, at 7:39 p.m. stated that resident was assist of one staff person with walker for ambulation. Review of the nursing care plan for Resident R441, dated as initiated (MONTH) 17, 2019, noted that the resident was an elopement risk/wanderer, no goal was specified, but the intervention was to notify appropriate department of resident risk for elopement, also dated as initiated (MONTH) 17, 2019. Review of an Elopement Evaluation, dated (MONTH) 17, 2019, at 7:37 p.m. indicated that resident was cognitively impaired, with poor decision making skills or with pertinent diagnosis, that resident had a history of [REDACTED]. Clinical record or facility documentation did not reveal why resident was assessed and identified as an elopement risk on (MONTH) 17, 2019. Also, the clinical record or facility documentation did not reveal if the appropriate departments were notified of Resident R441's risk for elopement. Further review of of the nursing progress notes revealed that on (MONTH) 18, 2019, at 2: 36 a.m. resident was confused and demanding to leave, and wanted roommate removed from room. Also noted was that the resident was redirectable. Nursing note of (MONTH) 18, 2019, at 10:53 a.m. further indicated that the resident was non-compliant and does not call for nursing assistance with transfers. Review of an activity progress note of (MONTH) 18, 2019, at 12:37 p.m. revealed that Resident R441 was concerned about personal affairs not being taken care of while resident was in facility, such as paying bills. Review of nursing progress note of (MONTH) 18, (YEAR), at 1:29 p.m. indicated that the resident was assist of one and made attempts to get up without assistance. Review of physician's progress note of (MONTH) 18, 2019, revealed that resident was insisting that he needed to leave today or tomorrow, that he had very important things to do at home. Review of nursing progress note of (MONTH) 18, 2019, at 8:35 revealed that a nursing assistant stated that the resident was not in his room and was unable to be found on the nursing unit. The note stated that the licensed nurse approached security and looked out ambulance entrance, heard someone yelling and found resident leaning against dietary dock. The same nursing note indicated that Resident R441 stated he fell and to call an ambulance because his hip was broken. The note also indicated that blood was noted on resident's pants from a laceration to right thumb base, which measured 1.5 centimeters by 0.5 centimeters. Resident was then escorted back to clinical unit via wheelchair. The nursing progress note further stated that an assessment of the resident was completed, and it was noted that the right leg was shorter and outwardly rotated, and unable to completely straighten without much discomfort. Result of X-ray ordered by physician found a right femoral neck fracture (right hip) and physician ordered resident to be transferred to acute care hospital emergency department. Review of the facility's investigation revealed that the nursing assistant entered Resident R441's room on (MONTH) 18, 2019, at 8:35 p.m. and resident's roommate informed the nursing assistant that the resident put his baseball cap on his head and told the roommate I'm leaving. The roommate also stated that the nursing assistant came into room within five minutes of resident leaving and he informed her that resident had left. The nursing assistant, Employee E14 reported to the licensed nurse, Employee E17, that resident was missing, who reported it to Employee E16, the nursing supervisor. Review of the statement by the nursing assistant indicated that the last time the she had seen the resident was 7:25 p.m. when he was in his room and refused to get ready for bed. Review of the statement by the licensed charge nurse, Employee E17, indicated that the last time she saw resident was at 8:05 p.m. when he was observed sleeping in bed with the walker at the foot of the bed. Review of the statement by Employee E18, licensed nurse, revealed she was on a break at approximately 8:35 p.m. out back and heard a man's voice yelling and Employee E16, nursing supervisor, came outside looking for the resident. The statement stated that Employee E16 and Employee E18 heard yelling and followed the voice which was coming from the dietary loading dock. Resident R441 was found leaning against the dock, and he stated that he fell and hit his head and that he had pain in right hip. Employee E16 asked resident where he was going and he answered, to my house. Resident was dressed with sneakers on his feet. Review of Resident R441's record revealed he was admitted to the short term unit of the facility for rehabilitation. Observation of the location of the resident's room on the day of the elopement, (MONTH) 18, 2019, found that the room was located approximately ten feet away from double doors that led to the dietary department via a hallway approximately ten feet in length leading to a second set of double doors leading directly into the dietary department. There was a door to the outside of the building off the hallway which was not equipped with an alarm when opened. The door to the outside of the building was approximately 80 feet from the dietary loading dock where the resident was found. During the interview with the resident following the elopement by Employee E16, he was unable to remember how he got to the loading dock. Interview with the Nursing Home Administrator on (MONTH) 7, 2019, at approximately 12:15 p.m. confirmed that the resident was not properly supervised and monitored which resulted in an elopement and injury to the resident. The facility failed to ensure that the residents' environment was safe and free of accident hazards by not ensuring that all agency staff received adequate fire safety education and failed to monitor one resident who eloped from the facility resulting in actual harm to the resident who sustained a [MEDICAL CONDITION]. Refer to F726, F838, F865. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 05/07/18, 03/01/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/25/18, 05/07/18, 03/01/17 28 Pa. Code 201.18(b)(1) Management Previously cited 05/07/18, 03/01/17 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 05/07/18 28 Pa. Code 201.20(c)(d) Staff development 28 Pa. Code 211.5(f)(h) Clinical records Previously cited 05/07/18 28 Pa. Code 211.5(g) Clinical records 28 Pa Code 211.11(d) Resident care plan Previously cited 05/07/18 28 Pa. Code 211.12(c) Nursing services Previously cited 05/07/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 05/07/18, 11/21/17, 03/01/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/07/18

Based on a review of clinical records, facility documentation and select facility policies and procedures and staff interview, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication administration resulting in a significant medication error and change in condition due to a medication overdose for one of 37 residents reviewed (Resident R103). Findings include: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.14. (a) A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. Review of facility policy, Medication Administration, dated last reviewed (MONTH) 24, (YEAR), revealed that licensed staff may transcribe and administer medications upon verification of a valid order from facility medical staff. The physician order [REDACTED]. Review of the clinical record for Resident R103 revealed that the resident was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident R103's clinical record revealed nursing progress notes dated (MONTH) 2, (YEAR), which indicated that Resident R103 had been found obtund (unresponsiveness) and only responded to pain. At 11:00 p.m., the nurse documented that emergency transport was called to take the resident to the hospital for further evaluation. Review of the hospital emergency room assessment, dated (MONTH) 3, (YEAR), indicated that upon arrival in the emergency room at approximately 1:12 a.m., Resident R103 was unresponsive (not arousable), not alert. The emergency room documentation further indicated that the resident presents with altered mental status. The onset was just prior to arrival. The character of the symptoms is decreased responsiveness. The degree at present is severe. emergency room documentation further indicated that the resident, . was in her normal health all day, last seen at 2200 (10:00 p.m.) for meds and then 2300 (11:00 p.m.) found to be unresponsive. Ambulance called one hour later. Staff think they may have given her 200 mg (milligrams) [MEDICATION NAME] (Antipsychotic drug used treat severly ill [MEDICAL CONDITION] patients) instead of her [MEDICATION NAME] ([MEDICATION NAME]-medication used to treat anxiety). A review of the facility documentation revealed a written statement dated (MONTH) 3, (YEAR), for Employee E7, Registered Nurse, who took care of Resident R103 on (MONTH) 2, (YEAR). The nurse wrote that an additional medication was administered to Resident R103 on (MONTH) 2, (YEAR). The medication [MEDICATION NAME] (an antipsychotic) was not ordered by the physician; however the nurse gave it to Resident R103, in error. This medication ([MEDICATION NAME]) was ordered for another resident. Resident R103 was subsequently found unresponsive and required emergency transport to the hospital for further evaluation and treatment due to a medication error. Further review of Resident R103's clinical record revealed a physician's orders [REDACTED]. Continued review of physician's orders [REDACTED]. Interview with Employee E2, Assistant Director of Nursing, on (MONTH) 4, (YEAR), at 11:18 a.m. confirmed that the medication error that occurred on (MONTH) 2, (YEAR), resulted in actual harm to Resident R103 who subsequently was transferred to the emergency room for further evaluation and treatment. Interview with Employee E1, Nursing Home Administrator, on (MONTH) 4, (YEAR), at 11:30 a.m. confirmed that the Registered Nurse, Employee E7, violated the rights of medication administration when taking care of Resident R103 on (MONTH) 2, (YEAR). The nurse failed to identify the correct resident, medication, route, time and dose prior to medication administration. The facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication administration. Services Provided Meet Professional Standards CFR(s); 483.21(b)(3)(i) - Previously cited 11/21/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/08/16 28 Pa. Code 201.18(b)(3) Management Previously cited 05/18/16 28 Pa. Code 211.9(a)(d)(e) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Previously cited 03/01/17 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/21/17, 03/01/17, 04/08/16

Based on observation, review of clinical records and facility policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure that four of 35 residents reviewed (Residents R103, R223, R277, R24) received treatment and care in accordance with professional standards of practice and the comprehensive care plan resulting in harm to one resident (Resident R103) who received a medication that was not given according to the physician's orders [REDACTED]. Findings include: According to the Commonwealth of Pennsylvania, Pennsylvania Code, Title 49, Professional and Vocational Standards, (MONTH) 2004, a registered nurse was responsible to administer a drug ordered for a patient in the dosage and manner prescribed. Clinical record review for Resident R103 revealed that this resident had [DIAGNOSES REDACTED]. Nursing progress notes dated (MONTH) 2, (YEAR), revealed that Resident R103 was found obtund (unresponsiveness) and was only responding to pain, and at 11:00 p.m. the nurse documented that emergency transport was called to take the resident to the hospital for further evaluation. The hospital emergency room assessment documentation indicated that upon arrival Resident R103 was unresponsive, not alert. The emergency room documentation indicated that the facility may have given the resident the wrong dose of medication. Blood testing (toxicology) at the hospital revealed that Resident R103 had positive levels of benzodiazepine (a class of drugs commonly prescribed to treat anxiety, [MEDICAL CONDITIONS], and alcohol dependence) in the blood stream. The resident had physician's orders [REDACTED]. This medication was in the pharmacologic category of a benzodiazepine. Clinical record documentation indicated that the nursing staff administered the [MEDICATION NAME] to Resident R103, as ordered by the physician, at 9:00 p.m. on (MONTH) 2, (YEAR). A review of facility documentation revealed a written statement dated (MONTH) 3, (YEAR), from Employee E7, Registered Nurse, that took care of Resident R103 on (MONTH) 2, (YEAR). The nurse wrote that an additional medication was administered to Resident R103 on (MONTH) 2, (YEAR). The medication [MEDICATION NAME] (an antipsychotic) was not ordered by the physician; however, the nurse gave it to Resident R103, causing an overdose. This medication ([MEDICATION NAME]) was another resident's medication and was administered causing a negative medication to medication interaction for Resident R103. Interview with the Assistant Director of Nursing, Employee E2, on (MONTH) 4, (YEAR), at 11:18 a.m. confirmed the medication error that occurred on (MONTH) 2, (YEAR), which resulted in harm to Resident R103. During an interview with the Nursing Home Administrator, at 11:30 a.m. on (MONTH) 4, (YEAR), it was confirmed that Employee E7 administered the wrong medication when taking care of Resident R103 on (MONTH) 2, (YEAR). Review of facility policy and procedure titled, Observation of Neurological Signs, (nerve function assessment) dated (MONTH) 22, 2013, indicated that it is facility practice to ensure, Observation of neurological signs is conducted on all residents who sustain a head injury or at the discretion of the physician. The policy also indicated, Neuro signs are monitored IMMEDIATELY following any head injury, every 15 minutes x 4, then every 30 minutes x 2, followed by every four hours x 5, and then every shift until the completion of 72 hours, unless ordered otherwise. Review of Resident R223's clinical record revealed a physician's orders [REDACTED]. Review of Resident 223's care plan, dated (MONTH) 16, (YEAR), indicated Resident R223 was legally blind and was a moderate risk for falls related to being legally blind. The fall care plan indicated measures for maintaining a safe environment for Resident R223 related to preventing falls and accidents. Review of annual Minimum Data Set assessment (MDS - periodic assement of resident needs) dated (MONTH) 4, (YEAR), indicated that Resident R223 was identifed as having modified independence in decision making. Continued review of Resident R223's clinical record revealed a nursing note, dated (MONTH) 5, (YEAR), which indicated that Resident R223 was found lying on the floor of her room at 2:45 p.m. with a laceration above her right eyebrow that was bleeding and had swelling to her right eye. The resident was guarding her right arm and indicated pain in her right arm. An interview with Employee's E5 and E15, both Licensed Nurses, confirmed that there was no indication that neuro signs were completed on Resident R223 after sustaining a fall, which resulted in a head injury before being transferred to the local hospital for evaluation and treatment. The employees also confirmed that Resident R223 sustained a brain bleed (an artery bursts in the brain, causing localized bleeding in the surrounding tissue) as a result of the fall and injury to head. Clinical record review indicated that Resident R284 revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].-400 administer 8 units Humalog, 401 to 450 administer 10 units Humalog). Resident R284 also had physician's orders [REDACTED]. Employee E8, Registered Nurse, confirmed during an interview at 10:00 a.m. on (MONTH) 2, (YEAR), that Resident R284 leaves the facility at 9:00 a.m. and returns at 3:30 p.m. on scheduled [MEDICAL TREATMENT] (a process that removes toxins from the blood) days. For the months of (MONTH) and (MONTH) (YEAR), there was no documentation to indicate that the nursing staff were following the physician's orders [REDACTED]. Review of facility policy titled, Urinary Catheter Maintenance and Monitoring, dated (MONTH) 11, (YEAR), stated, All residents with a urinary catheter will be monitored for intake and output every shift. Review of the clinical record for Resident R277 revealed that the resident was admitted to the facility with admitting [DIAGNOSES REDACTED]. Additional review of the clinical record revealed a physician's orders [REDACTED]. Review of the Treatment Administration Records (TAR) for the months of (MONTH) (YEAR) and (MONTH) (YEAR), revealed several shifts for which documentation was missing to verify that catheter care had been performed as required by the care plan or that catheter output had been recorded as required by the policy. An interview with Assistant Director of Nursing, Employee E2, on (MONTH) 4, (YEAR), at 11:00 a.m. confirmed that there was incomplete documentation on the treatment administration records. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan and the residents' choices, resulting in actual harm to one resident. CFR 483.25 Quality of Care Previously cited 04/08/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/08/16 28 Pa. Code 201.18(b)(1) Management Previously cited 03/01/17, 04/08/16 28 Pa. Code 201.18(b)(3) Management Previously cited 05/18/16 28 Pa. Code 211.5(f) Clinical records Previously cited 04/08/16 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/21/17, 03/01/17, 04/08/16 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 03/01/17, 04/08/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 04/08/16

Based on a review of clinical records, medication error reports, select incident and accident reports and select facility policy and staff and resident interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 21 residents reviewed (Resident 246). Findings include: A review of facility policy entitled, Medication Administration, last reviewed by the facility (MONTH) 28, (YEAR), revealed that medications shall be administered in a safe and timely manner. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Review of facility policy revealed that licensed staff may transcribe and administer medications upon verification of a valid order from facility medical staff. The physician order [REDACTED]. Review of the clinical record for Resident R103 revealed that the resident was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident R103's clinical record revealed nursing progress notes dated (MONTH) 2, (YEAR), which indicated that Resident R103 had been found obtund (unresponsiveness) and only responded to pain. At 11:00 p.m., the nurse documented that emergency transport was called to take the resident to the hospital for further evaluation. Review of the hospital emergency room assessment, dated (MONTH) 3, (YEAR), indicated that upon arrival in the emergency room at approximately 1:12 a.m., Resident R103 was unresponsive (not arousable), not alert. The emergency room documentation further indicated that the resident presents with altered mental status. The onset was just prior to arrival. The character of the symptoms is decreased responsiveness. The degree at present is severe. emergency room documentation further indicated that the resident . was in her normal health all day, last seen at 2200 (10:00 p.m.) for meds and then 2300 (11:00 p.m.) found to be unresponsive. Ambulance called one hour later. Staff think they may have given her 200 mg (milligrams) Clorazaril (Antipsychotic drug used treat severly ill [MEDICAL CONDITION] patients) instead of her [MEDICATION NAME] ([MEDICATION NAME]-medication used to treat anxiety). A review of the facility documentation revealed a written statement dated (MONTH) 3, (YEAR), for Employee E7, Registered Nurse, who took care of Resident R103 on (MONTH) 2, (YEAR). The nurse wrote that an additional medication was administered to Resident R103 on (MONTH) 2, (YEAR). The medication [MEDICATION NAME] (an antipsychotic) was not ordered by the physician; however the nurse gave it to Resident R103, in error. This medication ([MEDICATION NAME]) was ordered for another resident. Resident R103 was subsequently found unresponsive and required emergency transport to the hospital for further evaluation and treatment due to a medication error. Further review of Resident R103's clinical record revealed a physician's orders [REDACTED]. Continued review of physician's orders [REDACTED]. Interview with Employee E2, Assistant Director of Nursing, on (MONTH) 4, (YEAR), at 11:18 a.m. confirmed that the medication error that occurred on (MONTH) 2, (YEAR), resulted in actual harm to Resident R103 who subsequently was transferred to the emergency room for further evaluation and treatment. Interview with Employee E1, Nursing Home Administrator, on (MONTH) 4, (YEAR), at 11:30 a.m. confirmed that the Registered Nurse, Employee E7, violated the rights of medication administration when taking care of Resident R103 on (MONTH) 2, (YEAR). The nurse failed to identify the correct resident, medication, route, time and dose prior to medication administration. The facility failed to ensure that one resident was protected from a serious medication error resulting in harm to the resident and requiring transport to the hospital for an emergent evaluation and treatment following a medication error. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/08/16 28 Pa. Code 201.18(b)(3) Management Previously cited 05/18/16 28 Pa. Code 211.9(a)(d)(e) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Previously cited 03/01/17 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/21/17, 03/01/17, 04/08/16

Based on observations of resident care, clinical record and policy and procedure reviews, interviews with residents and staff, and reviews of pertinent facility documentation, it was determined that the facility failed to provide adequate supervision, care and assistance to prevent accidents for two of thirty-one residents reviewed for falls including falls with major injury, for one of thirty-one residents reviewed for speciality care in the rehabilitative services department and failed to secure potential environmental hazards from improper use by the cognitively impaired residents on the Eight North nursing unit. The residents injuries from falls and the improper use of a hot pack resulted in actual harm (Residents R96, R36, R202). Findings include: The minimum data set (an assessment of care needs) dated May 5, 2015 for Resident R96 indicated that this resident was cognitively intact, had a [DIAGNOSES REDACTED]. The assessment indicated that Resident R96 was receiving occupational therapy and that the resident's skin condition was impaired with a second or third degree burn. Clinical record review revealed that Resident R96 began occupational therapy services in February, 2015. There was no care plan devised for the use of hot pack therapy for Resident R96. This lack of care planning was confirmed during an interview with the director of rehabilitation services, Employee E6 at 11:00 a.m., on May 6, 2015. A review of the facility's incident/accident form indicated that Resident R96 sustained a burn measuring 3.0 cm. by 1.5 cm. by .1cm from a hot pack placed on the resident's right arm by the occupational therapy assistant on April 17, 2015. The facility's incident form indicated that Resident R96 reported having no have feeling in the right arm. The resident was unable to notify the therapist that the hot pack felt warm/hot. A review of the facility policy for hot pack therapy indicated that prior to beginning this type of therapy a resident's cognition, communication and sensation was to be assessed. Resident R96 had [DIAGNOSES REDACTED]. Both of these [DIAGNOSES REDACTED]. Based on these [DIAGNOSES REDACTED]. According to the facility's hot pack policy the therapist was required to check the resident's skin 5 minutes after application of the hot pack. There was no clinical record documentation to indicate that this was done by the staff member on April 15, 16 or 17, 2015. The hot pack policy indicated that eight to ten layers of toweling were to be used to wrap the hot pack before applying to the resident's skin. According to an interview with the director of rehabilitation, Employee E6, the therapy staff member did not use the proper amount of toweling on April 17, 2015 for Resident R96's hot pack therapy. Observation of Resident R96's treatment to the right arm burn at 10:30 a.m., on May 7, 2015 revealed an open blister measuring 1.0 cm by 1.5cm by 0.1cm. Resident R96 reported having no pain at the wound site during application of the treatment as ordered by the physician. The facility failed to provide adequate supervision, care and assistance to prevent the resident from receiving a burn to the upper extremity. Review of Resident R36's clinical record revealed an including October, 2014 physician orders, showed [DIAGNOSES REDACTED]. Further review of the physician's orders and plan of care, revealed that Resident R36 was to be assisted by two staff members for ambulation and transfers. Review of facility documentation dated October 23, 2014, revealed that at approximately 8:15 a.m. Resident R36 was ambulating in her room with the help of one certified nursing assistant. As Resident R36 approached the doorway, the resident fell forward onto the floor hitting the left side of the resident's face. Resident R36 had a brief period of unresponsiveness, a change in mental status, and noted to have a large amount of blood draining from the left side of the forehead. Resident R36 was transferred via 911 to a trauma center for evaluation, and was admitted to the hospital's intensive care unit with a [DIAGNOSES REDACTED]. The unit manager interviewed on May 6, 2015 at 10:30 a.m., confirmed the events of the fall of R36 on October 23, 2014, and that the resident was ambulating with the assist of one certified nursing assistant, instead of the assist of two as indicated on October 2014 physicians orders and plan of care. Review of Resident R36's plan of care dated October 2014, indicated safety measures and intervention for fall prevention to maintain a safe environment during ambulation and transfers by providing the assist of two certified nursing assistants. Based on clinical documentation, physician's records for October 2014, review of a record and the plan of care, there is no evidence that the facility followed the physician's orders or the plan of care to provide adequate supervision of R36, during ambulation, resulting in a fall which caused actual harm to the resident. The facility failed to ensure that the resident was provided a safe environment including adequate supervision consistent with a resident's needs, goals, plan of care, and standards of practice in order to reduce the risk of a fall or accident. Review of the clinical record for Resident R202 revealed an annual Minimum Data Set Assessment (MDS-periodic assessment of needs), dated November 5, 2014, indicating [DIAGNOSES REDACTED]. Review of an occupational therapy treatment encounter note, dated February 23, 2015, revealed that Resident R202 was signed off the unit for therapy by Employee E14, certified occupational therapy aide, that the resident was offered leg rests for the wheelchair by Employee E14, and the resident refused the leg rests. The note further indicated that in transit to the rehabilitation gym, Resident R202 dropped a foot to the floor, and the resident fell from the wheelchair to the floor face first. Review of a nursing progress note, dated February 23, 2015, revealed that Resident R202 fell and the resident's physician was made aware of the resident's current condition of abrasion (superficial scratch) and small hematoma (localized collection of blood resembling a large bruise) to the forehead. Review of another nursing progress note, dated February 24, 2015, revealed a hematoma persisted to Resident R202's forehead with ecchymotic (bruises) areas to both eyes, and cut to nose and lip. Review of the facility's investigation report revealed that on February 23, 2015, at approximately 10:00 a.m., Employee E14, certified occupational therapy aide, was transporting Resident R202 in a wheelchair and did not attach the leg rests to the wheelchair because the resident refused. During transit, the resident's leg dropped to the floor, resulting in the resident falling from the chair face first. Review of an occupational therapy treatment encounter note, dated February 24, 2015, revealed that Resident R202 complained of pain in the left knee from wearing leg rests, and stated that is why the resident does not like to wear them. The encounter note further indicated that Resident R202's wheelchair was provided with new leg rests. Observation of Resident R202 on May 6, 2015, at 3:15 p.m., revealed the resident was observed to have a fading bruise under the right eye. Additional observation of Resident R202 on May 7, 2015, at approximately 10:30 a.m., revealed the resident sitting in the bedroom in a wheelchair without leg rests on the wheelchair. During the observation, Employee E15, hairdresser, was noted to come in to Resident R202's room, and wheeled the resident out of the bedroom without leg rests in place. Approximately five minutes later, Employee E15 came back into Resident R202's room to retrieve the leg rests. Interview with Employee E6, Director of Physical Rehabilitation, on March 8, 2015, at 2:30 p.m., confirmed that Resident R202 should have wheelchair leg rests attached to the wheelchair for any transportation by staff members. A review of the Census and Condition Report for the 8 North nursing unit received on May 5, 2015 revealed that the nursing unit had a total of 47 Residents and that all of the residents had [DIAGNOSES REDACTED]. Observation of the 8 North nursing unit on May 8, 2015 at 10:30 a.m., accompanied by Employee E1, registered nurse manager, revealed a community bathroom located across from room 807. Multiple canisters of germicidal, disinfectant wipes, containing 160 6-inch by 6-inch wipes, for use on hard non-porous surfaces were observed. Two canisters were located on top of the sink right next to the toilet and one had the cover open. These canisters were marked "Danger Keep Out of the Reach of Children". In addition, the top of the canister was marked with a large red circle with a line thru it and stated "This is not a skin wipe, for use on hard surfaces only." Employee E1 stated at that time that the canisters should not be there. A canister of the disinfectant was also located in the community bathroom across from room 807 and two more containers were located in the bathroom opposite room 823. All of the canisters were located in places within easy reach of confused residents. The facility failed to maintain a safe physical environment for residents at risk. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/04/14. 28 PA Code: 211.12(d)(3) Nursing services.