Every finding on record at Pleasant Acres Rehabilitation and Nursing Center

Based on review of facility meal tray test form, select facility grievances, review of resident council meeting minutes, review of the menu and select facility recipes, observations, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.Findings include: Review of form, titled Food and Nutrition Services Test Tray and Accuracy Evaluation last revised January 3, 2025, revealed Standard Temperatures for hot foods at point of service is greater or equal to 135 degrees Fahrenheit (F- unit of measure); and the Standard Temperature for milk at point of service is less than or equal to 45 degrees F. Interview with Resident 1 on April 6, 2026, at 11:33 AM, revealed she dislikes the food, and was served items she dislikes. Interview with Resident 29 on April 6, 2026, at 12:23 PM, he stated the hot food is served cold, and the vegetables are hard. Interview with Resident 133 on April 6, 2026, at 12:35 PM, it was stated that hot food is served cold. Interview with Resident 241 on April 6, 2026, at 12:10 PM, he doesn't like the taste of the food. Interview with Resident 8 on April 7, 2026, at 9:44 AM, revealed the temperature and taste of the food are poor. Review of resident council meeting minutes on January 23, 2026, read, in part, Residents have concerns with food temperatures/timing of trays. Review of facility grievance log from February 2026 revealed a grievance filed on February 3, 2026, that stated, Meal on lunch tray was cold today. Meals are always cold. Review of facility grievance log from March 2026, revealed a grievance filed on March 23, 2026, that stated, Food not palatable. Review of facility menu on April 7, 2026, revealed the main lunch meal consisted of Roast Turkey, Mashed Potatoes, Lima Beans, and Chilled Pears. Observation of Resident 8's meal tray on April 7, 2026, at 1:31 PM, revealed he had eaten everything on his plate except for the lima beans, which were left untouched, and appeared opaque white, overcooked, dry, and blistered. Review of facility menu on April 8, 2026, revealed the main lunch meal consisted of Polish Sausage, Mac-N-Cheese, Braised Cabbage, Cornbread, and Pineapple Tidbits. A test tray was completed on April 8, 2025, at 12:46 PM, with Employee 3 (Certified Dietary Manager) that included the Polish Sausage, Mac-N-Cheese, Braised Cabbage, Cornbread, Pineapple Tidbits, Milk, and Coffee. The test tray was placed on a meal cart and delivered to M4 unit with other trays being delivered at that time. Employee 3 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the sausage had a highest recorded temperature of 123 degrees F; the macaroni and cheese had a highest recorded temperature of 119 degrees F; the cabbage had a recorded highest temperature of 116 degrees F; and the milk had a lowest recorded temperature of 51.8 degrees F. The aforementioned food and the milk were not served at appetizing temperatures. The macaroni was not cheesy with a sauce and was bland and covered in small green specks of seasoning. During an interview with Employee 3 on April 8, 2025, at 12:46 PM, at 12:49 AM, he revealed the aforementioned food and beverage temperatures were not within acceptable ranges. Review of the recipe that was provided for Macaroni-N-Cheese, read, in part, [NAME] macaroni in salted boiling water until tender. Do not overcook. Rinse with cold water. Prepare white sauce in a large pot by bringing milk to a simmer. Add all 4 cheeses. Stirring occasionally to avoid from sticking or burning. Add seasonings to cheese sauce. Add macaroni and stir gently. Further review of the recipe failed to reveal any green seasoning. During an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (Assistant Nursing Home Administrator) on April 9, 2026, at 10:44 AM, the surveyor revealed the concern with food palatability and the test tray results. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in five of five nourishment areas.Findings include: Review of facility policy, titled Food from Home- Safety last revised April 3, 2023, read, in part, It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy. Proper labeling and dating of each item. Leftover foods will be used within 3 days or discarded. Food requiring refrigeration will be received by the facility designee for proper and immediate storage including labeling and dating. Observation in the M1 pantry area refrigerator on April 6, 2026, at 10:33 AM, revealed a plastic bag that was not dated and contained slices of pizza with green spots on them consistent with mold; a container of sour cream not dated; and a container of soup not labeled with a residents name or dated. Observation in the M2 pantry area refrigerator on April 6, 2026, at 10:43 AM, revealed one bag of sliced cheese with a sell by date of March 2, 2026; one container of desserts not dated; two containers of food not dated; one plastic bag of food items in containers not dated; one egg salad sandwich not dated; one bag of Styrofoam take out containers not labeled with a resident's name or dated; two grocery bags of food not labeled with a resident's name or date; one bag of Styrofoam containers of takeout dated March 24, 2026, and three containers of yogurt from an outside source not labeled with a resident's name. Observation in the M3 pantry area freezer on April 6, 2026, at 10:55 AM, revealed one box of takeout pizza from November 2025. Observation in the M3 pantry area ice machine April 6, 2026, at 10:58 AM, revealed black and orange spots on the white part of the ice machine under the door that were able to be wiped away. Observation in the M5 pantry area ice machine April 6, 2026, at 11:03 AM, revealed black and orange spots on the white part of the ice machine under the door that were able to be wiped away. Observation in the M5 pantry area freezer on April 6, 2026, at 11:04 AM, revealed one container of ice cream from an outside source with a best by date of December 3, 2025; one packet of pancake syrup not dated; and one bag of food for a resident not dated. Observation in the M5 pantry area refrigerator on April 6, 2026, at 11:06 AM, revealed one container of rice without a resident's name or date; one black bag of food wrapped in foil without a resident's name or date; one ham sandwich not dated; one paper box container of food not dated; food wrapped in foil without a resident's name or date; one container of pizza without a date; and one Styrofoam container from an outside source not dated. Further observation in the M5 refrigerator revealed it was heavily soiled and had brown liquid spilled on the top shelf. Observation in the M4 pantry area freezer on April 6, 2026, at 11:11 AM, revealed foil wrapped food items with a resident's name but not dated; one container of sherbet labeled use by January 8, 2026; one ice cream cake not dated; one ice cream cake not labeled with a resident's name or date and not properly sealed; and one ice cream bar from an outside source not labeled with a resident's name or date. Observation in the M4 pantry area refrigerator on April 6, 2026, at 11:15 AM, revealed one package of chocolate candy without a resident's name and a best by date of November 2024; one danish without a resident's name or date; one container of chocolate candy bars not labeled with a resident's name or date; one fruit tart not labeled with a residents name or date; and one container of food not labeled with a resident's name or date. During an interview with the Nursing Home Administrator on April 7, 2026, at 2:11 PM, he revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policy, and equipment is kept clean in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 35 residents reviewed (Residents 13 and 176).Findings Include: Review of Resident 13's clinical record revealed diagnoses that included bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood episodes, ranging from extreme highs to severe lows) and dementia (a general term for severe mental function loss). Review of Resident 13's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated February 11, 2026, indicated in Section N0450 Antipsychotic Medication Review, section E, that Resident 13 had a GDR (gradual dose reduction) declined by the physician on December 17, 2025. Review of Resident 13's clinical record failed to reveal any evidence that Resident 13 had an antipsychotic GDR recommended or declined on December 17, 2025 Interview with the Director of Nursing (DON) on April 8, 2026, at 11:45 AM, revealed that it was marked in error and a correction was being completed. Review of Resident 176's clinical record revealed diagnoses that include muscle weakness (weakness in the muscles not explained by any medical diagnosis) and major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) Review of Resident 176's Significant change MDS dated [DATE], indicated in Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), that Resident 176 had one fall with no injury and one fall with major injury during the look-back period. Review of Resident 176's clinical record failed to reveal any falls during the lookback period. Interview with the DON on April 8, 2026, at 11:45 AM, revealed that Resident 176's MDS was marked in error, and it referred to falls that happened prior to the look-back period and that an MDS modification would be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure professional standards were followed when medications were left in the resident's room for one of 35 residents reviewed (Resident 41), and failed to accurately document the location of the treatment on the physician orders, the location of the skin tear on the care plan, and failed to apply a dressing as ordered by the physician for one of 35 residents reviewed (Resident 252).Findings include: Review of the facility policy, titled Self-Administration of Medications, last review date March 2026, stated, If the resident desires to self-medicate or is appropriate for self-administration teaching for discharge, an assessment will be completed by the nurse and reviewed by the IDT prior to implementing. Review of Resident 41's clinical record revealed diagnoses that included bipolar disorder (a chronic mental health condition characterized by intense mood shifts) and mixed obsessional thoughts and acts (a type of obsessive-compulsive disorder). Review of Resident 41's physician orders failed to include an order to self-administer medications. Observations made during an interview with Resident 41 on April 6, 2026, at 11, 2025, at 10:44 AM, revealed Systane Ultra Ophthalmic Solution 0.4-0.3 % on the Resident's bedside stand. Resident 41 said he does not pay for them, and added sometimes he administers the drops and sometimes the staff administers the drops. A review of the clinical record failed to reveal a resident assessment to self-administer medications. Observation on April 7, 2026, at 12:50 PM, revealed no eye drops on the bedside stand. Resident was asked about his eye drops that were present the day before. Resident 41 said he is no longer allowed to self-administer his eye drops and that staff placed them in the medication cart. During an interview with the Director of Nursing (DON) on April 8, 2026, at 2:33 PM, it was confirmed Resident 41 was not permitted to self-administer his medications and added that she spoke with a nurse who informed her that she forgot to take the Systane from Resident 41's room during the AM medication pass on April 6, 2026. Review of facility policy, titled Clean Non-sterile Dressing Change, last reviewed January 2026, read, in part, review the resident's care plan, current orders, and diagnoses. Check the treatment record. Review of Resident 252's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), obesity, and abnormal gait. Review of Resident 252's physician orders included to cleanse left elbow with normal saline solution, apply a non-adherent dressing, and secure in place with roll gauze one time a day and as needed, with a start date of April 2, 2026, and a discontinued date of April 7, 2026, at 3:07 PM. Review of Resident 252's treatment administration record documented the aforementioned treatment to the left elbow was completed April 2nd through 7th, 2026. Review of Resident 252's care plan included a focus area for open skin areas: incontinence-associated dermatitis on sacral crease and a skin tear to his left elbow, date-initiated March 6, 2026, and revised April 1, 2026. Review of Resident 252's progress notes documented a fall on April 1, 2026, he sustained a skin tear on his right elbow. Observation of Resident 252's elbows on April 6, 2026, at 10:07 AM, revealed a foam dressing on the right elbow; not marked with a date or initials, and the upper right corner was rolled back; no dressing to left elbow. Additional observation on April 7, 2026, at 2:59 PM, with Employee 8 (Registered Nurse, Unit Manager) revealed Resident 252 had a scabbed area on his right elbow that didn't contain a dressing. At that time, Employee 8 revealed the physician order and care plan documented the incorrect area of the skin tear and the area on the right elbow should contain a dressing. Interview with the Nursing Home Administrator and DON on April 8, 2026, at 3:10 PM, it was revealed the physician's order and care plan documented the incorrect location of the treatment and skin tear, and the treatment to Resident 252's right elbow should've been in place. The facility failed to accurately document the location of the skin tear on the physician orders and the care plan and failed to apply a dressing as ordered by the physician. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, facility policy review, product packaging, and staff interview, it was determined that the facility failed to store medication in accordance with manufacture guidelines for two of five medication carts reviewed (5th floor, South hall medication cart and 5th floor, North hall medication cart).Findings Include: Review of facility provided policy, titled Medication Storage, revised March 2021, revealed, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Observation of the 5th floor, South hall medication cart on April 8, 2026, at 10:57 AM, revealed one insulin aspart (diabetic medication) pen that was removed from refrigeration on December 24, 2025; two insulin aspart pens with no date removed from refrigeration; one Humulin (diabetic medication) 70/30 pen with no date removed from refrigeration; two Lispro (diabetic medication) pens with no date removed from refrigeration; one Lantus (diabetic medication) pen with no date removed from refrigeration; and one Lantus vial with no date removed from refrigeration. Observation of the 5th floor, North hall medication cart on April 8, 2026, at 10:57 AM, revealed one Humalog (diabetic medication) 75/25 with no date removed from refrigeration; four insulin aspart pens with no date removed from refrigeration; one lispro pen with no date removed from refrigeration; and two Lantus pens with no date removed from refrigeration. Review of Lantus product packaging on February 26, 2025, revealed when opened or removed from refrigeration, Lantus should be discarded after 28 days. Review of insulin aspart product packaging on February 26, 2025, revealed unopened medication should be stored in a refrigerator at a temperature between 36 to 46 degrees Fahrenheit (F) and should be discarded 28 days after removed from refrigeration. Review of Humalog product packaging, revised August 14, 2017, revealed unopened medication should be stored in a refrigerator at a temperature between 36 to 46 degrees F and should be discarded 28 days after removed from refrigeration. Review of Humulin 70/30 product packaging, revised December 2025, revealed a Humulin 70/30 pen can only be used for a total of 10 days after removed from refrigeration, whether opened or unopened. Interview with the Director of Nursing on April 9, 2026, at 10:35 PM, revealed an expectation that the product instructions would be followed, and the medication would be stored properly. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen. Findings include: Review of facility policy, titled Personal Hygiene, revised January 2026, read, in part, cover facial hair with a beard guard, nails trimmed and clean with unpolished fingernails. Review of facility policy, titled Dress Code, not date marked, read, in part, disposable gloves are single use and changed between tasks. Observations on February 9, 2026, in the kitchen revealed the following: At 11:16 AM, Employee 2 (Food Service Director) was preparing food for the lunch meal, removed her gloves, utilized a cell phone, donned fresh gloves without completing hand hygiene and returned to preparing food. At that time Employee 2's fingernails were one inch long and contained nail polish. At 11:20 AM, Employee 1 (Dietary Aide) had a full beard and was walking through the kitchen without a beard covering.At 11:30 AM, Employee 3 (Dietary Aide) was wearing gloves, retrieved a # 10 can (3 quarts) of chocolate pudding from the storage rack; with the same gloved hand dished a portion of salad into a bowl; then proceeded to open the reach-in refrigerator; then the walk-in refrigerator; touched her face, hair, pants and sweater; opened a bag of grated cheese and touched cheese with the same gloved hand to transfer it to a container, and then topped the salad in the bowl with the cheese. Employee 3 didn't change gloves or complete hand hygiene. At 11:35 AM, Employee 4 (Dietary Aide) with gloved hands emptied a bag of lettuce on top of the lettuce already in a large metal bow; moved a cardboard box from the counter to the floor; opened a bag of red shredded cabbage and emptied it into the bowl of lettuce and tossed it with the lettuce; and portioned the lettuce out into bowls with the same gloved hands. Employee 4 didn't change gloves or complete hand hygiene.At 11:40 AM Employee 5 (Cook) with gloved hands opened frozen cauliflower, placed it into a steamtable pan; using a hot pad retrieved chicken from the oven; using the same gloved hand topped the chicken with grated cheese; delivered the pan of chicken to the steam table. Employee 5 didn't change gloves or complete hand hygiene.At 11:55 AM Employee 6 (Dietary Aide) with gloved hands operated the elevator (touching buttons, the door and security fence), and with the same gloved hand retrieved two crustless grilled cheese sandwiches from the food warmer and placed the sandwiches on a plate on the tray line. Employee 6 didn't change gloves or complete hand hygiene.Interview with the Nursing Home Administrator (NHA) and Assistant NHA on February 10, 2026, at 3:00 PM, it was revealed they were made aware of a social media post from a former Dietary Aide documenting concerns with hand hygiene, hair coverings, and other food sanitation concerns at the facility. The consultant Food Service Company completed training on hand hygiene and use of hair coverings the week prior. It was revealed that the facility training personnel would be completing additional training with the Dietary Department. 28 Pa code 211.6(f) - Dietary Services

Based on observations, staff interviews, and review of pest control service reports, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the dish room.Findings include: Observation on February 9, 2026, at 11:05 AM, in the dish room revealed there was a musty odor. There was standing water on the floor behind the dish machine, 40 floor tiles contained a black substance that couldn't be wiped away with a broom, and on the floor the cover to the sump pump contained food debris and food wrappers. The dustpan on the floor near the sump pump contained food wrappers and food particles. Under the right end of the food trough (dirty side of the dish machine) was a blue trash can filled with water. The exhaust unit from the top of the dish machine to the exterior wall was dripping water onto the floor. A dead roach was observed on the floor near the clean side of the dish machine under the wall shelf. Interview with Employees 1 and 3 (Dietary Aides) on February 9, 2026, at 11:10 AM and 11:30 AM, revealed they have observed bugs in the dish room. Observation in the dish room with Employee 7 (Maintenance Director) on February 9, 2026, at 2:30 PM, revealed the condition of the dish room was as stated above, and the dead roach remained on the floor. At that time, it was revealed that the facility is treated for pests, to include roaches weekly. It was also confirmed that standing water and food debris minimizes the effectiveness of pest control treatments. Review of the contract pest control service inspection reports revealed weekly service to the facility to include the kitchen and basement or the dish room, and targeted pests included roaches. Review of the report dated January 15, 2026, documented unable to apply treatment in the dish room because the floor was wet. Interview with the Nursing Home Administrator (NHA) and Assistant NHA on February 10, 2026, at 3:00 PM, the surveyor discussed the concern with the dead roach, standing water, and food debris on the floor of the dish room. It was revealed that the grout is scheduled to be replaced in the dish room, and that there shouldn't be standing water of food debris on the floor. 28 Pa. Code 201.18 (e)(1)(2.1) Management

Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident to be free from abuse, which resulted in mental anguish and actual harm as evidenced by multiple bruises and swelling to the right side of the resident's face, bilateral legs, and bilateral knuckle areas on his hands after an alleged staff to resident altercation for one of five residents reviewed (Resident 1).Findings Include:Review of facility policy, titled Abuse Policy- Prevention and Management, last revised September 8, 2022, read, in part, the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff, family, friends, visitors, etc. Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. Examples of injuries that could indicate abuse include but are not limited to: bruises including those found in unusual locations such as the head, and facial bruising, bleeding or swelling. The facility assumes the responsibility of ensuring the safety and well-being of the residents.Review of Resident 1's clinical record revealed diagnoses that included tremors, insomnia, disorientation, Parkinsonism (neurological conditions causing similar movement problems, primarily slowness, rigidity, resting tremor and balance issues) and dementia.Review of Resident 1's physician orders included: 1:1 monitoring for fall prevention on 7-3 and 3-11 shifts, started June 17, 2025; 15-minute visual checks on 11-7 shift for fall prevention, started June 17, 2025.Review of Resident 1's care plan included focus areas for impaired cognitive function related to dementia and Parkinsonism, initiated November 14, 2024; potential to demonstrate physical behaviors related to dementia, initiated November 25, 2024; behavioral problem related to disrobing at times without known origin, hitting, kicking, placing himself on the floor, throwing water, and refusal of care at times, initiated December 16, 2024.Review of the facility investigation report, dated November 29, 2025, revealed that Resident 1 was noted to have bruising to his face and legs in the morning that, per staff, were not present the prior evening. The Resident was assessed by a Registered Nurse who noted red/purple bruises to the right side of Resident 1's face with swelling noted to the area. Bruising was also noted to bilateral legs and to bilateral knuckle areas on the Resident's hands. Per staff, bruises were not visible the evening prior.Further review revealed the Resident speaks Vietnamese and was unable to communicate the whole story of what happened with staff. At that time, the Power Of Attorney was at bedside, however, she speaks very little English herself and had difficulty with using the translation service line. Another visitor, who is multi-lingual, was able to translate and stated that the Resident told him that on November 28, 2025, at 11:00 PM, a large black female employee came into his room and told him to straighten out his legs. The Resident stated he did, but she then hit him in the legs with a shoehorn. He then said she hit him on the face with the shoehorn and then went to hit him again, and he put his hands up, which she then hit him on the hands and then on the right thigh with it. The Resident stated he did not yell at time of incident or attempt to report it. He stated that the employee worked there often and was wearing black scrubs and had shoulder length hair. The Registered Nurse (RN) Supervisor found a shoehorn in the Resident's room. The Nurse Aide (NA) (Employee 3) was an agency employee that was assigned to the Resident during alleged time of incident and matched the Resident's description.During interviews with staff, everyone concurred that the injuries were not present the prior evening and were not seen until the morning of November 29th, 2025.Resident 1 recanted the same story of events, that his injuries were obtained by a large black female, wearing dark scrubs on November 28, 2025, at approximately 11:00 PM. The description continued to match the night shift NA (Employee 3).On December 3, 2025, using a translation line service, Resident 1 was shown photos of two women, and when asked if either of them was the female that hurt him, he clearly pointed to Employee 3's picture and stated it was her. The facility substantiated abuse and Employee 3 was terminated.Review of the Resident's clinical records revealed a Nursing progress note dated November 29, 2025, at 5:26 PM, read, in part, Resident 1 made abuse allegations. Interviewed Resident with the assistance of an interpreter, Registered Nurse assessment completed, injuries noted (swelling to right side of face) was consistent with the allegation of being struck to the right side of his face. The Police responded and attempted to interview the Resident. The Resident became very tearful stating it was already taken care of and he didn't want to talk about it anymore.A Nursing progress note dated December 1, 2025, at 10:11 AM, read, in part, full body assessment completed on November 29, 2025, in-house acquired right zygomatic (check) bone region of the face with bruising and petechiae (tiny pinpoint-sized red, purple or brown spots on the skin caused by bleeding from ruptured small blood vessels) within the discoloration noted to be reabsorbing and ranging in color red, yellow, green measuring 7.0 cm x 5.0 cm (centimeter), skin intact, offered no complaint of discomfort with gentle palpation. Intact right anterolateral (front and to the side) thigh scabbed area measuring 2.0 cm x 1.5 cm, scabbed area is linear and, on an angle, no drainage, scab intact, offered no complaint of discomfort. Review of Employee 2's (Licensed Practical Nurse [LPN]) witness statement, dated November 29, 2025, read, in part, she worked on evening shift November 28th, 2025, with another Nurse and two Nursing Assistants. Resident 1 was assigned 1:1 with a Nursing Assistant. Employee 2 wasn't aware of any issues, she did not witness any bruises, nor did staff report any concerns or bruises on Resident 1. Employee 2 also cared for Resident 1 on night shift November 28th, 2025, and Resident 1 required 15-minute checks which were assigned to Employee 3 (NA). At no time during night shift did Employee 2 witness bruises or harm to Resident 1, nor did any of his care team bring any concerns to her attention.Review of Employee 4's (NA) witness statement dated November 29, 2025, read, in part, she worked November 28th, 2025, on evening shift and cared for Resident 1, and he had no bruises. She worked November 29th, 2025, day shift and while assisting Resident 1 with breakfast she noticed a bruise. Employee 4 reported it to Employee 1 (LPN).Review of Employee 1's witness statement, dated November 29, 2025, revealed that she worked November 28th, 2025, and didn't observe bruises on Resident 1. Dayshift on November 29th, 2025, Employee 4 notified Employee 1 that Resident 1 had a big hematoma on the right side of his face. Employee 1 went to speak with Resident 1's wife who was at the bedside. Resident's wife stated that he told her someone overnight hit him with a shoehorn.Review of Employee 5's (NA) witness statement, dated December 1, 2025, revealed she didn't observe bruises on Resident 1 prior to November 29th, 2025. She also revealed that she spoke with Resident 1's wife and pastor who stated Resident 1 described the person who caused the bruises as a black lady, who was fatter/bigger than him and wore black clothing.Review of Employee 3's witness statement, not dated, revealed she worked November 28th, 2025, on night shift and Resident 1 was asleep until 3:30 AM, and at 6:00 AM she washed Resident 1 and didn't notice any bruises at time of care.A second statement, not dated, revealed she didn't see anybody go into Resident 1's room except the nurse to administer medication. At 6:00 AM, she assisted Resident 1 into the bathroom to void, wash up and assist with dressing him; no bruises were observed at that time.During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 22, 2025, at 11:21 AM, it was revealed that Employee 3 was assigned to care for Resident 1 on nightshift November 28, 2025. The shoehorn belonged to the Resident, and the wife felt it would be helpful as she utilized it at home. Resident 1 was provided two pictures that fit the description provided and he pointed out Employee 3 as the perpetrator. It was also revealed that Employee 3 had only worked on M2 and no other units.Review of facility investigation documentation included interviews with staff who worked November 28th, 2025, on evening and night shifts, and November 29th, 2025, on dayshift. Interviews were conducted with other residents who resided in the same unit and received care from Employee 3, and no other abuse concerns were reported.During an onsite visit, on December 22, 2025, at 9:00 AM, the NHA and DON provided the facility's plan of correction that was put into place as a result of the facility's abuse investigation. The facility's education and audits were reviewed during the survey.As of December 8, 2025, facility staff were educated on Abuse, Standards of Care, focusing on creating an environment of respect, dignity, and protection from harm and competency tests were completed.As of December 2, 2025, initial audits were completed to ensure no other residents were affected. Weekly audits were conducted for an additional 4 weeks. No additional abuse concerns were identified. Review of facility documentation revealed that on December 8, 2025, the facility had completed education and audits to ensure compliance.During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no abuse concerns.28 Pa. code 201.18(b)(1) Management28 Pa. Code 201.29(c) Resident rights

Based on review of facility policy, clinical record review, observations, and interviews with staff and residents, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for five of 41 residents reviewed (Residents 75, 150, 180, 195, and 310). Findings include: Review of the facility policy, titled Dignity and Respect with a last reviewed and revised date of April 2024, revealed, Residents shall be treated with dignity and respect at all times .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident 75's clinical record revealed diagnoses that included Alzheimer's disease with early onset and secondary parkinsonism (different conditions that can cause movement symptoms similar to those associated with Parkinson's disease including tremor, slowed movements, and stiffness). Observation of Resident 75 on March 18, 2025, at 1:01 PM, revealed her independently ambulating around the nursing unit. Resident 75 was observed wearing a shirt made of thin fabric with no bra, which exposed her breasts underneath. During an immediate interview with Employee 14 (Nurse Aide) she revealed that Resident 75 does wear bras, and took Resident 75 back to her room to put one on. A follow-up observation of Resident 75, at 1:34 PM, revealed she was wearing the same shirt, with a bra, making her breasts no longer visible through her shirt. Review of Resident 75's upper body dressing task documentation for that morning revealed that it was documented at 10:00 AM that she was fully dependent on staff for that activity. Review of Resident 75's care plan failed to reveal a preference for not wearing undergarments. During an interview with the Director of Nursing (DON) on March 20, 2025, at 10:13 AM, she stated that another staff member had just noticed the concern with Resident 75 and was planning to address it when Employee 14 took Resident 75 to her room to redress her. Observation of Resident 150 on March 17, 2025, at 10:01 AM, revealed Resident 150 lying in bed. Employee 10 (Housekeeper) entered the room to sweep the floor while talking on her cell phone, via an in-ear device. Resident 150 attempted to ask Employee 10 if she was going to sweep the bathroom also, to which Employee 10 motioned for Resident 150 to stop talking and then told Resident 150, I'm on the phone with my grandma. An interview with Resident 195 on March 17, 2025, at 10:34 AM, revealed that staff members often answer his call bell while talking on the phone via an in-ear device and he finds it very disrespectful. An interview with Nursing Home Administrator on March 18, 2025, at 1:15 PM, revealed that he would expect staff members to treat residents with dignity and respect. Review of Resident 180's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and unspecified psychosis (abnormal condition of the mind that involves a loss of contact with reality). Review of Resident 310's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Observation on March 17, 2025, at approximately 12:10 PM, revealed Residents 180 and 310 sitting in the dementia care unit dining room during meal service; other residents were present and eating their meals. Employee 13 (Physician) approached Residents 180 and 310, placed his stethoscope on their chests, and asked them questions about their health status. Employee 13 was not observed asking Resident 180 or 310 for permission to examine them in a common area with other residents present. During an interview with the DON on March 20, 2025, at 10:13 AM, she revealed the expectation that residents would be provided privacy during examinations. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of five nursing units (Main 1 and fifth floor nursing units). Findings include: Observation in Resident 338's room on March 17, 2025, at 10:47 AM, revealed the black plastic fan on nightstand contained a dark grey fuzzy substance. Observation on March 20, 2025, at 10:31 AM, revealed the dark grey substance remained on the black plastic fan on the nightstand. During an interview with Employee 11 (Nurse Aide) on March 20, 2025, at 10:50 AM, it was revealed that she was aware of the dirty fan in Resident 338's room. It was also revealed that she told Employee 12 (Housekeeper) about it two days ago and requested that it be cleaned. Employee 12 was on the unit and Employee 11 asked her to clean Resident 338's. Employee 12 responded that she wasn't allowed to clean the fan. At 11:05 AM, Employee 12 was observed with Resident 338's fan entering the housekeeping closet. During an interview with Employee 1 (Assistant Nursing Home Administrator) it was revealed that housekeeping should've cleaned the fan when it was observed to be dirty. Observation on March 17, 2025, at 9:39 AM, in the Main 1 (locked dementia care unit) TV lounge revealed multiple chairs with dried liquid spills and other debris on the cushions and/or frames. Additionally, approximately three chairs were observed to have cracked or ripped cushions. Observations on March 17, 2025, at 9:53 AM; on March 18, 2025, at 9:41 AM; and on March 19, 2025, at 12:45 PM, in Resident 178's room revealed a medical pump and pole. The feet of the pole were covered in a dried liquid substance. Review of Resident 178's Medication Administration Record (MAR - form used to document physician orders as well as when and how medications are administered to a resident) revealed orders for intravenous hydration, which ended on March 14, 2025. Observations on March 17, 2025, at 10:00 AM, and on March 19, 2025, at 9:47 AM, in the Main 1 dining room revealed several chairs with dried liquid spills and other debris on the cushions and/or frames. Observation on March 17, 2025, at 12:14 PM, and on March 19, 2025, at 12:46 PM, revealed Resident 178's wheelchair had an accumulation of dried food and debris on the seat and arm rests. Observation on March 17, 2025, at 12:14 PM, and on March 19, 2025, at 12:52 PM, revealed 47's wheelchair had an accumulation of dried food and debris on the seat and frame. Observation of Resident 120's bedroom floor on March 18, 2025, at 9:46 AM, revealed it felt dusty/gritty and had a dark buildup around the edges of the walls and furniture. Observation on March 18, 2025, at 12:50 PM, in Resident 327's room revealed that each drawer of a dresser next to his bed was labeled with a resident's name. The names on the labels did not match any resident residing in that room. During an interview with the ANHA on March 20, 2025, at 10:16 AM, she revealed the expectation that Resident 47 and 178's wheelchair should have been clean, and that she was looking into the last time this had been done. During an interview with the Director of Nursing on March 20, 2025, at 10:17 AM, she acknowledged the concern with the pump and pole in Resident 178's room and confirmed that the pole had been removed and cleaned. During an interview with the Nursing Home Administrator on March 20, 2025, at 10:22 AM, he revealed the expectation that the chairs on Main 1 should be clean and in good condition. He also confirmed that the labels should not have been present on Resident 327's dresser, and that Resident 120's floor needed to be cleaned. 28 Pa. Code 201.18(e)(1)(2.1) Management

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for four of 41 records reviewed (Residents 144, 161, 221, and 265). Findings include: A review of Resident 144's clinical record revealed diagnoses that included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and anxiety disorder (a group of mental health conditions characterized by excessive and persistent fear or worry, significantly impacting daily life and functioning). A review of Resident 144's care plan dated March 2025 failed to reveal a care plan for the diagnosis of dementia. During an interview with the Director of Nursing (DON) on March 19, 2025, the DON thought that his care plan for traumatic brain injury and cerebrovascular accident was adequate. A dementia care plan for Resident 144 was developed on March 19, 2025, and presented to the surveyor. Review of Resident 161's clinical record revealed diagnoses that included cerebral vascular accident (aka stroke- damage to the brain from interruption of its blood supply) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Observation of Resident 161 on March 18, 2025, revealed the presence of bilateral enabler bars attached to his bed. Review of Resident 161's current physicians orders and care plan failed to reveal the Resident had enabler bars. Further review revealed the physician orders and care plan were not updated to include the enabler bars after the Resident returned from the hospital on October 26, 2024. The Director of Nursing (DON) was able to show that maintenance has been documenting safety checks on the enabler bars. During an interview with the DON on March 19, 2025, at 9:30 AM, the DON was able to reveal that Resident 161 was assessed and ordered enabler bars prior to his hospitalization on [DATE], and agreed that the current care plan and physician orders should reflect enabler bars are being utilized by Resident 161. A review of Resident 221's clinical record revealed diagnoses that included heart failure (sometimes called congestive heart failure, which means the heart can't pump enough blood to meet the body's needs, often due to a weakened or stiff heart muscle) and a history of falls. An observation in Resident 221's room on March 17, 2025, at 11:01 AM, revealed enabler bars attached to both sides of the bed. Review of Resident 221's interdisciplinary plan of care revealed none developed regarding the use of the bilateral enabler bars. An interview with the DON on March 19, 2025, at 12:54 PM, revealed an enabler bars care plan has now been developed and added to Resident 221's interdisciplinary plan of care. A review of Resident 265's clinical record revealed diagnoses that included impaired visual function. An observation and interview with Resident 265 on March 17, 2025, at 11:55 AM, revealed her eyes to appear bloody and red. The interview revealed she received eye injections for macular edema (a condition where fluid accumulates in the macula, the central part of the retina responsible for sharp, central vision). Review of Resident 265's interdisciplinary plan of care revealed none developed to address any visual function, diagnoses, or treatment by the ophthalmologist. An interview with the Assistant Nursing Home Administrator on March 19, 2025, at 10:32 AM, confirmed a vision care plan has now been developed and added to Resident 265's interdisciplinary plan of care. 28 Pa. Code 211.10(c) Resident care policies

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide a rationale and duration for expending a PRN (as needed) psychotropic dedication beyond 14 days for one of 41 residents reviewed (Resident 92). Findings include: Review of facility policy, titled Psychotropic medication use, including use in dementia residents, reviewed November 1, 2024, revealed, PRN orders for psychotropic drugs, other than antipsychotics, may not exceed 14 days. Rationale for use extending beyond the 14 days must be documented in the medical record and indicate duration of the PRN order. Review of Resident 92's clinical record revealed diagnoses that included anxiety disorder (group of mental health conditions characterized by excessive and persistent fear or worry, significantly impacting daily life and functioning) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and or daily routine). Review of Resident 92's physician's orders revealed an order for Lorazepam (anxiety medication) gel every 2 hours as needed for agitation/anxiety, with a start date of January 28, 2025, and no end date. Review of Resident 92's electronic medical record on revealed a review of psychoactive medications, dated February 18, 2025, in which the pharmacist recommends that the physician attempt a gradual dose reduction of psychoactive medications. The physician declined the gradual dose reduction but failed to provide a rationale for extending the PRN psychotropic medication beyond 14 days and neglected to add a stop date to the order. Interview with the Nursing Home Administrator on March 20, 2025, at 10:30 AM, revealed that the expectation is that the physician would provide a rationale and duration for PRN psychotropic medications extended beyond 14 days. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards regarding the operation of the dish machine in the kitchen. Findings include: Review of facility policy, Dish Machine Temperatures, revised April 5, 2024, read, in part, dish machine final rinse temperatures should be maintained at temperature not less than those established by the Food and Drug Administration, high temperature dish machine will be no less than 180 degrees Fahrenheit (F). Observation of the dish machine on March 17, 2025, at 9:32 AM, the final rinse temperature registered 176 degrees F. Observation of the dish machine temperature log for March 1st through 17th, 2025, breakfast read, in part, the final rinse temperature was documented below 180 degrees F for all meals. During an interview with the Employee 8 (Food Service Director) on March 17, 2025, at 9:34 AM, it was revealed the final rinse temperature should be 180 degrees F . It was also revealed that the documented final rinse temperatures on the log were below the standard of 180 degrees F. During an interview with the Employee 1 (Assistant Nursing Home Administrator) on March 18, 2025, at 1:30 PM, it was revealed that the facility Maintenance Department repairs the dish machine, and a request was submitted to Maintenance to assess the final rinse temperature. It was also revealed that the facility utilized the incorrect temperature log and, therefore, the Dietary Department failed to submit a maintenance request to evaluate the final rinse temperature. It was confirmed that the final rinse temperature should be 180 degrees F, and that Maintenance did recalibrate the temperature for final rinse cycle. 28 Pa code 211.6(f) - Dietary Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 41 residents reviewed (Residents 21, 259, and 351). Findings Include: Review of Resident 21's clinical record revealed diagnoses that include anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death and potential long-term impairments) and gastro-esophageal reflux disease (a chronic condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms). Review of Resident 21's Significant change MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated December 19, 2024, revealed in Section O0110. Special Treatments, Procedures, and Programs, that Resident 21 has not been treated for in the previous 14 days while a resident. Review of Resident 21's physician's orders revealed an order from December 11, 2024, to admit Resident 21 to hospice services. Review of Resident 21's care plan revealed a care plan with a date initiated of December 12, 2024, with a focus area of, I have been admitted to hospice related to end stage disease process. Interview with the Nursing Home Administrator (NHA) on March 20, 2025, at 8:58 AM, revealed that Resident 21's MDS completed on December 19, 2024, was marked in error and that Resident 21 had been receiving hospice services at that time. Review of Resident 259's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Further review of Resident 259's clinical record revealed that, in response to a pharmacy recommendation, the physician documented on September 25, 2024, that a gradual dose reduction of her Seroquel (antipsychotic) medication was contraindicated because the benefits outweighed the risks. Review of Resident 259's December 5, 2024, quarterly MDS revealed that it was coded to indicate that the physician had not documented that a gradual dose reduction of her antipsychotic medication was contraindicated. During an interview with Employee 15 (Registered Nurse Assessment Coordinator) on March 20, 2025, at 9:36 AM, she confirmed that Resident 259's assessment should have captured the date that the physician documented that a gradual dose reduction of the antipsychotic was contraindicated. During an interview with the Assistant NHA on March 20, 2025, at 10:11 AM, she confirmed that she was aware that Resident 259's MDS was coded in error. Review of Resident 351's clinical record revealed diagnoses that included dementia and cirrhosis of liver (a chronic liver disease characterized by the replacement of healthy liver tissue with scar tissue, which can lead to liver failure and other complications). Review of Resident 351's clinical record revealed a progress note dated December 20, 2024, at 3:16 PM, indicating Resident 351 left AMA (against medical advice) with her daughter and returned to her home in the community. Review of Resident 351's discharge MDS dated [DATE], revealed that Section A2105. Discharge Status was marked that Resident 351 was discharged to a short-term general hospital (acute hospital). During an interview with the NHA on March 20, 2025, confirmed that Resident 351 did leave the facility AMA and returned home, and revealed the discharge MDS dated [DATE], was marked inaccurately and should have reflected that Resident 351 was discharged to home instead, and that a modification has been made. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident's care plan to reflect the resident's current status for two of 41 residents reviewed (Residents 161 and 327). Findings include: Review of Resident 161's clinical record revealed diagnoses that included cerebral vascular accident and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident 161's POLST (Pennsylvania orders for Life-Sustaining Treatment) and advance directive (a form to make health care decisions for the individual if the individual loses the capacity to make health care decision) on March 19, 2025, revealed the Resident desired his code status be do not resuscitate (DNR). Review of Resident 161's March 2025 physician orders revealed the Resident desired his code status DNR. A review of Resident 161's care plan dated March 2025 stated, wants to be full code. With a created date of September 30, 2024. A review of the progress notes revealed that code status was clarified to be DNR status on October 3, 2024, but the care plan was never corrected. Interview with the DON on March 19, 2025, at 10:30 AM, revealed the care plan should have matched Resident 161's physician orders, POLST and advance directive code status. Review of Resident 327's clinical record revealed diagnoses that included presence of a cardiac implant and atrial septal defect (abnormal hole in the wall between the two upper chambers of the heart). Review of Resident 327's physicians orders revealed an order to ensure each shift that the loop recorder monitor (small device implanted under the skin of the chest to continuously monitor and record the heart's electrical activity) was attached to the nightstand and was plugged in starting February 21, 2025. Review also revealed an order for quarterly remote loop recorder monitoring, starting February 21, 2025. Observation on March 18, 2025, at 12:40 PM, revealed that the loop recorder monitor was present on Resident 327's nightstand. Review of Resident 327's current care plan failed to reveal any information regarding the presence or care of his loop recorder implant. During an interview with the DON on March 20, 2025, at 10:22 AM, she revealed the expectation that this information should have been included on Resident 327's care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on staff interviews, record review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when transcribing orders and administering medications to one of 41 residents reviewed (Resident 144). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. Review of the clinical record for Resident 144 revealed diagnoses that included dysphagia following nontraumatic subarachnoid hemorrhage (bleeding into the subarachnoid space of the brain) and gastrostomy tube status (a surgically created opening in the stomach through which a tube can be inserted for feeding and administering medications). Review of Resident 144's physician orders dated March 2025 NPO (Nothing by Mouth) diet, NPO texture, NPO consistency, effective September 26, 2024. On October 18, 2024, a physician order was written to allow patient to have ~6 ice cubes x3 daily w/ staff/family supervision for pleasure every 24 hours as needed. During an interview on March 19, 2025, with Employee 18 (Speech-Language-Therapist), Employee 18 revealed that Resident 144 was evaluated and approved for ice chips to decrease atrophy of his swallowing mechanism and confirmed that all nutrition and medications are administered via his gastrostomy tube. Review of Resident 144's physician orders revealed several medications had a route ordered to administer PO (per os) indicating to administer by mouth, that included; Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Elevated Temperature Give 2 tablets (650 mg) by mouth every 6 hours as needed for elevated temperature >100.5 *Do not exceed 3 gms acetaminophen in 24 hours* Pharmacy Active 12/18/2024 03:31 Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE 3/20/25 10:42 AM Lorazepam 0.5 mg 1 tablet PO two times a day effective 10/27/2024 Further review of the MAR (medication administration record) revealed that the orders were transcribed PO and staff were signing off as administered PO. During an interview on March 19, 2025, with Employee 19 (Licensed practical Nurse), Employee 19 informed the surveyor she was fully aware that Resident 144 had a gastrostomy tube, and that all medications are administered via the gastrostomy tube. During an interview with the Director of Nursing (DON) on March 20, 2025, at 10:30 AM, the DON informed the surveyor that all medication nurses provided statements that they are aware of the gastrostomy status for Resident 144 and administer all medications via the gastrostomy tube. The DON confirmed that the orders should have stipulated the gastrostomy route for administrations, and that staff should have contacted the physician to correct the ordered route of administration on the orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 41 residents reviewed (Resident 120). Findings include: Review of Resident 120's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. Review of Resident 120's care plan revealed that she was a self care deficit and required assistance with most activities of daily living. Further review revealed that she removes her footwear and walks barefoot. Observation of Resident 120 on March 18, 2025, at 9:42 AM, revealed her asleep in bed. Her feet were exposed, and she was barefoot. A significant accumulation of dark black soiling was present on the soles of her feet. Observation of the floor in Resident 120's room revealed it felt dusty/gritty and had a dark buildup around the edges of the walls and furniture. During an immediate interview with Employee 16 (Nurse Aide) she confirmed that Resident 120 liked to go barefoot and, therefore, should have her feet washed daily. During an interview with the Director of Nursing on March 20, 2025, at 10:23 AM, she confirmed that Resident 120 does like to disrobe, independently ambulates, and staff wash her feet as needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy, review of the clinical records, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with physician orders for three of 41 residents reviewed (Residents 121, 221, and 338). Findings include: Review of facility policy, Medication Administration/Disposition, last revised September 6, 2023, read, in part, medications shall be administered in a safe and timely manner, and as prescribed by the physician. Medications must be administered within one hour of their prescribed time. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method or rout of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and use the corresponding code on the Medication Administration Record (MAR - an electronic record of medication administration) to indicate the medication was not given and the reason for not administering. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of Resident 121's clinical record documented diagnoses that included bipolar (a mental health condition alternating periods of elation and depression), schizoaffective disorder (mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, affects a person's ability to think, feel, and behave clearly), cognitive communication deficit (difficulties in communication stemming from impairments in cognitive process), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and hypothyroidism (the thyroid gland doesn't produce enough thyroid hormone). Review of Resident 121's January 2025 MAR revealed there was no documentation (the MAR was blank) for the following medications: Lantus (insulin glargine - log acting insulin used to treat elevated blood sugar) inject 15 units subcutaneously (under the skin), with a start date of November 15, 2024, at 6:30 AM; Lantus inject 46 units, with a start date of January 11, 2024, at 8:30 PM; Levothyroxine Sodium (medication use to treat hypothyroidism) 75 micrograms, with a start date of January 11, 2023, at 6:30 AM; Melatonin 3 milligrams for sleeplessness, with a start date November 27, 2023, at 8:30 PM; Acetaminophen Oral Tablet 325 milligrams give 2 tablets three times a day for pain, with a start date of July 19, 2023, at 8:30 PM; and Blood Sugar monitoring before meals and at bedtime, with a start date of January 10, 2023, not documented as completed at 6:30 AM and 8:30 PM. Review of Resident 121's progress note failed to document weather or not the aforementioned medications and blood sugar monitoring were administered/completed or rational for not following physician orders. A review of the facility's policy, titled Catheter-Foley, recently revised May 2024, read, in part, This policy provides the procedure to ensure the safe, sterile placement and removal of the Foley catheter. It also provides guidelines for catheter care and specimen collection from the catheter. A Foley Catheter is a device that drains urine from the urinary bladder into a collection bag outside of the body when you can't void the urine on your own. A review of Resident 221's physician orders revealed diagnoses that included hypertension (elevated blood pressure) and neuromuscular dysfunction of the bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should. Common symptoms include dribbling urine, loss of feeling that the bladder is full, and being unable to control urine [urinary incontinence]). A review of Resident 221's Treatment Administration Record (TAR) dated January 2025, revealed the following physician's order Empty Foley drainage bag every shift and record output, every shift. A review of the TAR revealed the staff had not documented care to the Foley on the evening shift of January 5, 2025; the day and night shifts on January 9, 2025; the day shift on January 14, 2025; and the evening shift on January 31, 2025. A review of Resident 221's February 2025 TAR revealed the staff had not documented the Foley catheter care during the evening shift on February 1, 2025; the day shift on February 5, 2025; and the evening shifts on February 14, 15 and 16, 2025. Continued review of Resident 221's February 2025 TAR revealed the following physician's order Irrigate Foley catheter with 60 mls [milliliters] of Sterile Normal Saline solution every shift for patency (the condition of being open, expanded, or unobstructed). A review of the TAR revealed staff had not documented the irrigation of the Foley during the evening shift on February 1, 2025; the day shift of February 5, 2025; and the evening shifts on February 14 and 15, 2025. An interview with the Director of Nursing (DON), on March 20, 2025, at 10:05 AM, revealed an agreement that staff should be documenting the care to Resident 221's catheter per physician orders. Review of Resident 338's clinical record documented diagnoses that included diabetes mellitus, spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord), and hemiplegia left non-dominant side (paralysis or weakness on one side of the body). Review of Resident 338's January 2025 MAR failed to document the following medication were administered on the following dates: Atorvastatin Calcium (medication used to treat elevated cholesterol levels) 40 milligrams, with a start date of November 5, 2024, at 8:30 PM; Melatonin Oral Tablet 3 milligrams give 3 tablets for insomnia, with a start date of November 5, 2024, at 8:30 PM; Ativan 0.5 milligrams every 12 hours for anxiety, with a start date of November 20, 2024, at 8:30 PM; Baclofen Oral Tablet 10 milligram every 8 hours for spasms, with a start date of November 8, 2024, at 6:00 AM and 10:00 PM; and Insulin Lispro (fast acting insulin used to treat elevated blood sugar) Subcutaneous Solution Pen injector Inject as per sliding scale: if 0 - 150 milliliter/deciliter (ml/dl- unit of measure) = 0 units; 151 - 200 ml/dl = 2 units; 201 - 250 ml/dl = 4 units; 251 - 300 ml/dl = 6 units; 301 - 350 ml/dl = 8 units; 351 - 400 ml/dl = 10 units, before meals and at bedtime, with a start date of November 5, 2024, at 8:30 PM on January 19th and 24th. Review of Resident 338's progress note failed to document weather or not the aforementioned medications were administered or rational for not following physician orders. During an interview with the DON on March 20, 2025, at 10:09 AM, it was revealed that the MAR should be completed at time of administration or at time of resident refusal. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12 (d) (5) Nursing services

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed who received dialysis services (Resident 96). Findings Include: Review of facility policy, Dialysis Management, last revised March 28, 2024, read, in part, interchange of information necessary for the care of the resident, communication form is placed in the binder after completion of the pre dialysis assessment and sent to dialysis with the resident; dialysis center personnel to complete Dialysis communication form and return to facility; upon return the facility is to review information provided on the communication form and address as priorate; facility is to complete post-dialysis information/data and place in resident's medical record; and obtain resident's dry weigh from dialysis center, post treatment documentation. Review of Resident 96's clinical record documented diagnoses that included congestive heart failure (the heart doesn't pump blood as it should), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease stage 5 (kidneys are severely damaged and unable to filter waste and fluid from the blood), bipolar disorder (a mental health condition alternating periods of elation and depression). Review of Resident 96 March 2025, physician orders included: Dialysis Monday, Wednesday, and Friday, chair time at 10:30 AM, with a start date of September 12, 2024; record post-dialysis dry weight (weight after resident dialyzed - without excess fluid) on weight tab upon return from dialysis- use dialysis scale weekly every evening shift every Monday, with a start date of November 4, 2024. Review of Resident 96's weight history and January 2025 Medication Administration Record (documentation of medication or services per physician orders) failed to document dry weight per physician orders, Monday evening shift on January 6th, 20th, and 27th, 2025. Review of Resident 96's dialysis communication sheets revealed none were not completed for following dates in January 2025: 1st, 3rd, 8th, 10th, 13th, 15th, 17th, 20th, 22nd, 24th, 27th, 29th, and 31st. Review of Resident 96's dialysis communication sheets revealed none were not completed for following dates in March 2025: 12th and 14th. During an interview with the Director of Nursing (DON) on March 20, 2025, at 10:09 AM, it was revealed that the dialysis communication sheets should be completed, that the dialysis center has a history of not completing the post dialysis vital sign section, and that the facility had contacted the center to discuss the importance of completing the communication forms. During an interview with the DON on March 20, 2025, at 11:51 AM, it was revealed the dry weight should've been obtain and documented per physician orders, and that the facility could utilize the dry weight documented on the dialysis communication form from dialysis that day. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for two of 41 residents reviewed (Residents 90 and 144). Findings include: Review of facility policy, titled Medication Regimen Reviews, reviewed May 2024, revealed, 4. If the Attending Physician declines or otherwise rejects the Consultant Pharmacist's non-urgent Recommendation, an explanation as to the rationale for the rejection shall be documented in the Resident's medical record. Review of Resident 90's clinical record revealed diagnoses that included schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and anxiety disorder (group of mental health conditions characterized by excessive and persistent fear or worry, significantly impacting daily life and functioning). Review of Resident 90's electronic medical record on revealed a review of psychoactive medications, dated December 23, 2024, in which the pharmacist recommended a GDR (gradual dose reduction) for Resident 90's psychoactive medications. The physician responded to this request by the pharmacist by disagreeing. The physician failed to include a rationale for not attempting the GDR. Interview with the Director of Nursing (DON) on March 20, 2025, at 10:30 AM, revealed that they do not have any documents to show that a rationale was provided by the physician for disagreeing with the GDR attempt recommendation made for Resident 90 on December 23, 2025. Review of Resident 144's clinical record revealed diagnoses that included depressive disorder (a mental health condition characterized by persistent low mood, loss of interest, and other symptoms that can significantly impact daily life) and anxiety disorder. Review of Resident 144's electronic medical record revealed a review of psychoactive medications, dated August 25, 2024, in which the pharmacist recommended a GDR for Resident 144's psychoactive medications. The physician responded to this request by the pharmacist by disagreeing. The physician failed to include a rationale for not attempting the GDR and failed to date the response. Interview with the DON on March 20, 2025, at 10:40 AM, revealed that they do not have any documents to show that a rationale was provided by the physician for disagreeing with the GDR attempt recommendation made for Resident 144 on August 25, 2024. 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility investigation, facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility displayed past noncompliance, in that it failed to ensure the resident environment remains free of accident hazards while heating beverages for residents, which resulted in harm to one of three residents reviewed (Resident 1). Findings Include: Review of the facility's policy, titled Food-Reheating recently revised September 2023, read, in part, Staff members only are able to re-heat resident food and or liquids in the microwave to temperatures that are safe and palatable for residents. The policy continued, The staff member is to use the thermometer provided to ensure a maximum temperature of the item is not greater than 140 degrees F [Fahrenheit] at the time of service. Review of the facility's reported incident document dated September 21, 2023, revealed, [Resident 1] requested [Employee 1] heat up a cup of hot water for her. Employee 1 heated up the water and handed it to Resident 1. Resident 1 spilled it on her lap. Resident 1 screamed and began removing her clothes. Resident 1 had blisters and redness on her right thigh, redness down the right leg. According to documentation, Resident 1 was assessed by the Registered Nurse and procured an order from the physician to send Resident 1 to the hospital for additional assessment. Review of Employee 1's witness statement, dated September 21, 2023, read, in part, I did warm [water] for two minutes. I did not know the exact temperature of the water because I didn't have any instrument to measure the water temperature. The statement continued, I handed the water to [Resident 1] she poured it [onto] herself. Review of the hospital emergency department evaluation revealed Resident 1 required care and treatment for Second- degree burns involving the right thigh anteriorly and laterally. Review of the facility's contracted wound treatment document, dated September 29, 2023, revealed staff are providing Resident 1 with daily and as needed wound dressing care and treatment to the burned area. An interview with Resident 1 on October 3, 2023, at 9:36 AM, revealed facility staff are providing care and treatment to the burned and surrounding area. The interview revealed satisfaction with staff now using the thermometer to temp her beverages as requested. Review of facility staff education on October 3, 2023, revealed a facility-wide initiated education on reheating food and liquids. Further review revealed that this education was initiated on September 21, 2023, and completed on September 25, 2023. Review of facility staff competency information on October 3, 2023, revealed a facility-wide initiated competency, titled Competency for heating food. Further review revealed that this competency was initiated on September 21, 2023, and completed on September 25, 2023. Review of audit information on October 3, 2023, revealed the facility completed weekly microwave and thermometer audits on floors Main 1, Main 2, Main 3, Main 4, and Main 5 on September 22, 2023, and September 28, 2023. An interview with the Nursing Home Administrator on October 3, 2023, at approximately 11:15 AM, confirmed the incident and the facility's immediate response to prevent a future occurrence. Prior to the onsite complaint investigation survey on October 3, 2023, the facility failed to ensure staff heat water for one Resident at a temperature to avoid injury, such as burns and blisters, which resulted in harm to that Resident. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the onsite complaint survey there was a review of audits, staff education, and all microwaves were reviewed to now incorporate the availability of thermometers to temp all food and beverages prior to serving to the residents. Staff interviews revealed that staff were educated and knowledgeable regarding the location of the microwaves and thermometers, and the requirement of temping resident food and beverages prior to service. Observations on all resident areas failed to reveal continued or additional concerns regarding staff receiving the necessary training and equipment to prevent future accident hazards regarding hot beverages served to residents that may result in harm to residents. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) Nursing services

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident with a history of elopement (Resident 1). This failure placed 65 additional residents at the facility in an Immediate Jeopardy situation who were identified as having orders to be able to independently go outside of the facility to the main entrance area (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, and 67). Findings include: Review of facility policy, titled Elopement Prevention and Management revised September 8, 2022, revealed, The facility strives to prevent resident/patient elopement .The facility will define mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement to minimize the risk of the resident leaving a safe area area without the staff awareness and/or supervision. Review of facility policy, titled Resident LOA [Leave of Absence] off the unit undated, revealed, Steps: 1. Resident on the unit must sign out at the nurses' station in the designated binder and obtain a 'Hall Pass' filled out by the nursing staff on the unit. 2. Once a 'Hall Pass' is obtained, staff must accompany the resident to the elevator and select the floor where the resident would like to go. Resident then will take the 'Hall Pass' to the front desk where they will sign the resident out and will unlock the front door for the resident. 3. The resident will then be checked every 15 minutes by the front desk staff to ensure the resident is not showing signs of weather related illnesses, safe activities are occuring and lastly that all of our residents are accounted for. 4. Once our resident is ready to come in they will be buzzed back from the outside to our lobby where they will sign back in with our receptionist and receive their 'Hall Pass' to return to their unit. 5. The receptionist or assigned staff member will then scan their badge to give access for the resident to return to their unit. 6. Once the resident arrives back on the unit they will sign back into the book as well as return their 'Hall Pass' to the nursing staff on the unit. Review of Resident 1's clinical record revealed diagnoses that included paranoid schizophrenia (condition characterized by delusions of persecution, grandiosity or jealousy, and hallucinations) and pedal cyclist injured in unspecified traffic accident, sequela (a pathological condition resulting from an injury). Further review revealed that Resident 1 was admitted to the facility on [DATE], following surgery to repair a fractured right tibia (larger of the two bones of the lower leg) obtained by getting hit by a car while riding his bicycle. Review of facility reported incident investigation revealed that on July 25, 2023, Resident 1 signed off of his unit at 12:31 PM. Further review revealed that Resident 1 returned to the facility at 2:00 PM with a new bike. Resident 1 stated that he rode the bus to Walmart, purchased a bike, and rode the bike back to the facility. Review of Employee 3's (Licensed Practical Nurse) witness statement dated July 31, 2023, revealed, On Tuesday 7/25/23 at approximately 2:20pm I was on my way into work when I was driving on Market Street about to turn left onto Pleasant Acres Road when I looked to my left and saw [Resident 1] riding a bicycle. I looked again to ensure that it was [Resident 1]. I was unable to safely stop my car with traffic. As I was turning onto Pleasant Acres Road I looked and saw [Resident 1] riding his bike on Pleasant Acres Road making his way back to the facility. I immediately contacted the fourth floor and and spoke to [Employee 4 - Licensed Practical Nurse] and informed her that [Resident 1] had left the property but was making his way back via bicycle. [Employee 4] informed me she would take care of the situation. Upon getting my belongings and entering the building, [Resident 1] was back inside the building with [Employee 4] and his new bicycle. Review of Employee 4's (Licensed Practical Nurse) witness statement dated July 25, 2023, revealed, writer received phone call on unit phone from oncoming nurse [Employee 3] . [Employee 3] stated that she was on Market St coming to PA [facility] and observed [Resident 1] riding a bicycle on Market St also heading to [facility]. Writer immediately notified [Employee 2 - Registered Nurse], and then left the unit to locate resident. Writer located resident immediately upon walking out front doors. Writer took resident and bike items to nursing supervisor office. Resident explained that he had gotten on the bus, gotten off @ Walmart, and bought a bike and lock for the bike. He then rode the bike back to [facility] because he stated he was unable to take the bike on to the bus. When writer and resident returned to the floor, [Employee 2] assessed resident. No complaints/concerns per resident. No injuries observed or reported. Further review of the investigation report revealed that, following the incident, Resident 1 was educated to not leave the property unaccompanied and to be sure to inform staff of his whereabouts. Additionally, his independent off-unit privileges were revoked. Review of Resident 1's clinical record revealed that, at the time of the elopement on July 25, 2023, Resident 1 had orders for LOA [Leave of Absence]/ Allowed to go outside to main entrance area. This order was effective May 25, 2023. Further review revealed that, while Resident 1 had orders allowing him to go outside independently, he did have a history of elopement/ attempted elopement as follows: December 5, 2019 - left campus and went to store; February 8, 2020 - resident took bus and ate lunch at a local restaurant; and on April 21, 2023 - resident was intercepted while boarding the public bus. Review of Resident 1's care plan revealed that at the time of his elopement he had the following active care plan, Resident is at risk of elopement related to Cognitive Impairment with the intervention of, Notify other departments of resident's risk for elopement and wandering behavior. This care plan was initiated on April 22, 2023, and resolved following his elopement on July 26, 2023. At the time, Resident 1 also had a second active care plan related to elopement, Resident is at risk for elopement related to poor decision making with an intervention of, Notify other departments of risk of elopement and/or wandering behavior. This care plan was initiated on February 10, 2020, and was revised following his elopement on July 26, 2023. Observation on July 31, 2023, at approximately 3:50 PM, revealed a public transit bus picking up passengers near the end of the facility's parking lot driveway entrance. Review of the public transit bus schedule revealed that the bus stops at this location 19 times per day. Further review revealed that on July 25, 2023, one of the times the bus was scheduled to stop at this location was at 12:48 PM. Review of physician orders on July 31, 2023, at approximately 11:30 AM, for Residents 3-67 revealed that each Resident had active orders for LOA/Allowed to go outside to main entrance area or to leave floor unsupervised and go outside to the front patio. Observations on July 31, 2023, at 9:30 AM, 10:15 AM, 12:20 PM, 12:30 PM, 1:30 PM, 3:20 PM, and 3:50 PM revealed varying numbers of residents (between three and approximately 15) sitting outside of the front of the facility, both to the left and right side of the main entrance. During an interview with the Nursing Home Administrator (NHA) on July 31, 2023, at 11:35 AM, he revealed that for a resident to be permitted to sit out front without supervision, they must have an order for LOA for out front. The expectation is that residents sitting outside would be checked approximately every 15 minutes by the receptionist and that these checks would be documented. Review of the 15 minute check log for residents who are outside revealed that on the day of Resident 1's elopement (July 25, 2023), it was noted that Resident 1 signed out of the building at 9:07 AM, and again at 12:34 PM. It was noted that he was signed back in at 2:05 PM. No 15 minute safety checks were documented for Resident 1 or any other resident noted on the log during day shift. Review of resident check logs since that date failed to reveal an accurate accounting of resident sign in/out times or timely 15 minute safety checks. During an interview with Employee 5 (Receptionist) on July 31, 2023, at 10:15 AM, she revealed that she does her best to check on residents sitting outside every 15 minutes, but cannot always do this in a timely manner due to other assigned duties such as processing the mail, petty cash, visitor sign-in, answering the phones, and monitoring the door. During a later interview with Employee 5 at 1:30 PM, she revealed that she is not able to accurately account for all residents coming in and out due to a number of factors: other duties reception is assigned, visual barrier to the elevator bank due to the location of the reception station, and residents' non-compliance with dropping off or turning in Hall Pass slips. Employee 5 then presented a pile of Hall Passes for residents who were not outside at her last check. When asked how she was able to confirm that those residents were in the building, she stated she knew which residents she had to worry about (Residents 1 and 67). Review of Resident 67's clinical record revealed diagnoses that included schizoaffective disorder (condition in which a person experiences a combination of schizophrenia symptoms - such as hallucinations or delusions - and mood disorder symptoms, such as mania or depression) and intellectual disability (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Further review revealed that Resident 67 had a previous elopement on May 22, 2023. During an interview with Employee 6 on July 31, 2023, at 3:20 PM, Employee 6 revealed that it is too much to account for all residents who are outside due to the following factors: residents are non-compliant with handing in paper passes, and some refuse to do so; other duties assigned are time consuming (answering the telephone, badging people into the adjoining residence building, signing in visitors, and petty cash duties); reception does not have a full view of the patio area outside of the building to the left; and residents do not always stay within the parameters of the front entrance patio and sidewalk. During an interview with the NHA on July 31, 2023, at 11:35 AM, he revealed that Employee 5 was educated in May regarding the LOA policy, including the need to do 15 minute safety checks for residents who are outside, and was again educated following Resident 1's July 25, 2023, elopement. He also acknowledged that the 15 minute check documentation for July 25, 2023, and dates after were incomplete and inaccurate. During a final interview with Employee 5 (Receptionist) on August 1, 2023, at 8:07 AM, when asked about her recollection of Resident 1's elopement on July 25, 2023, she revealed that Resident 1 had a slip to go outside, but she had no idea that Resident 1 left the campus. Employee 5 stated she found out about it after the fact. She revealed that she was able to do 15 minute checks on that day, but it was sporadic and she did not realize Resident 1 was gone. The failure of the facility to consistently monitor resident whereabouts and safety when outside of the building, as well as the inability to maintain an accurate accounting of residents who are outside of the building, placed the residents with outside privileges in an Immediate Jeopardy situation. The NHA was provided the immediate jeopardy template on July 31, 2023, at 1:53 PM, and an immediate action plan was requested. On July 31, 2023, at 7:32 PM, the facility's immediate action plan was accepted, which included: Resident 1 will remain supervised out front of the building, but can be unsupervised in the locked courtyard off of Main 1. A head count of the whole facility is being conducted. Those residents that are outside are being accounted for. Going forward, the outside area will be supervised while residents are outside. Resident council will be held to update residents on the new policy on the morning of August 1, 2023. Responsible parties of residents with current out-front LOA order will be contacted by social services to let them know of the updated LOA policy. Full house education is being conducted to all facility staff in-person or by telephone on the updated LOA policy by end of day on August 1, 2023. On August 1, 2023, at 3:59 PM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management

Based on staff interviews, clinical record review, facility policy, and documentation review, it was determined that the facility failed to promptly take measures necessary to protect residents from further sexual abuse after sexual abuse was identified with two of five residents reviewed (Residents 1 and 5). This failure resulted in sexual assault for one resident (Resident 1) and placed residents in an immediate jeopardy due to the potential for further sexual abuse to occur. Findings Include: Review of the facility's policy, titled Abuse Policy-Prevention and Management last revised September 8, 2022, read, The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. The policy defines sexual abuse as Non-consensual sexual contact of any type; includes, but is not limited to, humiliation, harassment, coercion, or assault. The policy continues, Generally, sexual contact is nonconsensual if the resident either: o Appears to want the contact to occur, but lacks the cognitive ability to consent; or o Does not want the contact to occur. Other examples of nonconsensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma. Any investigation of an allegation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a preexisting or current sexual relationship, is sexual abuse. A facility is required to conduct an investigation and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. If an allegation of sexual abuse has been reported, Response to Alleged Violations of Sexual Abuse include the facility must immediately protect the alleged victim(s) involved, report the alleged violations to the Administrator and appropriate State and local authorities, and begin an investigation of the allegation. Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 2's clinical record revealed diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change resulting from organic disease of the brain) and anxiety (a feeling of worry, nervousness, or unease). Continued review of Resident 2's clinical record revealed an admitted to the facility on [DATE]. Review of Resident 5's clinical record revealed diagnoses that included Alzheimer's Disease and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). According to facility documentation, Residents 1, 2, and 5 all resided on the facility's Main 1 floor. Main 1 is the designated locked area focused on the care and treatment of residents diagnosed with cognitive impairments and varying degenerative brain diseases. Review of facility provided documentation, dated June 17, 2023, revealed Resident 2 was found in bed with a female [Resident 5]. Resident 5 was on her back in [Resident 2's] bed with her brief removed and naked from the waist down while [Resident 2] was on top of [Resident 5] naked from the waist down. Review of Resident 2's interdisciplinary progress notes, revealed a note dated June 17, 2023, also describing the incident discovered [Resident 2] laying on top of [Resident 5] who was in his [Resident 2's] bed, with his [Resident 2] pants below his waist, and [Resident 5] having no brief or underwear on. Resident 2, stood with an erect penis and fecal matter noted. Resident 2 pulled his pants up, and exited room. As a result of the incident, both Resident 2 and Resident 5 were placed on 15 minute checks by staff. Continued review of Resident 2's interdisciplinary progress notes revealed documentation on June 21, 2023, that included Increased sexual behavior. Also, Resident 2 was seen several times around female resident [Resident 1], holding her hand attempting to kiss her. The progress note continued, Writer walked into [Resident 2's] room and found [Resident 1] sitting on the edge of his [Resident 2's] bed. Resident 2 was standing in front of [Resident 1] with his [pants] unzipped and attempted to put [Resident 1's] face in his groin area. According to the documentation, staff immediately separated the Residents. Continued review of the progress notes for Residents 1 and 2 revealed no documentation of reporting or other interventions regarding the increase in sexual behaviors displayed by Resident 2 and any interventions to assist Resident 1 with the encounter in Resident 2's room. An interview with the Director of Nursing (DON) on July 24, 2023, at 2:23 PM, revealed the facility had no documentation of an investigation or incident reporting to address the incident between Resident 1 and Resident 2 on June 21, 2023. An interview with Employee 3 (Registered Nurse/Unit Manager) on July 24, 2023, also at 2:23 PM, who completed the documentation in the interdisciplinary progress notes on June 21, 2023, revealed she did not initiate any investigation or document the incident for further review by administration, as she didn't think anything happened. An additional interview with the DON at that time, revealed an expectation that this incident would have been reported to Administration and investigated by staff in order to institute possible interventions to address the sexual encounter between Resident 1 and Resident 2. Based on clinical record review, document review, and staff interview, Resident 2 had sexual encounters with Resident 5 on June 17, 2023, and Resident 1 on June 21, 2023, that was not investigated by the facility while Resident 2 remained on 15 minutes checks. Resident 2, again on July 16, 2023, had a sexual encounter with Resident 1, resulting in a transfer to the hospital with a sexual assault response and evaluation by the hospital emergency department. According to documentation in the interdisciplinary progress notes on June 23, 2023, Resident 2 was observed walking naked in the halls. On June 25, 2023, Resident 2 was redirected from entering female resident rooms. On July 2, 2023, Resident 2 made multiple attempts to touch women. On July 4, 2023, staff documented Resident 2 hit his roommate. Also on July 4, 2023, Resident 2 was found standing in front of a female in the bathroom while she used the toilet. On July 7, 2023, Resident 2 exhibited exit seeking behaviors via the emergency exit door and hitting the exit door with a fire extinguisher he removed from the wall. Resident 2 was transferred to the hospital due to increasing sexual and physically aggressive behaviors on July 7, 2023, and returned shortly after midnight on July 8, 2023, and readmitted to the facility. Review of facility provided documentation revealed Resident 2 was placed on 15 minute checks June 18, 2023, through June 28, 2023. Resident 2 was then downgraded to 30 minute checks on June 28, 2023, despite continued behaviors. Review of a facility submitted report dated July 16, 2023, revealed on that date Resident 1 and Resident 2 were found together once again in Resident 2's room. Staff observed [Resident 1] sitting on [Resident 2's] bed with his [Resident 2] penis in her mouth. The documentation continues, revealing Resident 1 was transported to the hospital for evaluation. The documentation also revealed Resident 2 was moved to another floor within the facility and 1:1 supervision was initiated. According to hospital documentation, Resident 1 was treated with the impression of Sexual Assault of adult. After the sexual abuse on June 17, 2023, a care plan was initiated for Resident 2 that stated, I have a behavior problem (Discovered with pants below waist lying on female resident on 6/17/23). Interventions included: Provide a program of activities that is of interest and accommodates residents status. Further review of the activities care plan revealed no updates to the care plan for activities. The additional interventions included: If reasonable, discuss I's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to I and to Intervene as necessary to protect the rights and safety of others. Approach/Speaking a calm manner. Divert attention. Remove from situation and take to alternate location as needed. There was no evidence that the aforementioned interventions were ever implemented despite continued episodes of sexual behaviors. There were also no updates to the care plan, despite continued sexual behaviors, until the sexual abuse that occurred on July 16, 2023. Further review of Resident 2's clinical record revealed no evidence that the Resident was seen in-patient by any psych services while in the facility for behavior management. The facility failed to protect Resident 1 from ongoing non-consensual encounters and other residents from non-consensual sexual encounters by Resident 2. A final interview with the Nursing Home Administrator (NHA) on July 25, 2023, at 10:54 AM, confirmed the incident on June 21, 2023, should have been reported to administration by Employee 3 for investigation and intervention to possibly protect Resident 1 from an additional encounter with Resident 2 on July 16, 2023. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the NHA on July 24, 2023, at 3:08 PM, for failure to ensure that residents were free from sexual abuse from Resident 2, and that other residents were protected from sexual abuse. The Immediate Jeopardy template was provided to the NHA and an Immediate action plan was requested. On July 24, 2023, the facility provided the following action plan at 6:19 PM: 1. Female residents on Main 1 and Main 3 will be interviewed to determine if they have had any type of inappropriate sexual advances. For residents unable to be interviewed due to a specific diagnosis, a skin check will be conducted. Progress notes for the past 30 days will be reviewed for any notes regarding perceived or actual sexual activity. 2. Resident 2 is on a continuous 1:1 (a 1:1 is within the eyesight of the resident) and will remain on 1:1 until he no longer resides in the facility. A wanderguard will also be placed on him to keep him from leaving the unit if he becomes physically aggressive. A referral has been made to transfer the Resident to an all-male facility. Social Services will continue refer to all male facilities and psychiatric facilities to find a more appropriate placement for the Resident. 3. Staff education has been initiated by staff development nurse in regard to the facility's Abuse Policy and sexual abuse. In-house staff are being educated and department heads will make phone calls until all staff have been educated. The staff educated via phone call will sign the education on their next day at work. Staff are also being educated on notifying their immediate supervisor on perceived or actual sexual behavior. Educations will be given to staff in person or via by telephone by end of day July 25, 2023. 4. If residents have displayed any type of sexual aggression, they will be placed on immediate 1:1 supervision and psych services will be consulted. 5. Audits will be conducted five times per week for 12 weeks to review progress notes on all shifts to ensure any sexual-like actions have been investigated and proper investigations have been initiated. The implementation of the action plan was verified on July 25, 2023, which included: interviews conducted with facility staff on July 25, 2023, observations of staff signing identifying abuse and reporting abuse education forms at entrance to the facility while reporting to work, and 1:1 supervision of Resident 2. The Immediate Jeopardy was lifted on July 25, 2023, at 12:17 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on document review, clinical record review and staff interview it was determined that the facility failed to ensure each resident the right to be free from neglect, resulting in physical harm for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's policy titled Abuse, most recently revised March 2021, describes neglect as Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's policy titled Certified Nursing Assistant Position Description effective October 2018, summarizes the position of the nursing assistant as The primary purpose of this position is to assume the responsibility of providing the highest level of quality of nursing care for specific residents as prescribed by the physcian's orders, the care plan, and other recognized sources and in accordance to facility policies and procedures. Review of the facility's policy titled Care Planning, recently revised in June 2019 reveals the facility will develop a comprehensive, resident centered care plan for each resident. Also, The resident centered care plan development will include the following interdisciplinary team members: Nursing . Nursing Assistant. The policy further reads All resident care and interventions must be carried out per the care plan. Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's interdisciplinary plan of care, specifically titled My Falls most recently revised on August 25, 2021, specifies fall interventions including bilateral [having or relating to two sides] body pillow while I'm in bed to assist me to be upright and not leaning to the side or rolling off edge of bed. Also, Fall mat to bilateral sides of the bed while I am in bed. Review of the facility's incident report, dated August 15, 2021, related to Resident 2, completed by the registered nurse (RN 1) reads NA [nursing assistant] was in hallway and heard a resident call out for help. NA alerted writer that resident was on the floor. Writer entered room to find resident lying on left side on the floor with blood pooling under her head. The incident reports details an assessment of Resident 2 with a transfer to the hospital based on observed injuries including Brusing noted along length of left lower leg. Large skin tear to noted to left elbow .unable to assess head wound. Review of the facility's investigation of the fall, completed on August 17, 2021, by the Director of Nursing (DON), reveals Upon further review of care plan and statements from staff , it has been determined that fall interventions were not in place per care plan. [NA 1 and NA 2] who provided care have been suspended. The investigation continues Allegation of neglect substantiated. Review of NA 1's written statement, dated August 16, 2021, reveals I was passing [Resident 2's] room and I heard a voice but I didn't see her in the bed, I looked again and I heard someone say can you get me a chair and that's when I saw [Resident 2] on the floor. The statement continues one fall mat on opposite side of where [Resident 2] fell . No body pillows at all. Review of NA 2's written statement revealed, in part, [Resident 2] was repotion [repositioned] and body pillow was on dresser I put in on left side of the bed and table and moved closer to [Resident 2] per request. Floor mats were no where to be found. Further review of Resident 2's clinical record revealed a hospital After Visit Summary that reads Patient presents to ED [emergency department] after an unwitnessed fall. Final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, the summary reads we placed four staples in [Resident 2's] head. Futher review of the summary reveals Resident 2 could not tolerate total care to her head wound and wished to terminate treatment. Resident 2's family member was contacted regarding initiating hospice care and services (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Hospice care prioritizes comfort and quality of life by reducing pain and suffering) upon Resident 2's return to the facility. Additional review of Resident 2's clinical record revealed an admission to hospice care and services on August 16, 2021. The review also revealed Resident 2 passed away at the facility on August 21, 2021. An interview with the Nursing Home Administrator and DON, on September 3, 2021, at 9:46 AM confirmed the investigation revealed NA 2 put Resident 2 in bed without the care plan interventions and NA 1 had also not initiated the care plan interventions. 28 Pa. Code 201.8 (b)(1) Management 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code (c)(d)(1)(2)(3)(5) Nursing services

Based on document review, clinical record review and staff interview it was determined that the facility failed to implement a comprehensive person-centered care plan ensuring services provided to maintain the resident's highest practicable physical well being, resulting in harm and or injury for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's policy titled Certified Nursing Assistant Position Description effective October 2018, summarizes the position of the nursing assistant as The primary purpose of this position is to assume the responsibility of providing the highest level of quality of nursing care for specific residents as prescribed by the physcian's orders, the care plan, and other recognized sources and in accordance to facility policies and procedures. Review of the facility's policy titled Care Planning, recently revised in June 2019 reveals the facility will develop a comprehensive, resident centered care plan for each resident. Also, The resident centered care plan development will include the following interdisciplinary team members: Nursing . Nursing Assistant. The policy further reads, All resident care and interventions must be carried out per the care plan. Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's interdisciplinary plan of care, specifically titled My Falls most recently revised on August 25, 2021, specifies fall interventions including bilateral [having or relating to two sides] body pillow while I'm in bed to assist me to be upright and not leaning to the side or rolling off edge of bed. Also, Fall mat to bilateral sides of the bed while I am in bed. Review of the facility's incident report, dated August 15, 2021, related to Resident 2, completed by the registered nurse (RN 1) reads NA [nursing assistant] was in hallway and heard a resident call out for help. NA alerted writer that resident was on the floor. Writer entered room to find resident lying on left side on the floor with blood pooling under her head. The incident report details an assessment of Resident 2 with a transfer to the hospital based on observed injuries including Brusing noted along length of left lower leg. Large skin tear to noted to left elbow . unable to assess head wound. Review of the facility's investigation of the fall, completed on August 17, 2021, by the Director of Nursing (DON), reveals Upon further review of care plan and statements from staff , it has been determined that fall interventions were not in place per care plan. [NA 1 and NA 2] who provided care have been suspended. The investigation continues Allegation of neglect substantiated. Review of NA 1's written statement, dated August 16, 2021, reveals I was passing [Resident 2's] room and I heard a voice but I didn't see her in the bed, I looked again and I heard someone say can you get me a chair and that's when I saw [Resident 2] on the floor. The statement continues one fall mat on opposite side of where [Resident 2] fell . No body pillows at all. Review of NA 2's written statement revealed, in part, [Resident 2] was repotion [repositioned] and body pillow was on dresser I put in on left side of the bed and table and moved closer to [Resident 2] per request. Floor mats were no where to be found. Further review of Resident 2's clinical record revealed a hospital After Visit Summary that reads Patient presents to ED [emergency department] after an unwitnessed fall. Final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, the summary reads we placed four staples in [Resident 2's] head. Futher review of the summary reveals Resident 2 could not tolerate total care to her head wound and wished to terminate treatment. Resident 2's family member was contacted regarding initiating hospice care and services (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Hospice care prioritizes comfort and quality of life by reducing pain and suffering) upon Resident 2's return to the facility. Additional review of Resident 2's clinical record revealed an admission to hospice care and services on August 16, 2021. The review also revealed Resident 2 passed away at the facility on August 21, 2021. An interview with the Nursing Home Administrator and DON, on September 3, 2021, at 9:46 AM confirmed the investigation revealed NA 2 put Resident 2 in bed without the care plan interventions and NA 1 had also not initiated the care plan interventions. Upon completion of facility investigation, it was determined that the care plan interventions were not in place at the time of the fall resulting in hospitalization with a laceration to the resident's scalp and forehead and a skin tear to the left elbow. The resident returned to the facility on hospice and passed away five days later. 28 Pa. Code 201.8 (b) (1) Management 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code (c) (d) (1) (2) (3) (5) Nursing services

Based on observation, clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by and failing to provide care and services for cardiac pacemakers for one of 20 residents reviewed (Resident 359) with a cardiac pacemakers without physician ordered pacemaker checks and a follow-up visit with the cardiologist and resulted in the resident being hospitalized with a syncopal episode and required surgery for [REDACTED]. This failure placed 19 other residents with cardiac pacemaker at risk for harm and in an Immediate Jeopardy situation and by failing to ensure timely meal service for one of 48 residents reviewed (Resident 226), by failing to implement an ordered bowel protocol for one of 52 residents reviewed (Resident 278), by failing to follow physician orders for wound care for two of 52 residents reviewed (Resident 62, and 309). Findings include: Review of the facility policy titled, Pacemaker/Automatic Implantable ICD Management, created (MONTH) (YEAR), and last revised (MONTH) (YEAR), revealed in Step 3. Obtain orders for Pacemaker management and Trans Telephonic/office monitoring as applicable (assure availability of transmitter box). Orders may include, but are not limited to: a. Contact number b. Dressing change if applicable c. Frequency of Trans telephonic checks d. Instructions on how to use the transmitter e. Schedule of planned phone checks f. Physician order for [REDACTED]. Additionally, Step 5. Conduct Trans Telephonic pacemaker monitoring, according to the manufacturer's instructions and as ordered. Document scheduled monitoring completion in the medical record and/or MAR (Medication Administration Record) or TAR (Treatment Administration Record). Review of Resident 359's clinical record revealed [DIAGNOSES REDACTED]. A review of Quarterly MDS (Minimum Data Set- periodic assessment of the resident) with a target date of (MONTH) 6, 2019, revealed that she had a BIMS (Brief Interview of Mental Status) of 15 out of a possible score of 15, indicating that she is cognitively intact. Further review of clinical record on (MONTH) 20, 2019, at 8:55 AM Resident 359 was found on the floor at her bedside and the decision was made to transport the resident to the hospital. When Resident 359 was in the elevator being transferred to the hospital she began seizing. Upon transfer the resident was admitted to the hospital with [REDACTED]. During an interview with Resident 359 on (MONTH) 28, 2019, at 3:11 PM, she stated that while she was a patient at the hospital the hospital staff informed her that the cardiology device clinic never received any cardiac pacemaker transmissions since her admission to the facility on (MONTH) 9, 2019. Review of care plan revealed interventions of Pacemaker checks as ordered and follow-up with cardiology. Further review of the clinical record revealed that there were no physician orders for pacemaker checks or follow-up appointments with the cardiology device clinic. Interview with the Director of Nursing on (MONTH) 29, 2019, at 10:45 AM revealed that she would expect nursing staff to follow facility policy and provide care in accordance with established standards of care. A review of the facility policy titled, Pacemaker/Automatic Implantable ICD Management last reviewed (MONTH) (YEAR) states that residents with a pacemaker or an Automatic Implantable Internal Cardioverter Defibrillator (ICD) be managed for safe operation and equipment. A review of the clinical record for Resident 316 on (MONTH) 27, 2019, revealed clinical [DIAGNOSES REDACTED]. Further review of the clinical record failed to reveal Resident 316 received any pacemaker checks since insertion of the pacemaker on (MONTH) 4, (YEAR), for symptomatic [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. A review of Resident 316's physician orders from (MONTH) 2019 revealed that a pacemaker check was scheduled to be performed on (MONTH) 27, 2019, at 9:00 AM and was not performed because staff didn't have the resident ready at the time the cardiology device clinic called the unit. It was observed that Licensed Practical Nurse (LPN) 7 was on the phone with the cardiology device clinic and informed them the resident wasn't ready for the check. The previous pacemaker check was not performed as scheduled on (MONTH) 12, 2019, and the reason documented in the progress notes state, not scheduled today. Prior to this a pacemaker check was scheduled on (MONTH) 13, 2019, at 8:30 AM and the progress notes state that it was not administered due to unavailability and will be placed on the calendar to contact cardiology on (MONTH) 20, 2019. There was no documentation to the physician notifying him that the pacemaker checks were not performed. On (MONTH) 28, 2019, at 11:01 AM a request was made to the Director of Nursing to provide all pacemaker checks since insertion date on (MONTH) 4, (YEAR) and requested all pacemaker reports be sent from the cardiology office. On (MONTH) 28, 2019, at 4:30 PM the Director of Nursing informed that she contacted the cardiology device clinic, but they were unable to provide any pacemaker check information until the following day, (MONTH) 29, 2019. No information regarding Resident 316's pacemaker checks was provided by the facility on (MONTH) 29, 2019. During an interview with the Director of Nursing on (MONTH) 29, 2019, at approximately 2:30 PM she stated that pacemaker checks should be performed every six months and the resident visits the cardiologist annually. On (MONTH) 28, 2019, at 5:48 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy and asked to provide an action plan of correction. On (MONTH) 28, 2019, at 10:50 PM the Corrective Action Plan was approved and accepted. This Corrective Action Plan included the following: 1. All residents with pacemakers in house identified. In addition, all new residents will be assessed for a pacemaker(s). Any devices not currently in the facility will require licensed nursing staff education prior to admission. A recent pacemaker check of the pacemaker will be required prior to admission. 2. Each resident assessed. Each device type identified, and proper pacemaker check method identified. Residents with pacemaker care plans and orders reviewed and updated if needed. 3. Pacemaker/ICD Management policy updated. Staff re-educated by Supervisors and Nursing Management to ensure understanding of policy and procedure regarding interrogation. Licensed nursing staff in the facility has already begun. Licensed nursing staff will be educated at the beginning of the shift. 4. All residents with Telephonic transmitters have appointments for next pacemaker check; the cardiology office will be contacted to attempt to receive confirmation of pacemaker check. 5. All residents with monitor devices in room will be checked nightly by either the LPN or RN caring for them to ensure that they are plugged in and functioning. 6. Physician orders for monitor devices will be transcribed to the Treatment Administration Records. 7. Director of Nursing or designee will audit 100% of home monitor devices daily, times 90 days to ensure compliance. Results will be reviewed at QAPI, times 3 months and recommendation for further auditing will be reviewed. 8. All current appointments for Telephonic checks have been placed on a calendar and will be audited to ensure that they have been completed by licensed nursing staff. This audit will be completed by the Director of Nursing or designee within 72 hours. 9. Residents identified with pacemaker checks that have not been performed timely have been reviewed. Physicians notified. Cardiologists to be contacted the next business day to schedule pacemaker check. 10. For Resident 316, orders were obtained, and care plan updated. Pacemaker check scheduled for (MONTH) 3, 2019, at 11:30 AM. Cardiology Device Clinic appointment scheduled for (MONTH) 25, 2019, at 8:00 AM. 11. For Resident 359, orders were obtained, and care plan updated. Pacemaker check done (MONTH) 27, 2019, at Cardiology Device Clinic which states 4.6 years battery life and follow up in 6 months. On (MONTH) 31, 2019, at 9:00 AM action plan was reviewed, observation was made of monitoring device functioning, interviews were conducted on the units with licensed staff to confirm education was completed. The NHA was notified that the Immediate Jeopardy was lifted on (MONTH) 31, 2019, at 10:15 AM. The Immediate Jeopardy was abated and the scope/severity was lowered to a E. The facility failed to ensure nursing services provided met professional standards of quality regarding care and services for cardiac pacemakers for one of 20 residents reviewed (Resident 359) with a cardiac pacemakers without physician ordered pacemaker checks and a follow up visit the cardiologist and resulted in the resident being hospitalized with a syncopal episode and required surgery for [REDACTED]. This failure placed 19 other residents other with cardiac pacemaker at risk for harm and in an Immediate Jeopardy situation. Review of Resident 62's clinical record revealed [DIAGNOSES REDACTED]. enough blood to meet the body's needs), [MEDICAL CONDITION] (kidneys are damaged and can't filter blood the way they should), and [MEDICAL CONDITION] (swelling). During an interview with Resident 62 on (MONTH) 26, 2019, at approximately 11:51 AM it was observed that Resident 62's right shin was slightly [MEDICAL CONDITION] (swollen), was weeping (wet with a clear substance) with skin removed in an area approximately 1/2 inch (unit of measure) X 1/2 inch. During an interview on (MONTH) 26, 2019, at approximately 11:55 AM with Licensed Practical Nurse 2 (LPN) 2 it was revealed that Resident 62's right shin should have a dressing on it, and a dressing was applied at that time. Review of Resident 62's (MONTH) 2019, physician orders revealed: Cleanse right shin with Normal Saline Solution (salt water), pat dry, apply calcium alginate with silver (an antibacterial wound dressing designed to be highly absorbent and for a gel-like covering over the wound to promote wound healing), then wrap loosely with clean gauze until healed, one time a day at 8:30 AM, with a start date of (MONTH) 17, 2019. Further review or Resident 62's (MONTH) physician orders revealed: [MEDICATION NAME] (a stretch compression bandage) wraps with stockinette underneath daily, re-wrap every morning for [MEDICAL CONDITION], one time a day related to [MEDICAL CONDITION] (swelling due to fluid retention), with a start date of (MONTH) 14, 2019, and scheduled for 8:30 AM. Review of Resident 62's Treatment Administration Record (a record of treatments that were administered) revealed that the aforementioned wound treatment was not available (MONTH) 17th and 18th, and was administered (MONTH) 19th through the 27th. Further review of Resident 62's Treatment Administration Record (a record of treatments that were administered) revealed that the compression wrap was applied (MONTH) 14th through 27th, with the exception of (MONTH) 16th, which was left blank. Review of Resident 62's Physician Assistant note dated (MONTH) 21, 2019, revealed under the section for assessment, lower extremity (leg) [MEDICAL CONDITION] (swelling): some improvement, continue [MEDICATION NAME] wraps; [MEDICAL CONDITION] (a skin infection) / right shin wound: continue local care, calcium alginate with silver and dressing changes until healed. Review of Resident 62's care plan and resident Care Card (a list of resident care needs and preferences) revealed a focus area for wound risk, however no interventions for a current treatment or use of leg wraps. During an interview with the Director or Nursing on (MONTH) 28, 2019, at approximately 12:22 PM it was revealed that Resident 62's right shin should be dressed and her legs wrapped after morning care was completed. It was also revealed that the care plan should contain statements to refer to the Treatment Administration Record for the dressing and the leg wrap. Observations on (MONTH) 27, 2019, at 12:42 PM revealed Resident 226 in bed in his room. During an interview with Resident at that time, he revealed that he had not yet received his lunch. Observation at 1:27 PM revealed NA 5 (Nurse Aide) loading finished lunch trays back into the tray cart. An interview with NA 5 at that time revealed that all lunch trays had been passed. Also at that time, NA 5 searched for Resident 226's tray, but was unable to locate it. At 1:31 PM, NA 5 called the kitchen and ordered a replacement tray. Observation revealed that a meal tray was delivered to Resident 226 at 1:52 PM. During an interview with the Director of Nursing on (MONTH) 28, 2019, at 1:01 PM she revealed the expectation that Resident 226 should have received a timely meal tray. Review of Resident 278's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 278's current orders revealed an order for [REDACTED]. Review of orders also revealed an order for [REDACTED]. Review of Resident 278's bowel detail report revealed that there was no documented bowel movement between (MONTH) 25, 2019, and (MONTH) 29, 2019, between (MONTH) 9, 2019, and (MONTH) 12, 2019, between (MONTH) 12, 2019, and (MONTH) 15, 2019, and between (MONTH) 22, 2019, and (MONTH) 25, 2019. Review of Resident 278's (MONTH) 2019, and (MONTH) 2019 MAR (Medication Administration Record [REDACTED]. During an interview with the Regional Nurse Consultant on (MONTH) 29, 2019, at approximately 1:30 PM she revealed the expectation that the bowel protocol should have been initiated for Resident 278. Review of the clinical record for Resident 309 revealed [DIAGNOSES REDACTED]. Review of the physician orders revealed an order for [REDACTED]. Review of the treatment record for (MONTH) 2019, revealed eight times where staff documented that they just checked the dressing but did not change it. There were also five times where staff did not document that the dressing was changed per physician order. During an interview with the infection control nurse on (MONTH) 29, 2019, at 1:12 PM she confirmed that the dressing should have been changed daily. The Director of Nursing and Nursing Home Administrator were present when findings were reviewed. No further information was provided 42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards. Previously cited 7/19/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/19/19, 2/1/19, 7/19/18, 8/10/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/1/19, 7/19/18, 10/5/17, 8/10/17. 28 Pa. Code 201.18(b)(3)(e)(1) Management. Previously cited 2/1/19, 7/19/18, 8/10/17. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.21(a) Use of outside resources. 28 Pa. Code 201.29(d) Resident rights. Previously cited 2/1/19, 7/19/18. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 8/10/17. 28 Pa. Code 211.10(b) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 2/1/19, 7/19/18, 8/10/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 2/1/19, 7/19/18, 8/10/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/1/19, 12/26/18, 11/13/18, 7/19/18, 8/10/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/1/19, 7/19/18, 10/29/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/1/19, 12/26/18, 11/13/18, 7

Based on a review of facility documentation, clinical records and interviews with staff it was determined that the facility failed to provide proper supervision and implement interventions to prevent an accident for one of three residents reviewed (Resident 1), resulting in harm when the resident fell , receiving a fractured left wrist and left hip. Findings include: Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident needs) dated (MONTH) 5, (YEAR), revealed, under functional status for activities of daily living for walking in the corridors on the unit, that Resident 1 required supervision and the physical assist of one. Review of documentation provided by the facility revealed Resident 1 was ambulating in the hallway and attempted to enter the room of Resident 2. Resident 2 became alarmed and tried to guide Resident 1 away from her room. This motion caused Resident 1 to lose her balance and fall to the floor. Resident 1 reported pain in her left wrist and hip. Physician and family were notified, and X-rays were ordered and revealed a left wrist and left [MEDICAL CONDITION]. Review of facility investigation documentation included a telephone statement provided to the facility by Licensed Practical Nurse (LPN) 1 dated (MONTH) 10, (YEAR), at 10:20 AM which revealed, Resident on back did not have walker with her and had slipper socks on at time. Review of a Physical Therapy screen dated (MONTH) 12, (YEAR), revealed falls as a precaution. Further review of the Physical Therapy screen revealed a suggestion to the Unit Manager indicating that Resident 1 could ambulate and transfer on the unit independently with RW (rolling walker). Resident 1's (right) foot is significantly smaller than her left due to an amputation. Nursing to order resident's shoes to always be on when ambulating. Review of an Occupational Therapy Screen dated (MONTH) 12, (YEAR), revealed under fall precautions wandering, sneakers when OOB (out of bed). Review of a Physical Therapy screen dated (MONTH) 27, (YEAR), revealed under assistive devices was rolling walker. Review of the facility's Main 1 (unit) (3-11 Peep Rounds sheet - used to document when checks are done on residents) dated (MONTH) 9, (YEAR), revealed Resident 1's room was on the South Hall and Resident 2's room was on the West Hall where the fall occurred. During an interview on (MONTH) 1, 2019, at 1:00 PM with the Nursing Home Administrator no further comments were made. The facility failed to provide proper supervision and implement interventions to prevent an accident for one of three residents reviewed (Resident 1), resulting in harm when the resident fell , receiving a fractured left wrist and left hip. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 7/19/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 7/19/18, 8/10/17 28 Pa. Code 201.18(b)(1) Management Previously cited 7/19/18, 10/5/17, 8/10/17 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 7/19/18, 8/10/17 28 Pa. Code 201.29(a)(d) Resident rights Previously cited 7/19/18 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 7/19/18, 8/10/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 7/19/18, 8/10/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 12/26/18, 11/13/18, 7/19/18, 8/10/17 28 Pa. Code 211.12(d)(3)Nursing services Previously cited 7/19/18, 10/29/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 12/26/18, 11/13/18, 7/19/18, 10/29/17, 8/10/17

Based on review of facility policy, clinical record review, documentation provided by the facility and staff interview, it was determined that the facility failed to ensure one of 47 residents reviewed (Resident 168) was free of neglect during a transfer without a mechanical lift which resulted in actual harm to Resident 168 who sustained right knee pain, was transferred to an Orthopedic Urgent Care Center, and diagnosed with [REDACTED]. Findings include: Review of the facility's policy and procedure titled, Abuse Prevention Program: Standards of Care, reviewed (MONTH) (YEAR) focus is on creating an environment of respect, dignity and protection from harm. Residents have the right to an environment that takes care of physical, .needs. The facility's Abuse Prevention Program policy: Identification, revised (MONTH) (YEAR) . will not condone any form of resident abuse or neglect; neglect is the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain .Neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care . Review of Resident 168's clinical record revealed [DIAGNOSES REDACTED]. in which the bones become brittle and fragile), [MEDICAL CONDITION] (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints), lower back pain, muscle weakness, and lack of coordination. Review of Resident 168's quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated (MONTH) 10, (YEAR), revealed that Resident 168 is cognitively impaired, required extensive assistance with one person physical assistance for bed mobility and transfer between surfaces, which did not occur during the 7-day period of the assessment. Further review of Resident 168's clinical record revealed on the resident care card (information pertaining to a resident's psychosocial, physical and care needs) that Resident 168 transfer level is total dependence with assistance of two and the use of a full mechanical lift. Resident 168's care plan revealed that she has impaired mobility, impaired balance, impaired cognition, and chronic back pain. Interdisciplinary note dated (MONTH) 8, (YEAR), at 3:44 a.m. revealed the Nurse Practitioner was contacted regarding complaint of right knee pain and [MEDICAL CONDITION]. A new order was obtained for Tylenol 1000 mg., every 8 hours for 48 hours, and stat (urgent or rush) X-ray: all views to rule out fracture/dislocation of right knee. An X-ray exam dated (MONTH) 8, (YEAR), at 7:30 a.m. revealed acute lateral tibial plateau fracture (right knee fracture) may be considered. Magnetic Resonance Imaging (MRI-a diagnostic technique that uses magnetic fields and radio waves to produce a detailed image of the body's soft tissue and bones) was recommended for better evaluation. Interdisciplinary note dated (MONTH) 9, (YEAR), at 2:45 p.m. revealed that at 11:00 a.m. Resident 168 was sent out to Orthopedic Urgent Care Center to evaluate right knee and returned at 2:00 p.m. with the right knee in hinged brace, to follow-up with Orthopedics in one week, and a [DIAGNOSES REDACTED]. Review of Orthopedic Urgent Care report dated (MONTH) 9, (YEAR), revealed right knee pain and closed fracture of upper end of tibia (right knee fracture), instructions for non-weight bearing, ice and elevate knee, and follow up in one week with Orthopedics. Review of Resident 168's (MONTH) (YEAR) physician orders [REDACTED].) 18, (YEAR), and an orthopedic follow up on (MONTH) 31, (YEAR), for a right lateral tibia (knee) fracture with a start date of (MONTH) 18, (YEAR). Review of the Nurse Practitioner exam dated (MONTH) 9, (YEAR), at 2:48 p.m. revealed that staff reported that Resident 168 was transferred via assist of two this weekend, when resident is to be transferred via a Hoyer lift (a lift used for transfers when a person requires 90-100% assistance to get into and out of bed). After transfer resident reported right knee pain, X-ray obtained, which could not rule out fracture. Resident seen by Orthopedic Urgent Care, where a second X-ray was preformed and showed positive for right tibial plateau fracture (right knee fracture). Resident with [MEDICAL CONDITION], and had not experienced a fracture since lumbar compression fractures, she experienced in regards to a fall in (YEAR) while at home. Review of the information provided by the facility on (MONTH) 8, (YEAR), revealed that at approximately 4:22 a.m. Resident 168 reported right knee pain with notable swelling. Registered Nurse assessment revealed right knee to be swollen, tender, and with limited range of motion. Resident 168 was not able to consistently state what happened to her knee, did mention that it may have happened when she stood to transfer, sometime during daytime. Resident 168 is non-ambulatory, has a physician order [REDACTED]. Following Resident's initial complaint of pain, a Registered Nurse assessment was completed; Nurse Practitioner and guardian were contacted; pain medication was administered; X-ray was ordered and administered; subsequently Resident 168 was sent to Orthopedic Urgent Care; was diagnosed with [REDACTED]. Review of Licensed Practical Nurse 2 (LPN 2) statement obtained by the facility on (MONTH) 8, (YEAR), revealed that at approximately 7:20 p.m. on (MONTH) 7, (YEAR), LPN 2 witnessed Nurse Aide 1 (NA 1) transferring Resident 168 by herself without a mechanical lift. LPN 2 felt that NA 1 didn't have a good grip of Resident 168 and rushed over to provide assistance with transferring Resident 168 to bed. LPN 2 stated she was unaware of Resident 168's transfer status. At the time of transfer Resident 168 didn't display signs of distress, it wasn't until approximately 1:45 a.m. during care that Resident 168 complained of pain in her right knee. Review of Nurse Aide 1 (NA 1) statement obtained by the facility on (MONTH) 9, (YEAR), revealed that on (MONTH) 7, (YEAR), at approximately 7:15 p.m. NA 1 transferred Resident 168 via a stand pivot and during the transfer the nurse provided assistance. NA 1 stated that Resident 168 did not complain about her knee after transferring her, it wasn't until approximately 1:00 a.m. during care that Resident 168 complained about knee pain, and NA 1 requested assistance from the nurse at that time. During an interview with the Director of Nursing on (MONTH) 19, (YEAR), at approximately 11:00 a.m. it was revealed the expectation that care needs should have been followed, the mechanical lift should have been used to transfer Resident 168. The facility failed to assure that Resident 168 was free of neglect, during a transfer without a mechanical lift, which resulted in actual harm to Resident 168, who sustained right knee pain, was transferred to an Orthopedic Urgent Care Center, and diagnosed with [REDACTED]. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. Previously cited 10/5/17, 8/10/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/10/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/5/17, 8/10/17, 4/17/17, 12/13/16, 12/1/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 8/10/17, 12/13/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/10/17, 12/1/16. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited: 8/10/17, 4/20/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/10/17, 6/29/17, 4/17/17, 12/13/16, 12/1/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/29/17, 4/17/17, 12/1/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/29/17, 8/10/17, 6/29/17, 4/20/17, 4/17/17, 12/13/15, 12/1/16.

Based on clinical record review, select facility investigation reports, and staff interview, it was determined that the facility failed to implement the interventions necessary to prevent an accident by not utilizing a mechanical lift to transfer a resident per physician order, for one of 47 residents (Resident 168) reviewed, which resulted in actual harm to Resident 168, who sustained right knee pain, required transfer to an Orthopedic Urgent Care Center, and diagnosed with [REDACTED]. Findings include: Review of Resident 168's clinical record revealed [DIAGNOSES REDACTED]. despondency and dejection), [MEDICAL CONDITION] (a condition in which the bones become brittle and fragile), [MEDICAL CONDITION] (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints), lower back pain, muscle weakness, and lack of coordination. Review of Resident 168's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident needs), dated (MONTH) 10, (YEAR), revealed that Resident 168 is cognitively impaired, required extensive assistance with one person physical assistance for bed mobility and transfer between surfaces, which did not occur during the 7 day period of the assessment. Review of Resident 168's (MONTH) (YEAR) physician orders [REDACTED]., (YEAR) and a discontinue date of (MONTH) 18, (YEAR), and an orthopedic follow-up for (MONTH) 31, (YEAR), for a right lateral tibia (knee) fracture with a start date of (MONTH) 18, (YEAR). Further review of Resident 168's clinical record revealed on the resident care card (information pertaining to a resident's psychosocial, physical and care needs) that Resident 168's transfer level is total dependence with assistance of two and the use of a full mechanical lift. Resident 168's care plan revealed impaired mobility, impaired balance, impaired cognition, and chronic back pain. Review of an interdisciplinary note dated (MONTH) 8, (YEAR), at 3:44 a.m. revealed that the Nurse Practitioner was contacted regarding complaint of right knee pain and [MEDICAL CONDITION], obtained new order for Tylenol 1000 mg., every 8 hours for 48 hours, and stat (urgent or rush) X-ray: all views to rule out fracture/dislocation of right knee. Review of an X-ray exam dated (MONTH) 8, (YEAR), at 7:30 a.m. revealed acute lateral tibial plateau fracture (fracture to lower left leg bone) may be considered. Magnetic Resonance Imaging (MRI- a diagnostic technique that uses magnetic fields and radio waves to produce a detailed image of the body's soft tissue and bones) recommended for better evaluation. Interdisciplinary note dated (MONTH) 9, (YEAR), at 2:45 p.m. revealed that at 11:00 a.m. Resident 168 was sent out to Orthopedic Urgent Care Center to evaluate right knee and returned at 2:00 p.m. with the right knee in a hinged brace, to follow up with Orthopedics in one week, and a [DIAGNOSES REDACTED]. Review of Orthopedic Urgent Care report dated (MONTH) 9, (YEAR), revealed right knee pain and closed fracture of upper end of tibia (right knee fracture), instructions for non-weight bearing, ice and elevate knee, and follow up in one week with Orthopedics. Review of the Nurse Practitioner exam dated (MONTH) 9, (YEAR), at 2:48 p.m. revealed that staff reported resident was transferred via assist of two this weekend when resident is to be transferred via a Hoyer lift (a lift used for transfers when a person requires 90-100% assistance to get into and out of bed). After transfer resident reported right knee pain, X-ray obtained, and could not rule out fracture. Resident was seen by Orthopedic Urgent Care, where a second X-ray was preformed and showed positive for a tight tibial plateau fracture (right knee fracture). Resident with [MEDICAL CONDITION] and had not experienced a fracture since lumbar compression fractures, she experienced in regards to a fall in (YEAR) while at home. Review of the information submitted by the facility on (MONTH) 8, (YEAR), revealed that at approximately 4:22 a.m. Resident 168 reported right knee pain with notable swelling. Registered Nurse assessment revealed right knee to be swollen, tender, and with limited range of motion. Resident 168 was not able to consistently state what happened to her knee, did mention that it may have happened when she stood to transfer, sometime during daytime. Resident 168 is non-ambulatory, has a physician order [REDACTED]. Following resident's initial complaint of pain, a Registered Nurse assessment was completed, Nurse Practitioner and guardian were contacted, pain medication was administered, X-ray was ordered and administered, and subsequently Resident 168 was sent to Orthopedic Urgent Care, where resident was diagnosed with [REDACTED]. Review of Licensed Practical Nurse 2 (LPN 2) statement obtained by the facility on (MONTH) 8, (YEAR), revealed that at approximately 7:20 p.m. on (MONTH) 7, (YEAR), LPN 2 witnessed Nurse Aide 1 (NA 1) transferring Resident 168 by herself without a mechanical lift. LPN 2 felt that NA 1 didn't have a good grip of Resident 168 and rushed over to provide assistance with transferring Resident 168 to bed. LPN 2 stated she was unaware of Resident 168's transfer status. At the time of transfer Resident 168 didn't display signs of distress, it wasn't until approximately 01:45 a.m. during care that Resident 168 complained of pain in her right knee. Review of Nurse Aide 1 (NA 1) statement obtained by the facility on (MONTH) 9, (YEAR), revealed that on (MONTH) 7, (YEAR), at approximately 7:15 p.m. NA 1 transferred Resident 168 via a stand pivot and during the transfer the nurse provided assistance. NA 1 stated that Resident 168 did not complain about her knee after transferring her, it wasn't until approximately 1:00 a.m. during care that Resident 168 complained about knee pain, and NA 1 requested assistance from the nurse at that time. During an interview with the Director of Nursing on (MONTH) 19, (YEAR), at approximately 11:00 a.m. it was revealed the expectation that care needs should have been followed, the mechanical lift should have been used to transfer Resident 168. The facility failed to implement the interventions necessary to prevent an accident by not utilizing a mechanical lift to transfer Resident 168 which resulted in actual harm to Resident 168, who sustained right knee pain, required to be transferred to an Orthopedic Urgent Care Center, and diagnosed with [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 12/13/16, 12/1/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/10/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/5/17, 8/10/17, 4/17/17, 12/13/16, 12/1/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 8/10/17, 12/13/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/10/17, 12/1/16. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 8/10/17, 6/29/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/10/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/10/17, 6/29/17, 4/17/17, 12/13/16, 12/1/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/29/17, 4/17/17, 12/1/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/29/17, 8/10/17, 6/29/17, 4/20/17, 4/17/17, 12/13/15, 12/1/16.

Based on clinical record review and a review of facility documentation, facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that the residents were protected from neglect resulting in harm by failing to provide adequate supervision related to leaving a resident unattended in the shower room for one of 59 residents who received a shower on November 11, 2016, and for 186 residents requiring the assist of two out of 341 residents who use the showers. Resulting in actual harm to a resident (Resident 1) who sustained a fractured right hip when the resident fell . This situation was identified as an Immediate Jeopardy situation to the residents' health and safety. Findings include: Review of the facility's policy titled, Shower/Bath, Policy number 11.5(a) with a review date of January 2015, and a revised date of August 2016, revealed under procedure #7, NEVER LEAVE RESIDENT UNATTENDED (bold and capitalization in text of policy). A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan titled Falls, which was initiated on February 18, 2015, and was current at the time of the fall, revealed that the transfer status of the resident was: See NA KARDEX (Nurse Aide-Resident Care Card). The NA KARDEX dated October 8, 2016, revealed the transfer status of the resident was to be transfer level EXTENSIVE ASSIST X (times) 2 (Physical Assist of two staff). Further review of the NA KARDEX revealed Bathing Level of Extensive Assist of one. Further review of a quarterly Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated September 26, 2016, revealed that Section C Cognitive Patterns, C0100 Should Brief Interview for Mental Status be Conducted, was coded as a 0 (no, resident is rarely/never understood). The instructions then say to skip to and complete section C0700-C1000, Staff assessment for Mental Status. Section C0700 Short Term Memory, was coded as a 1 (memory problem), section C0800 Long Term Memory, was coded as a 1 (memory problem), section C 0900 Memory Recall Ability, was coded as a Z (none of the above was recalled), and section C1000 Cognitive Skills for Daily Decision Making, was coded as a 3 (severely impaired-never/rarely made decisions). Review of the MDS section G Functional Status revealed under G0110 Activities of Daily Living Assistance, assessment B transfer was coded as a 3 (two plus persons physical assist). Section G0120 Bathing-Self Performance was coded as a 4 (total dependence). A review of the nurses' notes dated November 11, 2016, at 12:12 p.m. revealed that Registered Nurse (RN) 1 was called to assess the resident who was found unattended on the floor in her bathroom at 11:20 a.m. The resident was lying on her right side, partially dressed, and had last been visualized in the shower chair. The resident was awake, alert, and her orientation was at her baseline, which is extensive dementia. RN 1 noted bruising on the right buttock, the right hip, and the right temple. The right leg was drawn up towards the torso and the resident was guarding (protecting) the right lower extremity. The physician was called and an X-ray was ordered. The nurses' note dated November 11, 2016, at 4:27 p.m. revealed that the X-ray results stated a mildly impacted right subcapital [MEDICAL CONDITION] (a [MEDICAL CONDITION] of the femur (the bone in the upper leg) in which the parts of the broken bone are driven toward or into each other by force) cannot be excluded. The physician was again contacted and he gave new orders for the resident to be transferred to the hospital for evaluation and clarification of a possible right [MEDICAL CONDITION]. The resident returned to the facility at 9:00 p.m., with a [DIAGNOSES REDACTED]. The physician ordered an orthopedic (a physician that specialized in the bones) follow up. Documentation indicated that the resident was seen by the orthopedic physician who ordered a follow up X-ray. A review of that report dated November 16, 2016, indicated there was a fractured right femoral (the bone in the upper leg) hip. Review of the facility investigation dated November 11, 2016, for the incident occurring on November 11, 2016, revealed that Nurse Aide (NA) 1 left the resident unattended on a shower chair, while she went to look for help to transfer the resident. While the Nurse Aide was out of the shower room the resident fell and suffered a right [MEDICAL CONDITION]. Review of NA 1's written statement dated November 11, 2016, revealed that, I had assistance from a fell ow employee to put the resident into the shower chair, that employee had to then go to lunch, so when I was finished showering the resident I pulled the bathroom call light while waiting for the light to be answered, I started drying and dressing the resident, after waiting approximately 15 minutes, I stepped out to check the hall for a helper. I found a staff member coming out of the tub room. Only gone approximately 45 seconds upon entering the room I heard a bang and found the resident on the floor. I asked the other staff member to get a nurse and waited for help with resident until nursing arrived. An interview with the Director of Nursing on December 12, 2016, confirmed that NA 1 was hired on July 1, 2013. A review of the nurse aide orientation program check list revealed that the employee was educated on the shower/bathing policy on July 2, 2013. The Special Considerations form, which includes the education on showering/bathing procedures was revised in June 2014, and NA 1 was educated on the revised form on June 25, 2014. No other documentation was available for review indicating that the employee had been re-inserviced after June 25, 2014. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 12, 2016, at 5:34 p.m. related to Resident 1 being left unattended in the shower on a shower chair, which resulted in a fall with a fracture. An interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2016, at 5:40 p.m. revealed that the facility failed to re-educate the nursing staff regarding the correct number of staff to be used when transferring a resident and not leaving a resident unattended in the shower. An immediate corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on how re-education was going to be provided to all nursing personnel regarding the safe and proper showering. An acceptable corrective action plan was received from the facility on December 12, 2016, at 7:25 p.m. that included re-educating staff on the proper transfer of residents according to their needs. The Immediate Jeopardy was removed on December 13, 2016, at 11:30 a.m. after the implementation of the corrective action plan was verified. The facility neglected to provide direct supervision of Resident 1 by leaving the resident unattended in a shower chair in the shower room resulting in the resident falling and sustaining a right [MEDICAL CONDITION], being transferred to the hospital and a consult with an orthopedic physician. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 12/1/16, 7/22/16, 11/23/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/1/16, 7/27/16, 7/22/16, 11/23/15, 11/5/15.

Based on observations, review of a clinical record, facility policies and procedures and interviews with facility staff, it was determined that the facility failed to provide adequate supervision related to leaving a resident unattended in the shower room for one of 59 residents who received a shower on November 11, 2016, and for 186 residents requiring the assist of two out of 341 residents who use the showers. Resulting in actual harm to a resident (Resident 1) who sustained a fractured right hip when the resident fell . This situation was identified as an Immediate Jeopardy situation to the residents' health and safety. Findings include: Review of the facility's policy titled Shower/Bath Policy number 11.5(a) with a review date of January 2015, and a revised date of August 2016, revealed under procedure #7, NEVER LEAVE RESIDENT UNATTENDED (bold and capitalization in text of policy). Review of Resident R1's quarterly Minimum Data Set assessment (MDS- a periodic assessment of resident care and service needs), dated September 26, 2016, revealed that Resident 1 was admitted to the facility on [DATE]. Further review of the MDS revealed that the resident was admitted with [DIAGNOSES REDACTED]. Further review of the quarterly Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated September 26, 2016, revealed that section C Cognitive Patterns, C0100 Should Brief Interview for Mental Status be Conducted, this was coded as a 0 (no, resident is rarely/never understood). The instructions then say to skip to and complete section C0700-C1000, Staff assessment for Mental Status. Section C0700 Short Term Memory, was coded as a 1 (memory problem), section C0800 Long Term Memory, was coded as a 1 (memory problem), section C 0900 Memory Recall Ability, was coded as a Z (none of the above was recalled), and section C1000 Cognitive Skills for Daily Decision Making, was coded as a 3 (severely impaired-never/rarely made decisions). Review of the MDS section G Functional Status revealed under G0110 Activities of Daily Living Assistance, assessment B transfer was coded as a 3 (two plus persons physical assist). Section G0120 Bathing-Self Performance was coded as a 4 (total dependence). Review of an Interdisciplinary Note dated November 11, 2016, revealed that at approximately 11:20 a.m. the resident was found on the floor in her bathroom. Registered Nurse (RN) 1 assessed the resident, which revealed bruising to the right buttock, right hip, and diamond shaped patterns on the right side of her forehead. The resident was resistive to attempts to move the right hip, with an observation of facial grimacing. A review of the nurses' notes dated November 11, 2016, at 12:12 p.m. revealed RN 1 was called to assess the resident who was found unattended on the floor in her bathroom at 11:20 a.m. The resident was lying on her right side, partially dressed, and had last been visualized in the shower chair. Resident was awake, alert, and her orientation was at her baseline, which is extensive dementia. Registered Nurse (RN) 1 noted bruising on the right buttock, the right hip, and the right temple. The right leg was drawn up towards the torso and the resident was guarding (protecting) her right lower extremity. The physician was called and an X-ray was ordered. The nurses' note dated November 11, 2016, at 4:27 p.m. revealed that the X-ray results stated a mildly impacted right subcapital hip fracture (a fracture of the neck of the femur (the bone in the upper leg) in which the parts of the broken bone are driven toward or into each other by force) cannot be excluded. The physician was again contacted and he gave new orders for the resident to be transferred to the hospital for evaluation and clarification of a possible right hip fracture. The resident returned to the facility at 9:00 p.m., with a [DIAGNOSES REDACTED]. The physician ordered an orthopedic (a physician that specialized in the bones) follow up. Documentation indicated that the resident was seen by the orthopedic physician who ordered a follow up X-ray. A review of that report dated November 16, 2016, indicated there was a fractured right femoral (the bone in the upper leg) hip. Review of Nurse Aide (NA) 1's written statement dated November 11, 2016, revealed that, I had assistance from a fell ow employee to put the resident into the shower chair, that employee had to then go to lunch, so when I was finished showering the resident I pulled the bathroom call light while waiting for the light to be answered, I started drying and dressing the resident, after waiting approximately 15 minutes, I stepped out to check the hall for a helper. I found a staff member coming out of the tub room. Only gone approximately 45 seconds upon entering the room I heard a bang and found the resident on the floor. I asked the other staff member to get a nurse and waited for help with resident until nursing arrived. An interview with the Director of Nursing on December 12, 2016, confirmed that NA 1 was hired on July 1, 2013. A review of the nurse aide orientation program check list revealed that the employee was educated on the shower/bathing policy on July 2, 2013. The Special Considerations form, which includes the education on showering/bathing procedures was revised in June 2014, NA 1 was educated on the revised form on June 25, 2014. No other documentation was available for review indicating that the employee had been re-inserviced after June 25, 2014. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 12, 2016, at 5:34 p.m. related to Resident 1 being left unattended in the shower on a shower chair, which resulted in a fall with a fracture. An interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2016, at 5:40 p.m. revealed that the facility failed to re-educate the nursing staff regarding the correct number of staff to be used when transferring a resident, and not leaving a resident unattended in the shower. An immediate corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on how re-education was going to be provided to all nursing personnel regarding the safe and proper showering. An acceptable corrective action plan was received from the facility on December 12, 2016, at 7:25 p.m. that included re-educating staff on the proper transfer of residents according to their needs. The Immediate Jeopardy was removed on December 13, 2016, at 11:30 a.m. after the implementation of the corrective action plan was verified. The facility failed to provide direct supervision of Resident 1 by leaving the resident unattended in a shower chair in the shower room resulting in the resident falling and sustaining a right hip fracture, being transferred to the hospital and a consult with an orthopedic physician. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/supervision/devices. Previously cited 12/1/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/1/16, 7/22/16, 11/23/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/1/16, 7/27/16, 7/22/16, 11/23/15, 11/5/15.

Based on clinical record review, review of select policies and procedures and staff interview, it was determined that the facility failed to provide treatment to promote healing and prevent infection for a pressure ulcer for one of 30 residents reviewed (Resident 1) which resulted in the resident being hospitalized with an infection to the pressure ulcer. Findings include: Review of the current policy titled, Pressure Ulcer (injuries to skin and underlying tissue resulting from prolong pressure on the skin) Treatment Protocol (instructions on pressure ulcer care) stated to notify the physician within 24 hours of finding a pressure ulcer to obtain orders for treatment. The wound nurse and the unit manager should also be notified of the newly developed area. Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Review of the, Interdisciplinary Notes (progress notes written by nursing home staff) revealed a note on May 24, 2016, written by the Wound Nurse, Licensed Practical Nurse (LPN) 1, stating that nursing staff found an open area on Resident 1's sacrum (area between buttocks and lower back). Review of LPN 1's assessment on May 24, 2016, revealed a Stage III pressure ulcer (full thickness skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed as a result of pressure). The wound measured 1.6 x 0.3 x > (less than) 0.1 centimeters (cm - metric unit of measurement). Review of the physician's orders [REDACTED]. Review of the treatment order revealed that the physician did not sign the new treatment order until two days later, on May 26, 2016, at 12:20 p.m. Review of the interdisciplinary notes revealed no evidence that the physician was made aware of the new pressure ulcer at the time it was identified. Review of the electronic physician's orders [REDACTED]. The order indicated to cover the pressure ulcer with Durafiber AG (absorbent, antimicrobial (kills viruses and bacteria) dressing) then cover with Allevyn Life every day and as needed. The order was signed by the physician two days later on June 2, 2016. Review of interdisciplinary notes revealed a note on June 9, 2016, written by LPN 1 who assessed the pressure ulcer and noted no change. On June 13, 2016, LPN 1 wrote a note after her assessment of Resident 1's pressure ulcer. The note revealed that the pressure ulcer was getting worse and measured, 2.2 x 1.5 x ? cm. The pressure ulcer also developed necrosis (death of skin tissue). LPN 1 recommended to increase the dressing change treatment to two times a day. Review of the physician's orders [REDACTED]. The order read to add [MEDICATION NAME] (antibiotic ointment to kill bacteria) to the existing pressure ulcer treatment and change daily. The physician did not sign the order until June 17, 2016. On June 24, 2016, LPN 1 wrote a note after her assessment of Resident 1's pressure ulcer which revealed the pressure ulcer continued to get worse. It increased in size to, 3.0 x 2.2 x ? cm. The wound also developed undermining (tunneling under the intact tissue). Review of the electronic physician's orders [REDACTED]. The physician did not sign off on the order until June 25, 2016. On July 1, 2016, Registered Nurse (RN) 1 was made aware that Resident 1's pressure ulcer had an odor. During an interview with RN 1 on July 21, 2016, at 1:25 p.m. she stated that she assessed the pressure ulcer because LPN 1 was not at work. RN 1 assessed the wound and then notified the physician of her findings. On July 1, 2016, the physician assessed the pressure ulcer and wrote a note. The note read that Resident 1 was seen for advanced, non-healing sacral wound. He stated that Resident 1 was under the treatment of [REDACTED]. The physician stated that nursing reported the wound is not healing and is now odorous. He stated the pressure ulcer is a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) with undermining on all sides of the wound with foul odor. He stated that the wound needs to be cleaned out thoroughly and changed the treatment order to cleanse the wound with [MEDICATION NAME] (a broad spectrum antiseptic used in the treatment and prevention of infections in wounds), apply a wet to dry [MEDICATION NAME] dressing, apply A&D ointment (protective barrier cream) to surrounding skin and cover with Alleyvn two times a day and as needed. Review of the, Treatment Record (form used to document when a treatment was done) for July 2016, revealed that the pressure ulcer dressing for Resident 1 was not changed two times a day per the physician's orders [REDACTED]. There was also a delay in treatment on the following day when the dressing was changed on the evening shift on July 4, 2016, and not again until July 6, 2016, on day shift. Review of the interdisciplinary notes revealed a note on July 7, 2016, by LPN 1 noting significant deterioration since the last assessment. The wound measured, 3.3 x 4.4 x ? with a foul odor. She noted that recommendations were offered but care and treatment of [REDACTED]. On July 8, 2016, the physician entered a note stating that the area surrounding the wound was slightly more macerated (skin breakdown due to wetness). The physician changed the order to add a no sting barrier spray to the skin surrounding the wound. Further review of the, Treatment Record revealed that on July 9, 2016, the physician's orders [REDACTED]. On July 11, 2016, the physician assessed Resident 1's wound. He noted that the wound needs to be checked and redressed at least two times a day. He changed the treatment order to cleanse the wound with normal saline and pat dry, apply Santyl mixed with [MEDICATION NAME] to sterile packing strip and pack wound bed loosely with packing strip. The treatment continued to spray surrounding skin with no sting barrier spray and cover with Allevyn patch two times a day and as needed. On July 14, 2016, Resident 1 presented with a temperature of 99.3 degrees Fahrenheit (indicating a fever) and a low blood pressure of 90/54 mm Hg (millimeters of Mercury. A normal blood pressure is 120/80 mm Hg). At this time Resident 1 was sent to the hospital for evaluation. Review of the hospital records revealed that Resident 1 had an, infected Stage IV sacral pressure ulcer and was admitted to the medical floor and started on antibiotics. He also had consults with infectious disease and the surgical team. As of July 22, 2016, Resident 1 remained in the hospital. During an interview with the Director of Nursing (DON) on July 22, 2016, at 9:35 a.m. she stated that she would expect Resident 1's treatment order for his pressure ulcer to be changed per physician's orders [REDACTED].>During an interview with LPN 1 on July 22, 2016, at 11:22 a.m. she stated that she initiated treatment orders based on her judgment. She stated that she talks to the physician if the wound has problems. During an interview with the DON on July 22, 2016, at 12:00 p.m. she confirmed that the physician was not made aware of the new findings of the pressure ulcer. The DON confirmed that a LPN cannot initiate a new treatment order. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 6/25/15. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/25/15. 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/25/15. 28 Pa. Code 211.10(a)(d) Resident care policies. Previously cited 6/25/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. previously cited 11/23/15, 11/5/15, 6/25/15.

Based on clinical record reviews, facility policy reviews and staff interviews, it was determined that the facility failed to provide the highest practicable care for one of four residents reviewed resulting to harm to the resident (Resident 1). Findings include: Review of the facility's, Neurological Checks form (an assessment record of the function of the bodies nerves) policy, last reviewed February 2015, revealed that any resident who experiences a possible head injury due to a fall, accident or acute neurological (nerve function) condition will be started on neurological checks (an assessment ordered by a physician to be performed to determine nerve and brain function) for a twenty four hour period after the incident occurred or was noted. The Neurological Checks form will be used to determine any abnormality of the nerve impulses (activity) and reflexes resulting from a head trauma from the fall or the injury. When the neurological checks are done, an observation for any changes in the pupillary (opening at the center of the eyes) size and reaction will be observed and documented. The charge nurse, supervisor, physician and responsible party are to be notified immediately of changes in status. The neurological checks consisted of checking the size and reactiveness of the pupils, the level of consciousness, orientation, speech, extremity strength, vital signs and additional assessments. A normal pupil assessment is a pupil size of 4-5 mm, pupils should be equal in size and contract equally when exposed to light. Review of Resident 1's clinical record, Interdisciplinary Notes (notes written by the staff) dated September 26, 2015 at 10:13 a.m., completed by Registered Nurse (RN) 1 revealed that Resident 1 fell forward out of the wheelchair the morning of September 26, 2015. Resident 1 sustained a skin tear (a partial or complete separation of the outer skin layers from the inner tissue) and had a red abrasion (a wound caused by superficial damage to the skin, no deeper than the epidermis) on their forehead. Resident 1 was alert and responding to questions appropriately. Resident 1 stated that his foot got caught up under his wheelchair, and when he was asked by staff to move to the side of the hallway, he tried to move forward but his foot was caught and he fell forward. The note indicates that following the fall, RN 1 gave Resident 1 a left foot rest to utilize for his left leg. Resident 1 was able to mobilize with the foot rest in place. RN 1 indicated that she would consult with Occupational Therapy (OT) to see if other seating would be available. There was no further evidence of a complete assessment. Review of the, Interdisciplinary Notes dated September 26, 2015 at 10:43 a.m., revealed that Certified Registered Nurse Practioner (CRNP) 1 was notified of Resident 1's fall by RN 1. Review of, Interdisciplinary Notes dated September 26, 2015 at 10:51 a.m., completed by Licensed Practical Nurse (LPN) 1 revealed that a, PFA (Post Fall Assessment) was completed which included neurochecks. The assessment tool was documented as WNL (within normal limits). LPN 1 was notified of the fall by the restorative staff yelling, there's a fall. The resident was found on the floor, in the door frame, between the hallway and the room resting on his stomach with his head hitting the doorframe. The Interdisciplinary Notes revealed that the, resident fell forward out of his w/c (wheelchair) at 8:15 a.m. The chair alarm was sounding. The resident sustained [REDACTED]. Resident 1 stated left foot got caught up under his w/c and when he was asked by staff to move to the side of the hallway he tried to move forward but foot caught and fell forward. RN notified. POA notified (power of attorney) of fall at 10:45 a.m. Review of Interdisciplinary Notes dated September 26, 2015 at 9:48 p.m., completed by LPN 2 revealed bilateral (both sides) pupils non-reactive (not reactive) to light (a normal response would be to constrict to light) and 2 cm (indicating the size of the pupils) (4-5 mm is considered normal size), left hand grasp slightly weaker than the right. The Interdisciplinary Notes revealed that Resident 1 was placed in bed before dinner because he was leaning forward in his wheelchair. There was no evidence that the physician was notified of the change in condition. Review of Interdisciplinary Notes dated September 27, 2015 at 2:03 p.m. completed by LPN 2 revealed bilateral pupils non-reactive to light and 2 cm, Left hand grasp noted to be slightly weaker than right hand grasp. The, Interdisciplinary Notes revealed that Resident 1 was complaining of a headache during lunch. There was no evidence that the physician was notified of the change in condition. Review of the, Interdisciplinary Notes dated September 27, 2015 at 11:44 p.m., completed by LPN 2 revealed that Resident 1's left hand grasp was weaker than his right hand grasp. Resident 1 was complaining of head, neck, leg and arm pain. Resident 1 remained in bed all of the 3-11 shift. The Interdisciplinary Notes revealed that the charge nurse (nurse in charge of unit) was made aware of Resident 1's condition. Review of Interdisciplinary Notes dated September 28, 2015 at 10:46 a.m., completed by RN 2 revealed that while Resident 1 was in therapy, to have his seating system evaluated, the therapy staff noted that Resident 1 was lethargic (drowsy or sluggish) with slurred speech. Resident 1's baseline speech is garbled, his vital signs (a measurement of the essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) while in therapy were HR (heart rate) 89 (60-100 is considered normal) and BP (blood pressure) 88/57 (120/80 is considered normal). Resident 1 was to be allowed to rest in bed and the, Interdisciplinary Notes revealed that the covering physician was to assess the resident that day, November 28, 2015. Review of Interdisciplinary Notes dated September 28, 2015 at 12:37 p.m., completed by RN 3 revealed that the covering physician was notified of the resident's vital signs this a.m. Therapy returned the resident to the unit due to his BP and pulse (being abnormal), resident was hard to arouse, experiencing lethargy with garbled/slurred speech. The Interdisciplinary Notes failed to reveal any evidence that Resident 1 was seen by the covering physician. Review of Interdisciplinary Notes dated October 5, 2015 at 2:28 p.m., completed by LPN 3 revealed that Resident 1's condition was reviewed by a physician. The Interdisciplinary Notes revealed that the physician was notified of the decline in Resident 1's condition, his decline in his ability to stand and ambulate. The physician was also notified of Resident 1's increased pain in the neck, head and shoulders. The physician reviewed Resident 1's episodes of low BP's. The physician gave a new order to send the resident to the hospital for evaluation. Review of Interdisciplinary Notes dated October 5, 2015 at 8:55 p.m., completed by RN 4 revealed that the resident was admitted to the hospital on October 5, 2015 with [DIAGNOSES REDACTED]. Review of the, Post Fall Assessment (facility assessment tool to be completed after a fall) revealed on the neurological flow sheet, in the Pupils section dated September 26, 2015 at 8:30 a.m., 8:45 a.m., 9:00 a.m., 9:15 a.m., 10:15 a.m., 11:15 a.m., 12:15 a.m., 4:15 p.m., 8:15 p.m., September 27, 2015 at 12:15 a.m., 4:15 a.m., and 8:15 a.m., that the right and left pupils of the eyes were 2 mm in size (4-5 mm is considered normal size), and non-reactive to light. Review of the PFA revealed that on the front of the document where the results of the individual assessments are summarized, in the section titled, Neuro Checks (required for all unwitnessed falls whether resident is alert or not) in the following columns September 26, 2015, at 8:30 a.m., September 26, 2015, at 4:00 p.m. and September 27, 2015 at 1:00 a.m., WNL is circled indicating that the assessment for those dates and times was within normal limits. There is no evidence that the physician was notified regarding the resident's small non-reactive pupils. Interview November 13, 2015 at 10:30 a.m., with LPN 1, revealed that the neurological assessment were done and that they were WNL. LPN 1 was asked what WNL meant and the response was normal. Review of the Interdisciplinary Care Card (instructions directing and describing the care resident's require) dated August 8, 2015 at 2:24 a.m., September 25, 2015 at 11:29 a.m. and September 26, 2015 at 10:23 a.m., for Resident 1 revealed, regarding locomotion in a wheelchair, that the resident was, independent on the unit and no help was needed. Review of the, Interdisciplinary Care Card dated October 5, 2015, for Resident 1 revealed that the resident was now in a Broda chair (a reclining wheelchair) and was totally dependent on staff requiring a one person physical assist, indicating a decline in the resident's condition since the fall on September 26, 2015. An interview on November 11, 2015 at 10:40 a.m., with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the CRNP (Certified Register Nurse Practioner), was in the building September 26, 2015 between 12:52 p.m. and 4:15 p.m. and that the CRNP did not evaluate Resident 1 because it was reported by RN 1 to the CRNP on September 26, 2015 at 10:43 a.m., that the assessment of Resident 1 was normal. An interview on November 11, 2015 at 11:45 a.m., with the DON and the NHA revealed that the neurological checks completed between September 26, 2015 and September 28, 2015, documented that the pupils did not react to light and that this was a normal finding. The DON and the NHA revealed that the designation WNL should not have been circled on the PFA. They also revealed that the CRNP should have been notified when the first assessment was completed on September 26, 2015 to determine the extent of the injury, resulting in a delay in physician notification and a delay in treatment. 42 CFR 483.25 Quality of Care Previously cited 6/25/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/25/15. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 11/26/15, 6/25/15.

Based on review of the clinical record, facility documentation, and staff interview, it was determined that the facility failed to provide care and services in accordance with each resident's comprehensive plan of care for two of 30 residents reviewed (Residents 4 and 8). Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. Review of facility documentation revealed that Resident 4 suffered a fall on November 4, 2014, at 5:10 p.m. Review of Resident 4's clinical record, Interdisciplinary care card (information on resident care needs) revealed that Resident 4 was to have Dycem (assistive device to decrease sliding on a surface) applied above the chair alarm pad (a device used to alert staff of a resident's attempt to move independently.) Review of facility documentation revealed that at the time of Resident 4's fall from the chair, the Dycem was not applied to the chair per the comprehensive plan of care. As a result of the fall, Resident 4 suffered a [MEDICAL CONDITION] hip and was sent to the hospital for treatment. Review of facility documentation revealed that Resident 8 suffered a fall from a, transfer chair on January 23, 2015, at 7:45 a.m. Review of Resident 8's clinical, Interdisciplinary care card revealed that at the time of the fall, Resident 8 was to have a wheelchair with anti-roll back bars (prevents the wheel chair from going backwards), an air gel cushion to chair, and a chair alarm (a devise that sounds when resident attempts to get up from the chair) to prevent fall occurrence. Review of staff statements after the fall revealed that Resident 8 was in a wheelchair that did not have an air gel cushion, anti-roll back bars, or an alarm per Resident 8's comprehensive plan of care. Review of Resident 8's comprehensive plan of care for falls revealed that Resident 8 has glasses. During multiple observations on June 22, 23, and 24, 2015, Resident 8 was observed without glasses. During observation of interactions between Resident 8 and the staff members on June 22, 2015, at approximately 5:14 p.m., and June 24, 2015, at approximately 9:30 a.m., the staff did not ask Resident 8 if he would like his glasses. During an interview with Resident 8 on June 25, 2015, at approximately 10:30 a.m., Resident 8 was unaware that he had glasses but reported he would wear glasses. During a staff interview at 10:35 a.m., Registered Nurse (RN) 1 reported it was not clear where Resident 8's glasses were located. A subsequent search of Resident 8's belongings revealed that Resident 8's glasses were in the back of a drawer. Resident 8's glasses were cleaned and Resident 8 placed the glasses on. Interview with the Director of Nursing on June 25, 2015, at 1:00 p.m., revealed that at the time of Resident 4's November 4, 2014 fall, Resident 4's comprehensive plan of care was not followed. The Director of Nursing also revealed that at the time of Resident 8's January 23, 2015 fall, Resident 8's comprehensive plan of care was not followed. The Director of Nursing revealed that it is the facility's expectation that the staff members offer glasses to Resident 8 when he is not wearing them. The Director of Nursing revealed that it is the facility's expectation that care and services are provided to residents in accordance with their comprehensive plan of care. 483.20(k)(3)(ii) Services By Qualified Persons/Per Care Plan. Previously Cited 5/23/14, 8/6/14, 7/18/13. 28 Pa. Code 211.11(d) Resident care plan. Previously Cited 5/23/14, 7/18/13. 28 Pa. Code 211.12(d)(5) Nursing services Previously Cited 5/23/14, 7/18/13.

Based on review of select facility policies and clinical records, observations and interviews with staff, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for four of 5 Units (Units 2, 3, 4 and 5) and the facility failed to provide assistive devices to prevent accidents for one of 30 residents reviewed (Resident 4). Findings include: Review of facility documentation revealed that Resident 4 suffered a fall on November 4, 2014, at 5:10 pm. Review of Resident 4's clinical record, Interdisciplinary care card (information on resident care needs) revealed that Resident 4 was to have Dycem (assistive device to decrease sliding on a surface) applied to the right armrest bolster above the chair alarm pad between the resident and the chair alarm pad. Review of facility documentation revealed that at the time of Resident 4's fall from the chair, the staff did not apply the Dycem to the chair per the comprehensive plan of care. As a result of the fall, Resident 4 suffered a fracture of the right hip and was sent to the hospital for treatment. During a staff interview on June 25, 2015, at 1:00 p.m., the Director of Nursing revealed that at the time of Resident 4's November 4, 2014 fall, the staff did not follow Resident 4's comprehensive plan of care which resulted in a fall with injuries. Observation during the initial tour of Unit 4 on June 22, 2015, 12:30 p.m., revealed hard plastic coolers on the nurses' station counter. The boxes were unsecured and had a slide lid closure. The boxes were labeled for lab specimens (blood, urine etc.) to be placed in special biohazard bags, and to add ice to the specimen containers. Observation revealed that the specimen container was not within view of any staff. The surveyor observed residents ambulating and in wheelchairs within reach of the specimen containers. Observation of Units 2, 3 and 5 revealed the same type of specimen containers located in the same location at the nurses' stations. Interview with the Infection Control Nurse on June 23, 2015, at 2:00 p.m., revealed that the staff place blood, urine, and other body fluid specimens in these containers and that outside contracted laboratory staff retrieve the specimens twice a day. The Infection Control Nurse confirmed that the placement of the containers (behind a podium) do not allow the staff to monitor the specimen containers. The Infection Control Nurse revealed that the specimen container is kept behind the nurses' station on the locked Dementia Unit (Unit 1) but not on Units 2, 3, 4 and 5. Interview with the Nursing Home Administrator on June 24, 2015, at 3:20 p.m., revealed that the specimen containers should be located in an area that is visible to staff. During observation of the Third Floor East Hall on June 23, 2015, at 10:30 a.m., a housekeeping cart was observed unattended in the hallway. It was observed that the door to the housekeeping cart was against the wall and was unlocked. Cleaning supplies were observed in the cart. During observation of the Fifth Floor North Hall on June 24, 2015, at 1:00 p.m., a housekeeping cart was observed unattended in the hallway. It was observed that the door was unlocked. Cleaning supplies were observed in the cart. During a staff interview on June 25, 2015, at 1:00 p. m., the Director of Nursing provided a record of a housekeeping inservice that indicated that the housekeeping carts should not be left unattended. The Director of Nursing revealed that it is the facility's expectation that the carts should be locked. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 5/23/14, 7/18/13. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/23/14, 7/18/13. 28 Pa. Code 211.1 (d)(1)(5) Nursing services. Previously cited 5/23/14, 7/18/13.