Every finding on record at Presbyterian Homes-Presby

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for six of nine residents observed (Residents 10, 15, 26 34, 53, 59). Findings include:The facility's policies regarding oral medication administration and hand hygiene, dated January 30, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after glove removal.Observations during the medication pass on the 200 hall on October 1, 2024, at 7:40 a.m. revealed that Licensed Practical Nurse (LPN) 6 prepared Resident 53's medications and administered them. Without sanitizing his hands he prepared and administered Resident 26's medications, without sanitizing his hands LPN 6 donned gloves, prepared and administered Resident 59's medications, doffed his gloves and without sanitizing his hands he prepared and administered Resident 34's medications, without sanitizing his hands he prepared and administered Resident 15's medications. He then went to Resident 10's room and without sanitizing his hands he prepared and administered her medications. Interview with Licensed Practical Nurse 6 on October 1, 2025, at 8:36 a.m. confirmed that he should have sanitized his hands between residents, and after glove removal, while doing the medication pass. Interview with the Infection Control Nurse on October 16, 2025, at 9:13 a.m. confirmed that Licensed Practical Nurse 6 did not properly sanitize his hands during medication administration and after glove removal, and he should have. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in two of two kitchenettes reviewed (first and second floor).Findings include: The facility policy regarding food storage, dated January 30, 2025, revealed that food should be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. Observations in the kitchen's walk in dry storage room on September 29, 2025, at 9:37 a.m. revealed that there a bag of decorative sprinkles (approximately 10 pounds) that was open to the air, and one pound of [NAME] powder that expired on April 18, 2022. Observations in the second floor kitchenette's refrigerator/freezer on October 1, 2025, at 8:35 a.m. revealed a head of lettuce that was open to the air in the refrigerator, and two bags of frozen hot dogs (approximately 40) and a bag of six frozen hamburgers that were open to the air in the freezer.Observations in the fist-floor kitchenette freezer on October 1, 2025, at 8:50 a.m. revealed a bag of 16 frozen hot dogs and a platter of 14 frozen hamburgers that were open to the air.Interview with the Dietary Manager on October 1, 2024, at 12:00 p.m. confirmed that all food items in the kitchen/kitchenettes should be sealed in such a way as to prevent air from entering the food, and that expired food should be removed from the kitchen, and they were not.28 Pa. Code 211.6(f) Dietary services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 31 residents reviewed (Residents 6, 7, 28, 55, 61). Findings include:The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2024, revealed that Section N was to be coded for medications received in the last seven days. Section N0415C was to be coded if the resident received an antidepressant medication in the previous seven days, Section N0415F1 was to be coded if the resident received an antibiotic medication in the previous seven days, and Section N0415K1 was to be coded if the resident received an anticonvulsant medication in the previous seven days. Physician's orders for Resident 6, dated August 29, 2025, included an order for the resident to receive 300 mg of Gabapentin (an anticonvulsant) at bedtime for neuropathy (when nerves are damaged and cause weakness, numbness and pain, usually in the hands and feet).Review of the Medication Administration Record (MAR) for Resident 6, dated August and September 2025, revealed that staff administered the 300 mg of Gabapentin to the resident at bedtime from August 29 through September 3, 2025. However, a quarterly MDS assessment for Resident 6, dated September 3, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.A nursing note for Resident 7, dated August 20, 2025, revealed that the resident was starting on hospice services and that all of his medications were discontinued.Review of the MAR for Resident 7, dated August, 2025 revealed that the resident did not receive antidepressants or anticonvulsants from August 21-August 31, 2025. However, a significant change MDS for Resident 7, dated August 31, 2025, revealed that Section N0415C was coded to indicate that the resident received an antidepressant medication and Section N0415K was coded to indicate that the resident received an anticonvulsant medication during the seven day look back period.Physician's orders for Resident 28, dated August 9, 2025, included an order for the resident to receive 500 mg of Divalproex (an anticonvulsant) at bedtime for seizures.Review of the MAR for Resident 28, dated August 2025, revealed that staff administered 500 mg of Divalproex to the resident at bedtime from August 9 through 31, 2025. However, an admission MDS assessment for Resident 28, dated August 13, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.Physician's orders for Resident 55, dated July 24, 2025, included an order for the resident to receive 500 mg of Cephalexin twice a day for cellulitis (infection of the skin).Review of the MAR for Resident 55, dated July and August, 2025, revealed that staff administered 500 mg of Cephalexin to the resident twice a day from July 24 through July 31, 2025. However, a quarterly MDS assessment for Resident 55, dated August 5, 2025, revealed that Section N0415F1 was not coded, indicating that the resident did not receive an antibiotic during the seven-day look-back assessment period.Physician's orders for Resident 61, dated August 9, 2025, included an order for the resident to receive 100 mg of Gabapentin in the morning and 200 mg in the evening for neuropathy.Review of the MAR for Resident 61, dated September 2025, revealed that staff administered 100 mg of Gabapentin to the resident in the morning and 200 mg of Gabapentin in the evening from September 1 through 9, 2025. However, a significant change MDS assessment for Resident 61, dated September 9, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.An interview with the Regional Registered Nurse Assessment Coordinator on October 16, 2025 at 10:51 a.m. confirmed that the MDS assessments listed above were coded incorrectly.28 Pa. Code 211.5(f) Clinical Records.

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of five hospice residents reviewed (Resident 10). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). Physician's orders for Resident 10, dated April 25, 2025, revealed that the resident was to receive hospice services. As of September 30, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form from the hospice provider. Interview with the Social Service Manager and the Hospice Representative on September 30, 2025, at 1:30 p.m. confirmed that there was no evidence that the election of benefits form was on Resident 10's hospice chart, and it should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 61).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 9, 2025, revealed that the resident was cognitively intact and was frequently incontinent of bowel movements. Physician's orders for Resident 61, dated April 28, 2025, included orders for the resident to receive 30 milliliters of Milk of Magnesia as needed for no bowel movements for three days, give on day 4 of no bowel movement; a 10 milligram dulcolax suppository rectally as needed for no bowel movement for four days, give on day five of no bowel movement; and a Fleets enema to be given rectally as needed for no bowel movement for five days, give on day six of no bowel movement. Review of Resident 61's bowel records for August and September 2025 revealed that there was no documented evidence that the resident had a bowel movement from August 24 through 27, September 3 through 6, September 16 through 19, and September 25 through 28, 2025. Review of the August and September 2025 MAR's for Resident 61 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. Interview with the Nursing Home Administrator on October 16, 2025, at 11:08 a.m. confirmed that the physician's orders for bowel medications were not followed for Resident 61. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, investigation reports, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 31 residents reviewed (Resident 55). Findings include:The facility's policy regarding Abuse, Neglect, and Exploitation, dated January 31, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse, and that residents would be protected from mistreatment, neglect, exploitation, and misappropriation of property.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55 dated July 13, 2025, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia.Resident 55's care plan, dated June 1, 2025, indicated that the resident had dementia, as well as anxiety and agitation.The facility's investigation documents for Resident 55, dated August 15, 2025, indicated that Nurse Aide 1 was observed holding a baby doll that belonged to another resident in front of Resident 55 and would pull it away when Resident 55 reached for it. Nurse Aide 1 stated she knew the doll did not belong to Resident 55 and that she was trying to return the doll to the other resident. Nurse Aide 1 was observed pulling the doll away from Resident 55 and laughing at the resident as she did it. The investigation revealed that Resident 55 experienced visible distress, yelling, and anxiety due to the actions by Nurse Aide 1. A witness statement from Nurse Aide 1, dated August 15, 2025, revealed that she knew the doll did not belong to Resident 55 and that she was taking the doll to give it to the resident that it belonged to. She stated that she did tell Resident 55 it was not her doll and that the resident was visibly upset.A witness statement from Nurse Aide 2 on August 15, 2025 revealed that Nurse Aide 1 was holding another resident's doll in front of Resident 55 and telling the resident that it wasn't hers. She stated that Resident 55 was chasing after Nurse Aide 1 stating that she bought it and that it was hers. She stated that Nurse Aide 1 was making the episode go on for far too long.A witness statement from Nurse Aide 3, dated August 15, 2025, revealed that Nurse Aide 1 was teasing Resident 55 with a doll that belonged to another resident and that Resident 55 was visibly upset. She stated that Nurse Aide 1 appeared to be holding the doll in front of Resident 55 and when the resident would get close she would pull the doll away from her.A witness statement from Nurse Aide 4, dated August 15, 2025, revealed that Nurse Aide 1 was teasing Resident 55 with a baby doll and laughing at Resident 55. A witness statement from Nurse Aide 5, dated August 25, 2025, revealed that when she arrived to work for night shift she overhead very loud laughter and saw that Resident 55 was very upset with a red face and tears in her eyes. She stated that Nurse Aide 1 was teasing Resident 55 and laughing very hard about it.Interview with Director of Nursing on October 16, 2025, at 11:25 a.m. revealed Nurse Aide 1 was terminated for teasing Resident 55 with a baby doll and for causing emotional stress to the resident who was visibly upset.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for three of 31 residents reviewed (Residents 4, 8, 75), Findings include:The facility policy for Admission, Transfer and Discharge Notification, dated January 30, 2025, indicated that upon transfer to the hospital the resident and resident representative will be notified in writing, and the ombudsman will be notified.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 14, 2025, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for her daily care needs and had diagnoses that included, cerebral infarct (stroke).Review of Resident 4's clinical record indicated that on July 4, 2025 at 1:23 p.m. the registered nurse was called to second floor dining room where Resident 4 was complaining of chest pain. The resident winced when the registered nurse touched her chest. Resident 4 was transported to the hospital where she was admitted .Review of Resident 4's progress notes revealed that there was no documentation that the resident and legal guardian were notified in writing of the purpose for resident's transfer, or that the ombudsman was notified regarding her hospitalization of July 4, 2025.An admission MDS for Resident 8, dated July 18, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nurse's note for Resident 8, dated August 3, 2025 revealed that the resident was sent to the emergency room for an evaluation related to tremors, weakness, and stiff neck. There was no documented evidence that written notification of transfer was provided to Resident 8 or his representative, or that the ombudsman was notified of the transfer to the hospital as required.An admission MDS assessment for Resident 75, dated July 13, 2025, indicated that the resident was cognitively intact and required assistance from staff for his daily care needs.A nursing note for Resident 75, dated July 28, 2025, revealed that the resident was discharged home with his wife.There was no documented evidence that written notification of discharge was sent to the ombudsman as required.Interview with the Assistant Director of Nursing on October 16, 2025 at 9:13 a.m. confirmed that there was no documented evidence that Resident 4 and Resident 8, and their guardians were notified in writing of their transfer to the hospital, or that the ombudsman was notified regarding the hospitalizations, and also confirmed that the ombudsman was not notified of Resident 75's discharge and should have been.28 Pa. Code 201.29(j) Resident Rights.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident representative was notified timely about a change in condition for one of three residents reviewed (Resident 2).Findings include:The facility's policy regarding changes in condition, dated January 30, 2025, indicated that the facility would provide timely notification to families, resident representatives, powers of attorney, physicians, and staff of changes in resident medical conditions consistent with regulation and resident choice.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 5, 2025, revealed that the resident was severely cognitively impaired, usually understood, could sometimes understand, required assistance with care needs, and had diagnoses that included dementia.A grievance filed by the resident representative on July 24, 2025, revealed that Resident 2's glasses were missing. The glasses were replaced by 360 care. The investigation determined that the resident representative was not notified of optometry visit in house or that new glasses were ordered. There was no process in place to notify families when residents are seen for new glasses by 360 (consult vision services). A skin/wound note dated July 16, 2025, for Resident 2, revealed that she was noted to have intact edema blister on left medial lower extremity, approximately three by four centimeters (cm) in diameter. Surrounding skin pink and warm to the touch with some weeping present. A skin/wound note dated July 24, 2025, for Resident 2, revealed that the blister was no longer intact and the medical director was aware. Physician's orders for Resident 2, dated July 24, 2025, included an order for the resident to receive 500 milligrams (mg) of Cephalexin (antibiotic medication) twice a day for cellulitis (bacterial infection of the skin) for seven days.There was no documented evidence that the resident's representative was notified about the Resident 2's appointment with a consult for vision services, changes in a skin alteration, or a new ordered antibiotic medication.Interview with Director of Nursing on September 10, 2025, at 4:45, 5:03, and 5:21 p.m. confirmed that there was no documented evidence of notification to the resident's representative about a new medication and confirmed that the family should have been notified of any consult appointments, but was not.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of six residents reviewed (Resident 2) who was at risk for falls, resulting in a fall with multiple fractures. This deficiency was cited as past non-compliance. Findings include: The facility's fall management policy, dated January 30, 2025, indicated that the facility would provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. The facility would ensure the resident environment remained as free of accident hazards as possible. When a resident sustained a fall, the assessment process would include an investigation using the Fall Investigation analysis sheet. The fall investigation would be used to evaluate probable causal factors, which may include environmental factors, resident medication condition, resident behavioral manifestations, and medical or assistance devices that may implicated in the fall. The investigation and appropriate interventions would be initiated at the time of the fall. Resident who sustained a fall would have a care plan developed or the existing care plan updated at the time the incident occurs that included the date of the new intervention. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 22, 2024, revealed that the resident was cognitively impaired, was independent with ambulation, and had diagnoses that included dementia and seizures. An incident report, dated January 8, 2025, at 6:25 a.m. revealed that Resident 2 was observed on the floor lying on her left side. There was a large amount of blood on the floor around her head, and the nurse aide was holding a towel to the laceration on her head. The resident remained unresponsive for 15 to 20 minutes. The resident was transferred to the hospital for further evaluation. A fall investigation, dated January 8, 2025, at 9:23 a.m., revealed that on January 8, 2025, Resident 2 was observed on the floor lying on her left side. There was a large amount of blood on the floor around her head, and the nurse aide was holding a towel to the laceration on her head. The resident remained unresponsive for 15 to 20 minutes. Per staff interviews, the resident was ambulating at her baseline throughout the unit, she paused and stood still, stared blankly for a short period, and then fell backwards. The resident remained at the hospital for evaluation and treatment. A nursing note, dated January 8, 2025, at 12:04 p.m. revealed that the resident was admitted to the hospital due to having another seizure. A nursing note, dated January 10, 2025, at 3:51 p.m., revealed that Resident Family Member 1 called the facility and reported that Resident 2 would be returning to the facility the next day. Resident Family Member 1 was concerned that the resident was going to fall upon return to the facility and was agreeable to placing hipsters on Resident 2 upon her return and starting a prompted toileting program. Nursing notes, dated January 12, 2025, at 2:42 p.m. and January 17, 2025, at 8:54 p.m. revealed that Resident 2 had seizure activity and was transferred to the hospital for evaluation and returned to the facility on [DATE]. A care plan for Resident 2, dated January 17, 2024, included interventions for hipsters to be worn at all times unless performing personal hygiene, and to toilet the resident upon rising, before and after meals, and at bedtime. An incident report, dated January 18, 2025, at 11:05 p.m. revealed that Resident 2 had a fall in the hallway that was witnessed by another resident. Upon entering the hall, Resident 2 was noted to be lying on her right side with her legs bent and gripper socks on. She complained of left hip pain, and the resident who witnessed the fall stated the resident fell backwards and hit her head on railing on wall. She was transferred to the emergency room for evaluation. A fall investigation, dated January 20, 2025, at 10:07 a.m., revealed that on January 18, 2025, Resident 2 had a fall in the hallway that was witnessed by another resident and complained of left hip pain. She was transferred to the emergency room for evaluation. Hospital records revealed that she had an acute (broken bone from traumatic injury) left hip fracture and acute fracture of the seventh vertebrae of the thoracic spine (T7). The investigation found that Resident 2 did not have hipsters on at the time of the fall and that the care-planned intervention was not visible to Nurse Aide 1 due to a facility process error. A witness statement from Nurse Aide 1, date January 19, 2025, revealed that Resident Family Member 1 told her about the hipsters and said that they were not on. Nurse Aide 1 told Resident Family Member 1 that she would obtain the hipsters and apply them in a little bit when she put her in bed. Nurse Aide 1 reported that she did not apply the hipsters to the resident during the shift that evening and it was not showing in her care planned items for them to be applied. A witness statement from Registered Nurse Supervisor 2, dated January 19, 2025, revealed that when she completed her post-fall assessment, she took the resident's pants down and confirmed that the hipsters were not in place and were not present. An interview with the Assistant Director of Nursing and Nursing Home Administrator on February 5, 2025, at 3:04 p.m. confirmed that Resident 2 did not have hipsters on at the time of the fall on January 18, 2025, and should have had them on as care planned. Following the incident/investigation on January 18, 2025, the facility's corrective actions included: Resident 2 was sent to the hospital and her falls care plan would be reviewed and updated upon return. An audit was completed on fall care plans for all current residents. Education was provided to all nursing staff regarding the care plan policy and following the care plan. Education was completed with licensed staff and interdisciplinary team members who edit care plans on appropriate entering of interventions in the care plan and appropriate linkage to nurse aide charting. Audits to identify any issues with the care plans and fall interventions were started. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on January 19, 2025. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for bowel protocols/medications were followed for three of six residents reviewed (Residents 1, 2, 3). Findings include: The facility's policy regarding bowel management, dated January 30, 2025, indicated that the facility would follow the facility-specific bowel protocol or physican orders. A quarterly MDS assessment for Resident 1, dated November 9, 2025, revealed that the resident was severely cognitively impaired, was continent of bowel, and had diagnoses that included kidney failure, anemia, and dementia. Physician's orders for Resident 1, dated July 10, 2024, included orders for the resident to receive 30 mL of Milk of Magnesia as needed for constipation if no bowel movement on day four, a 10 mg Dulcolax suppository as needed if the resident did not have a bowel movement on day five day, and a Fleets enema on day six with no bowel movement if the Dulcolax suppository was not effective. Review of Resident 1's bowel records for January 2025 revealed that there was no documented evidence that the resident had a bowel movement from January 18 through 24, 2025. Review of the MAR's for January 2024 for Resident 1 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. A quarterly MDS assessment for Resident 2, dated October 22, 2024, revealed that the resident was cognitively impaired, was continent of bowel, and had diagnoses that included dementia. Physician's orders for Resident 2, dated July 17, 2024, included orders for the resident to receive 30 mL of Milk of Magnesia as needed for constipation if no bowel movement on day four, a 10 mg Dulcolax suppository as needed if the resident did not have a bowel movement on day five day, and a Fleets enema on day six with no bowel movement if the Dulcolax suppository was not effective. Review of Resident 2's bowel records for November 2024 revealed that there was no documented evidence that the resident had a bowel movement from November 1 through 6, 2024. Review of the MAR's for November 2024 for Resident 2 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. An admission MDS assessment for Resident 3, dated November 4, 2024, revealed that the resident was cognitively intact and was occasionally incontinent of bowel. Current physician's orders for Resident 3 included orders for the resident to receive 30 mL of Milk of Magnesia as needed for constipation if no bowel movement on day four, a 10 mg Dulcolax suppository as needed if the resident did not have a bowel movement on day five day, and a Fleets enema on day six with no bowel movement if the Dulcolax suppository was not effective. Review of Resident 3's bowel records for January 2025 revealed that there was no documented evidence that the resident had a bowel movement from January 18 through 21 and January 24 through 27, 2025. Review of the MAR's for January 2025 for Resident 3 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. Interview with the Assistant Director of Nursing on February 5, 2025, at 3:56 p.m. confirmed that the bowel protocol was not followed for Residents 1, 2 and 3 on the above-mentioned dates. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of six residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 4, 2024, indicated that the resident was cognitively intact and had a history of falls. The care plan, dated December 22, 2024, through February 1, 2025, for Resident 3 revealed that the resident was non-compliant and at risk for falling and had the following interventions in place: provide environment free of clutter, keep call bell light in reach at all times, keep personal items and frequently used items within reach, kid cushion to the night stand, gripper socks on while in bed, reminder signs to ring for assistance, non-skid strips to the right side of the bed, bed height marked on the wall for bed height, anti-roll back devices to wheelchair, offer to lie down after breakfast and lunch, perimeter mattress to bed, reminder sign placed on bathroom door to remind resident of location, reminder sign on wall beside bed to remind resident to ring for assistance, reflective tape to wheelchair and walker, attempt to walk resident with front-wheeled walker if she appears restless, motion activated night light at foot of bed, walker at bedside, dycem (anti-slip material) to wheelchair cushion, offer to toilet if resident seems restless, family agreeable to soft helmet when it arrives, offer fidget dog, offer stuffed animal if resident seems restless, large face alarm clock when it arrives. A nursing note, dated February 2, 2025, at 9:00 p.m. revealed that Resident 3 had an unwitnessed fall in her room. Upon entering the room the resident was noted to be lying flat on her back with her legs extended straight in front of her. She had a bump noted on the back of her head that was painful to touch. She was transferred to the hospital for further evaluation and was admitted with a subdural hematoma (collection of blood on the brain). There was no documented evidence that the resident's care plan was updated to include the intervention of calling the resident's son when she was restless. A nursing note, dated February 2, 2025, at 7:45 p.m., revealed that Resident 3 had an unwitnessed fall in her room. Upon entering the room the resident was noted to be lying flat on her back with her legs extended straight in front of her, with her head towards the bed and legs toward the door. There were no injuries noted. A fall investigation, dated February 1, 2025, revealed that the resident was restless at the time of the fall and the care plan was followed. A witness statement from Licensed Practical Nurse 3, dated February 1, 2025, revealed that following the fall the resident's son was called and the resident was more relaxed. Interview with the Assistant Director of Nursing and the Nursing Home Administrator on February 5, 2025, at 5:50 p.m. revealed that staff were to call the resident's son and have the resident talk with him when she was restless to help prevent further falls, but the care plan was not updated following the fall of February 1, 2025. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat in accordance with the resident's care plan for one of six residents reviewed (Resident 1). Findings include: The facility's policy regarding adaptive feeding devices, dated January 30, 2025, indicated that the facility would provide the resident with the most independent and safe way of eating. A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated November 9, 2024, indicated that the resident was severely cognitively impaired and was independent with eating after set up. The resident's care plan, dated November 27, 2024, and speech therapy clinical notes, dated December 21, 2024, indicated that her food was to be provided in bowls and given to her one at a time. Observations of Resident 1 during the lunch meal on February 5, 2025, at 11:50 p.m. revealed that the resident was at a dining room table eating her meal, and her pork, mashed potatoes and sauerkraut were served on a plate. The resident's meal ticket, dated February 5, 2025, indicated that the resident was to have her food served in separate bowls, one at a time. Interview with the Nursing Home Administrator on February 5, 2025, at 2:46 p.m. confirmed that Resident 1's food should have been served in separate bowls one bowl at a time, as care planned. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to transcribe physician's orders related to medication changes for one of seven residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 30, 2024, indicated that the resident was cognitively impaired, required partial/moderate assist for transfers, and had a diagnosis that included dementia. Review of clinical records for Resident 1 revealed diagnoses that included a history of falls, adjustment disorder with anxiety and depression, and generalized anxiety disorder. Progress notes for Resident 1, dated October 18, 2024, at 3:53 p.m. indicated that the social worker and the Certified Registered Nurse Practitioner (CRNP) with Psychogeriatric Services called the resident's daughter to review medications. The daughter indicated that she did not have any concerns with the medications that the resident was on, but felt adjustments needed to be made to help the resident get more rest at night. The CRNP discussed increasing the resident's trazodone (an antidepressant used to help with sleep) and melatonin (a medication used to help with sleep) if appropriate, and the daughter was in agreement. Psychogeriatric consult notes for Resident 1, dated October 18, 2024, indicated that the resident was increasingly anxious, depressed, and agitated after family visits and had difficulty sleeping at night. The CRNP recommended to increase the trazadone to 75 milligrams (mg) at bedtime and to increase the melatonin to 10 mg at bedtime. Documentation in the resident's clinical record revealed that the psychogeriatric consult notes and recommendations were reviewed and initialed by the nurse and by the resident's physician on October 22, 2024. Nurse's notes for Resident 1, dated October 25, 2024, at 10:38 a.m., indicated that the interdisciplinary team reviewed the resident after a fall that occurred on October 25, 2024, at 12:01 a.m., indicating that the resident's trazodone and melatonin were increased during the consult with psychogeriatric services. Psychogeriatric consult notes for Resident 1, dated November 1, 2024, indicated that the resident continued to have difficulty sleeping at night and that resident's current psychiatric medications at that time included trazadone 75 mg at bedtime and melatonin 10 mg at bedtime. Review of Resident 1's Medication Administration Record (MAR) for October and November 2024 revealed that the resident received 50 mg of trazadone daily at bedtime and received 3 mg of melatonin daily at bedtime. There was no documented evidence that the trazadone and melatonin were increased per the consult recommendations of October 18, 2024, and signed by the physician on October 22, 2024. Interview with the Director of Nursing on November 5, 2024, at 2:51 p.m. confirmed that Resident 1's physician had approved the increase in trazadone and melatonin as per the psychogeriatric consult recommendations and that the nurse failed to transcribe the recommendations into the physician's orders. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of 23 residents reviewed (Resident 9). Findings include: The facility's policy regarding catheter care, dated February 8, 2024, indicated that catheter care will be performed with morning and evening care and as needed after incontinence or bowel movements. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated July 10, 2024, revealed that the resident was cognitively impaired and required extensive assistance from staff for all care. A care plan for Resident 9, dated July 6, 2024, revealed that the resident had an indwelling foley 16 French, 10 cc balloon catheter (a thin flexible tube inserted into the bladder to drain urine). Observations of Resident 9 on September 4, 2024, at 11:35 a.m. revealed that the resident was in bed and the indwelling foley that was in place was a 16 French, 10 cc balloon catheter. There was no documented evidence in Resident 9's clinical record to indicate that staff provided care for the resident's indwelling urinary catheter from July 6, 2024, to September 4, 2024. Interview with the Director of Nursing on September 4, 2024, at 11:26 a.m. confirmed that there was no documented evidence that staff provided care for the resident's indwelling urinary catheter from July 6, 2024, until September 4, 2024. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was discarded after it was outdated. Findings include: The facility's policy regarding labeling and dating food, dated February 8, 2024, revealed that food was to be discarded past the use-by or expiration date. Observations in the kitchen on [DATE], at 9:15 a.m. revealed three half-gallons of half and half creamer that were expired. Observations in the cooler revealed two large containers of expired sour cream and two large containers of expired ricotta cheese. Observations in the dry storage room revealed two cartons of expired apple juice and five cartons of apple juice with no manufacturer's expiration date. Interview with the Dietary Manager on [DATE], at 9:43 a.m. confirmed that all items should be thrown out when they expire and should not be used. Observations in the first floor kitchenette on [DATE], at 2:12 p.m. revealed a large container of cottage cheese, opened and in use, that had expired on [DATE]. There were also 10 cartons of frozen Nutrijuice in the freezer that were expired. Interview with Kitchen Aide 4 on [DATE], at 2:12 p.m. confirmed that the expired items should have been thrown away and not used. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen therapy was provided as ordered for one of 23 residents reviewed (Resident 38). Findings include: The facility's policy regarding oxygen administration, dated February 8, 2024, indicated that a physician's order for oxygen was to include the liter flow and method of administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 8, 2024, revealed that the resident was cognitively intact, required substantial assistance with care needs, used supplemental oxygen, and had diagnoses that included respiratory failure. Physician's orders for Resident 38, dated August 31, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 3 liters per minute via nasal canula (tubes that deliver oxygen into the nostrils) for hypoxia (low levels of oxygen in body tissues). Observations of Resident 38 in her room on September 3, 2024, at 9:08 a.m. and September 4, 2024, and at 10:57 a.m. revealed that the resident was receiving supplemental oxygen continuously at a flow rate of 4.5 liters per minute via nasal canula. Interview with Registered Nurse 2 on September 4, 2024, at 11:00 a.m. confirmed that Resident 38's oxygen was set at a flow rate of 4.5 liters per minute via nasal cannula. Interview with the Director of Nursing on September 4, 2024, at 12:58 p.m. confirmed that Resident 38's oxygen was not being administered at the correct flow rate. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 23 residents reviewed (Residents 4, 49). Findings include: The facility's policy regarding care plans, dated February 8, 2024, indicated that the facility would evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by their Mission Statement as well as State and Federal guidelines. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that she was cognitively intact, was dependent on staff for activities of daily living, and had a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall). A care plan for Resident 4, dated June 19, 2024, indicated that the resident was to have her colostomy emptied when the bag is one-third full and to have colostomy care completed by staff. Review of the Treatment Administration Record for Resident 4, dated August and September 2024, revealed no documented evidence that the resident had colostomy care completed by staff or had the colostomy bag emptied when it was one-third full. Interview with Resident 4 on September 4, 2024, at 2:09 p.m. revealed that the resident does all the care for her colostomy herself, and that she will also empty and change the bag as needed. Interview with Licensed Practical Nurse 1 on September 4, 2024, at 9:49 a.m. confirmed that Resident 4 does all care for the colostomy herself, including changing and emptying the bag. Interview with the Director of Nursing on September 4, 2024, at 2:34 p.m. revealed that Resident 4 was no longer requiring help from staff for her colostomy care, including changing and emptying her bag, and that her care plan should have been revised to reflect that. A significant change MDS assessment Resident 49, dated June 2, 2024, revealed that she was cognitively intact, was dependent on staff for activities of daily living, and had diagnoses that included having a heart failure, atrial fibrillation. (irregular heartbeat), and high blood pressure. A care plan for Resident 49, dated July 25, 2024, indicated that the resident was receiving Digoxin therapy for a diagnosis of atrial fibrillation. Review of the Medication Administration Record for Resident 49, dated September 2024, revealed no documented evidence that the resident received any Digoxin medication. Interview with the Assistant Director of Nursing on September 5, 2024, at 3:15 p.m. revealed that Resident 49 was no longer taking Digoxin and her care plan should have been revised to reflect that; however, it was not. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for the care and to maintain the patency of an intravenous access device for one of 23 residents reviewed (Resident 4). Findings include: The facility's policy for intravenous device care, dated February 8, 2024, indicated that orders for flushing and care of intravenous device will be obtained to maintain device and prevent obstruction. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 21, 2024, revealed that the resident was cognitively intact and required assistance from staff for his daily care needs. A nurse's note for Resident 4, dated July 24, 2024, at 7:53 p.m., revealed that the right port flush was completed and had a good blood return. The next port flush will be in three months. Observations on September 3, 2024, at 11:48 a.m. revealed that Resident 4 had a Mediport (intravenous access device that allows for long-term intravenous (IV) treatments and blood draws) in her right chest area. There was no documented evidence in Resident 4's clinical record to indicate that a physician's order was obtained for the care and maintenance of the Mediport per the facility's policy. Interview with the Director of Nursing on September 4, 2023, at 12:07 p.m. confirmed that a physician's order for a port flush to be completed every three months was not obtained and should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 23 residents reviewed (Resident 38). Findings include: A facility policy for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), dated February 8, 2024, revealed that if a resident had a blood glucose (sugar) reading of 350 mg/dL or greater, the physician would be notified. If the blood glucose was less than 70 mg/dL and the resident was able to swallow without symptoms, offer three to four glucose tablets or four to five saltine crackers and may repeat in 15 minutes if glucose remains low. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated June 21, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and received insulin (medication that lowers blood sugar levels). Physician's orders for Resident 38, dated February 2, 2023, included an order for the resident to have her blood sugar checked four times a day and to notify the doctor if her blood sugar is above 350 mg/dL. Resident 38's Medication Administration Record (MAR) for July and August 2024 revealed that on July 11, 2024, at 8:00 p.m. the resident's blood sugar was 360 mg/dL; on August 15, 2024, at 8:00 p.m. it was 371 mg/dL; and on August 17, 2024, at 8:00 p.m. it was 361 mg/dL. There was no documented evidence that the physician was notified about the resident's blood sugar being above 360 mg/dL on these dates and times. Interview with the Director of nursing on September 5, 2024, at 10:44 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 38's elevated blood sugars per physician's orders. Physician's orders for Resident 38, dated February 2, 2023, included an order for the resident to have hypoglycemia protocol initiated if resident had a blood sugar less than 70 mg/dL. A review of the MAR for Resident 38 for September 2024 revealed that on September 1, 2024, at 6:31 a.m. the resident's blood sugar level was 69 mg/dL. There was no documented evidence that the hypoglycemia protocol was initiated for the resident on the above date and time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 23 residents reviewed (Resident 57). Findings include: The facility's policy regarding destroying medications, dated February 8, 2024, indicated that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. Physician's orders for Resident 57, dated July 1, 2024, included an order for the resident to receive 5 milligrams (mg) (0.25 milliliters) of morphine sulfate (a controlled narcotic pain medication) orally every 2 hours for pain, and 5 mg of Oxycodone (a controlled narcotic pain medication) orally every 6 hours for pain. A discharge summary for Resident 57, dated July 4, 2024, revealed that the resident ceased to breathe on that date; however, there was no documented evidence of the disposition of the morphine sulfate and oxycodone. Interview with the Assistant Director of Nursing on September 5, 2024, at 10:54 a.m. confirmed that there was no documented evidence that a disposition of Resident 57's morphine sulfate or Oxycodone was completed as required. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow the facility's policy for obtaining temperatures of hot liquids for one of two residents reviewed (Resident 1), resulting in the resident spilling her coffee and causing a burn. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated February 8, 2024, revealed that each resident is provided a safe environment where they are not subjected to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Neglect is defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's policy regarding reheating of hot food/beverages, dated February 8, 2024, revealed that when serving hot beverages, the maximum temperature should not be greater than 140 degrees Fahrenheit (F). An accurate temperature of all menu items, including hot beverages, were to be taken and recorded on the food temperature log. The facility's policy regarding food temperature logs, dated February 8, 2024, revealed that food temperatures of cold and hot items will be recorded on all menu items for meal service. All employees are responsible for notifying their supervisor of any food items that are not in the regulated safe acceptable service ranges (below 41 degrees F or above 135 degrees F). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 2, 2024, revealed that the resident was understood, could understand others, had a diagnosis which included Parkinson's disease, and was on a mechanically altered diet (foods that are easy to chew and swallow because they are blended, chopped, grounded, or mashed). A care plan for the resident, dated June 5, 2024, revealed that the resident had a potential risk for altered nutritional status and/or weight loss related to dementia and prefers to eat in the dining room. At times the resident requires assistance with feeding, and staff were to provide assistance as needed. Physician's orders for Resident 1, dated June 11, 2024, included an order for the resident to receive a mechanical soft regular diet with thin liquids. A speech therapy note for Resident 1, dated June 21, 2024, revealed that the writer spoke with nurse aides/nursing staff to inform them that the resident had no changes in her speech/swallow/cognition, and that the resident was at her baseline. A nursing note for Resident 1, dated June 30, 2024, at 6:30 p.m. revealed that the writer was called to the resident's room for a report of the resident spilling coffee and obtaining a burn. The resident was noted to have an area to her right upper thigh 30 centimeter (cm) by 10 cm, and two areas on her lower right abdomen measuring 10 cm by 6 cm and 6 cm by 1 cm. The areas were red with no blisters noted at the time of assessment. Orders were received from the physician for Silvadene (used to treat and prevent wound infections in people with severe burns) to the areas every shift and cool compress to the areas times 20 minutes as needed. Emergency contact was updated on the events. A nursing note at 7:06 p.m. revealed that a registered nurse assessment was done due to the resident spilling her coffee and obtaining a burn. The resident continued to have a reddened area noted to her upper right thigh by her groin area. One blister was noted on her thigh at the time of assessment. An Interdisciplinary Team note for Resident 1, dated July 1, 2024, at 9:33 a.m. revealed that on June 30, 2024, at 4:15 p.m. the resident was observed by a visitor spilling coffee into her lap. The resident was noted to have an area to her right upper thigh 30 cm by 10 cm and two areas on lower right abdomen measuring 10 cm by 6 cm and 6 cm by 1 cm. The areas were noted to be red without blisters at the time of initial assessment. Upon review by the wound nurse that morning, there were seven blistered areas noted. The physician and family were aware. A nursing note for Resident 1, dated July 2, 2024, at 12:40 p.m. revealed that the wound nurse saw the resident that morning for a follow up on her burns to her abdomen and right anterior (the front surface of) thigh. On assessment that morning, the redness to the abdomen had resolved, the abdominal open area just below the umbilicus is unchanged in size, and there was a scant amount of clear/yellow serous (a clear fluid that leaks out of wounds) drainage. On assessment, the burn to her right anterior thigh had changed from yesterday's assessment. Of the seven blisters reported in the assessment yesterday, three had ruptured while four remain intact. The redness at the site of the right anterior thigh has almost completely resolved, with some diffuse areas of pink coloration still remaining. A skin condition note for Resident 1, dated July 4, 2024, revealed that the resident had a third degree burn (a serious wound that damages all three layers of skin) to her right anterior thigh, secondary to a hot beverage spill, that measures 7.5 cm by 23.0 cm by 0.1 cm. The current treatment was to cleanse the burned area to her right anterior thigh with wound cleanser, pat dry, apply Silvadene to the wound base, then apply Xeroform (a fine mesh gauze occlusive dressing impregnated with petrolatum and 3 percent Xeroform) cut-to-fit the wound base, cover with ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds), and secure with netted retention gauze or rolled gauze and tape once daily and as needed. A nursing note for Resident 1, dated July 4, 2024, revealed that the resident's daughter was provided an update on the degree of the burns and current appearance as well as the treatment changes. A statement completed by a resident's visiting family member, dated June 30, 2024, revealed that Dietary Server 1 came over and sat the coffee down with no lid. Resident 1 picked up the cup, took a drink, and stated, that's hot. She set the cup down and then spilled it soon after. A statement completed by Dietary Server 1, dated June 30, 2024, revealed that he got Resident 1 a cup of coffee and set it down in front of her. A statement completed by Registered Nurse 2, dated June 30, 2024, revealed that she was called to Resident 1's room for reports of a burn. The resident was in bed with three burn areas, two on her stomach measuring 6 cm by 1 cm and 10 cm by 6 cm, and the third area was on the resident's right upper thigh and down between her legs and measured 30 cm by 10 cm. Registered Nurse 2 went to the kitchen, asked for the coffee pot that the resident was served from, and the temperature of the coffee was 164.1 degrees F. While temping the coffee in the pot, Dietary Server 1 said, The pot has been there for hours. Registered Nurse 2 asked him if the resident had a lid and he said no. A statement completed by Dietary Aide 3, dated July 1, 2024, revealed that on June 30, 2024, she worked breakfast and lunch. She made coffee during lunch about 12:30 p.m., which she did not temp, and Resident 1 got coffee at dinner and got burnt. It was from the same pot that she had made for lunch. She knew that she should have temped it and not to serve it unless it is 140 degrees F. She did not temp it because she was busy then forgot. A statement completed by the Dining Services Director, dated June 30, 2024, revealed that on June 30, 2024, at approximately 5:30 p.m. he spoke with Dietary Server 1 via phone. He was informed that Dietary Server 1 had used a pot of coffee previously brewed for lunch and did not log the temperature of the coffee being served. He was aware of the requirement to log the temperatures of hot beverages and acknowledged that coffee needs to be under 140 degrees F. He confirmed that he did not brew the coffee that caused the burn, and it was from lunch. A statement completed by the Assistant Dining Services Director, dated July 1, 2024, revealed that she called Dietary Server 1 and asked why he did not take the temperature of the coffee and he said that he forgot. The coffee pot out front of the counter was empty, so he pulled the full pot that was there already from the back of the counter, then placed the empty one to be brewed. A statement completed by the Dining Services Director, dated July 3, 2024, revealed that he spoke with Dietary Server 1 on the phone on July 3, 2024, at 8:30 a.m. He had asked him if he had heard Resident 1 state that the coffee he served her was hot. He said that he did not hear the resident or anyone else make that statement. An investigation summary revealed that on June 30, 2024, at 4:15 p.m. Resident 1 was observed by a visitor to have spilled coffee on her lap. The visitor notified staff, who called the registered nurse to assess the resident. The resident was noted to have three reddened areas to her right upper thigh (30 cm by 10 cm), her right lower quadrant (10 cm by 6 cm), and a separate area next to her right lower quadrant (6 cm by 1 cm). The provider was notified and ordered Silvadene Cream to the area and pain control with Tylenol (an over-the-counter pain medication) as needed. Upon reassessment at 7:00 p.m. the resident was noted to have three fluid-filled blisters to the right thigh, each measuring 2 cm by 2 cm. The registered nurse supervisor temped the coffee from the carafe that Resident 1 was served from, and it was temped at 165 degrees F. An investigation was initiated as the maximum temp for hot beverages per facility policy is 140 degrees F. The investigation revealed that Dietary Server 1 served Resident 1 coffee that was above the maximum temperature of 140 degrees F per policy. This occurred at the start of the evening meal on Sunday, June 30, 2024. The resident received three burns after spilling the coffee on herself. A statement from Dietary Server 1 revealed that he should have temped the coffee prior to service. When asked why he did not temp the coffee he said, I forgot. Dietary Server 1 stated that the coffee in question was brewed at lunch. Dietary Server 1 was placed on administrative leave on June 30, 2024. Dietary Server 1 was last educated on the hot beverage policy on May 23, 2024. Dietary Aide 3 worked breakfast and lunch on June 30, 2024. It was determined that she had brewed the pot of coffee in question (at lunch time) that was later served to the resident several hours later. Dietary Aide 3 was asked if she brewed and temped the coffee at lunch time, to which she responded that she did brew the coffee, got busy and then forgot to temp it. Dietary Aide 3 was placed on administrative leave on July 1, 2024. Dietary Aide 3 was last educated on the hot beverage policy on May 24, 2024. Resident 1 was served coffee that was over the maximum temperature of 140 degrees F. The resident spilled the coffee on her lap and sustained three burns to her abdomen and right thigh. Dining staff did not follow the procedure for temping coffee prior to the meal service. Neglect was substantiated for Dietary Aide 3 and she was terminated on July 5, 2024. Interview with the Nursing Home Administrator and the Assistant Director of Nursing on July 22, 2024, at 2:40 p.m. confirmed that the facility's investigation substantiated neglect because Dietary Aide 3 did not follow the facility's policy for temping hot beverages prior to the meal service. Following the incident/investigation on June 30, 2024, the facility's corrective actions included: Dietary Server 1 and Dietary Aide 3 were both placed on administrative leave. Dietary Aide 3 was terminated from employment at the facility July 5, 2024. The coffee and hot water were removed from the units and discarded on June 30, 2024. New pots of coffee were brewed, and the temperatures were verified to be under 140 degrees F before serving. The next morning two staff brewed and temped the coffee made for the breakfast meal on July 1, 2024, and confirmed that the coffee was at 140 degrees F before service. Coffee makers will be removed from the units and the coffee, as well as any hot beverages, will be made in the main kitchen and will be temped by two staff, verifying that the temperature is 140 degrees F or less. Residents will be served hot beverages with coffee lids. Dietary staff were re-educated on the facility's hot beverage policy, temperature logs, and educated on the new process for serving hot beverages, which was completed on July 1, 2024. The nursing staff was educated on the new procedure that coffee is only brewed in the main kitchen and that the temperature is verified by two individuals. Audits to identify any issues with the temperatures of hot beverages were started. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on July 1, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by serving hot coffee in a cup without a lid to one of two residents (Resident 1) without first obtaining a temperature to ensure that it was not greater than 140 degrees Fahrenheit, resulting in third degree burns when it was spilled on the resident. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding reheating of hot food/beverages, dated February 8, 2024, revealed that when serving hot beverages the maximum temperature should not be greater than 140 degrees Fahrenheit (F). An accurate temperature of all menu items, including hot beverages, are to be taken and recorded on the food temperature log. The facility's policy regarding food temperature logs, dated February 8, 2024, revealed that food temperatures of cold and hot items will be recorded on all menu items for meal service. All employees are responsible for notifying their supervisor of any food items that are not in the regulated safe acceptable service ranges (below 41 degrees F or above 135 degrees F). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 2, 2024, revealed that the resident was understood, could understand others, had a diagnosis which included Parkinson's disease, and was on a mechanically altered diet (foods that are easy to chew and swallow because they are blended, chopped, grounded, or mashed). A care plan for the resident, dated June 5, 2024, revealed that the resident had a potential risk for altered nutritional status and/or weight loss related to dementia and prefers to eat in the dining room. At times the resident requires assistance with feeding, and staff were to provide assistance as needed. Physician's orders for Resident 1, dated June 11, 2024, included an order for the resident to receive a mechanical soft regular diet with thin liquids. A speech therapy note for Resident 1, dated June 21, 2024, revealed that the writer spoke with nurse aides/nursing staff to inform them that the resident had no changes in her speech/swallow/cognition, and that the resident was at her baseline. A nursing note for Resident 1, dated June 30, 2024, at 6:30 p.m. revealed that the writer was called to the resident's room for a report of the resident spilling coffee and obtaining a burn. The resident was noted to have an area to her right upper thigh 30 centimeter (cm) by 10 cm, and two areas on her lower right abdomen measuring 10 cm by 6 cm and 6 cm by 1 cm. The areas were red with no blisters noted at the time of assessment. Orders were received from the physician for Silvadene (used to treat and prevent wound infections in people with severe burns) to the areas every shift and cool compress to the areas times 20 minutes as needed. Emergency contact was updated on the events. A nursing note at 7:06 p.m. revealed that a registered nurse assessment was done due to the resident spilling her coffee and obtaining a burn. The resident continued to have a reddened area noted to her upper right thigh by her groin area. One blister was noted on her thigh at the time of assessment. An Interdisciplinary Team note for Resident 1, dated July 1, 2024, at 9:33 a.m. revealed that on June 30, 2024, at 4:15 p.m. the resident was observed by a visitor spilling coffee into her lap. The resident was noted to have an area to her right upper thigh 30 cm by 10 cm and two areas on lower right abdomen measuring 10 cm by 6 cm and 6 cm by 1 cm. The areas were noted to be red without blisters at the time of initial assessment. Upon review by the wound nurse that morning, there were seven blistered areas noted. The physician and family were aware. A skin condition note for Resident 1, dated July 4, 2024, revealed that the resident had a third degree burn (a serious wound that damages all three layers of skin) to her right anterior thigh secondary to a hot beverage spill that measured 7.5 cm by 23.0 cm by 0.1 cm. The current treatment was to cleanse the burned area to her right anterior thigh with wound cleanser, pat dry, apply Silvadene to the wound base, then apply Xeroform (a fine mesh gauze occlusive dressing impregnated with petrolatum and 3 percent Xeroform) cut-to-fit the wound base, cover with ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds), and secure with netted retention gauze or rolled gauze and tape once daily and as needed. A nursing note for Resident 1, dated July 4, 2024, revealed that the resident's daughter was provided an update on the degree of the burns and current appearance as well as the treatment changes. A statement completed by a resident's visiting family member, dated June 30, 2024, revealed that Dietary Server 1 came over and sat the coffee down with no lid. Resident 1 picked up the cup, took a drink, and stated, That's hot. She set the cup down and then spilled it soon after. A statement completed by Dietary Server 1, dated June 30, 2024, revealed that he got Resident 1 a cup of coffee and set it down in front of her. A statement completed by Registered Nurse 2, dated June 30, 2024, revealed that she was called to Resident 1's room for reports of a burn. The resident was in bed with three burn areas, two on her stomach measuring 6 cm by 1 cm and 10 cm by 6 cm, and the third area was on the resident's right upper thigh and down between her legs and measured 30 cm by 10 cm. Registered Nurse 2 went to the kitchen, asked for the coffee pot that the resident was served from, and the temperature of the coffee was 164.1 degrees F. While temping the coffee in the pot Dietary Server 1 said, The pot has been there for hours. Registered Nurse 2 asked him if the resident had a lid, and he said no. A statement completed by Dietary Aide 3, dated July 1, 2024, revealed that on June 30, 2024, she worked breakfast and lunch. She made coffee during lunch about 12:30 p.m., which she did not temp, and Resident 1 got coffee at dinner and got burnt. It was from the same pot that she had made for lunch. She knew that she should have temped it and that it should not be served unless it was 140 degrees F. She did not temp it because she was busy then forgot. A statement completed by the Dining Services Director, dated June 30, 2024, revealed that on June 30, 2024, at approximately 5:30 p.m. he spoke with Dietary Server 1 via phone. He was informed that Dietary Server 1 had used a pot of coffee previously brewed for lunch and did not log the temperature of the coffee being served. He was aware of the requirement to log the temperatures of hot beverages and acknowledged that coffee needs to be under 140 degrees F. He confirmed that he did not brew the coffee that caused the burn, and it was from lunch. A statement completed by the Assistant Dining Services Director, dated July 1, 2024, revealed that she called Dietary Server 1 and asked why he did not take the temperature of the coffee, and he said that he forgot. The coffee pot out front of the counter was empty, so he pulled the full pot that was there already from the back of the counter, then placed the empty one to be brewed. A statement completed by the Dining Services Director, dated July 3, 2024, revealed that he spoke with Dietary Server 1 on the phone on July 3, 2024, at 8:30 a.m. He had asked him if he had heard Resident 1 state that the coffee he served her was hot. He said that he did not hear the resident or anyone else make that statement. An investigation summary revealed that on June 30, 2024, at 4:15 p.m. Resident 1 was observed by a visitor to have spilled coffee on her lap. The visitor notified staff, who called the registered nurse to assess the resident. The resident was noted to have three reddened areas to her right upper thigh (30 cm by 10 cm), her right lower quadrant (10 cm by 6 cm), and a separate area next to her right lower quadrant (6 cm by 1 cm). The provider was notified and ordered Silvadene Cream to the area and pain control with Tylenol (an over-the-counter pain medication) as needed. Upon reassessment at 7:00 p.m. the resident was noted to have three fluid-filled blisters to the right thigh, each measuring 2 cm by 2 cm. The registered nurse supervisor temped the coffee from the carafe that Resident 1 was served from, and it was temped at 165 degrees F. An investigation was initiated as the maximum temp for hot beverages per facility policy is 140 degrees F. The investigation revealed that Dietary Server 1 served Resident 1 coffee that was above maximum temperature of 140 degrees F per policy. This occurred at the start of the evening meal on Sunday June 30, 2024. The resident received three burns after spilling the coffee on herself. A statement from Dietary Server 1 revealed that he should have temped the coffee prior to service. When asked why he did not temp the coffee he said, I forgot. Dietary Server 1 stated that the coffee in question was brewed at lunch. Dietary Server 1 was placed on administrative leave on June 30, 2024. Dietary Server 1 was last educated on the hot beverage policy on May 23, 2024. Dietary Aide 3 worked breakfast and lunch on June 30, 2024. It was determined that she had brewed the pot of coffee in question (at lunch time) that was later served to the resident several hours later. Dietary Aide 3 was asked if she brewed and temped the coffee at lunch time, to which she responded that she did brew the coffee, got busy and then forgot to temp it. Dietary Aide 3 was placed on administrative leave on July 1, 2024. Dietary Aide 3 was last educated on the hot beverage policy on May 24, 2024. Resident 1 was served coffee that was over the maximum temperature of 140 degrees F. The resident spilled the coffee on her lap and sustained three burns to her abdomen and right thigh. Dining staff did not follow the procedure for temping coffee prior to the meal service. Dietary Aide 3 and was terminated on July 5, 2024. Interview with the Nursing Home Administrator and the Assistant Director of Nursing on July 22, 2024, at 2:40 p.m. confirmed that Dietary Aide 3 did not follow the facility's policy for temping hot beverages prior to the meal service. Following the incident/investigation on June 30, 2024, the facility's corrective actions included: Dietary Server 1 and Dietary Aide 3 were both placed on administrative leave. Dietary Aide 3 was terminated from employment at the facility July 5, 2024. The coffee and hot water were removed from the units and discarded on June 30, 2024. New pots of coffee were brewed, and the temperatures were verified to be under 140 degrees F before serving. The next morning two staff brewed and temped the coffee made for the breakfast meal on July 1, 2024, and confirmed that the coffee was at 140 degrees F before service. Coffee makers will be removed from the units and the coffee, as well as any hot beverages, will be made in the main kitchen and will be temped by two staff, verifying that the temperature is 140 degrees F or less. Residents will be served hot beverages with coffee lids. Dietary staff were re-educated on the facility's hot beverage policy, temperature logs, and educated on the new process for serving hot beverages, which was completed on July 1, 2024. The nursing staff was educated on the new procedure that coffee is only brewed in the main kitchen and that the temperature is verified by two individuals. Audits to identify any issues with the temperatures of hot beverages were started. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on July 1, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions for one of three residents reviewed (Resident 1), resulting in a fall with a hip fracture. This deficiency was cited as past non-compliance. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 20, 2023, revealed that the resident was understood, could understand, required extensive assistance from staff for her daily care tasks including with her bed mobility and transfers, was not steady and only able to stabilize with staff assistance for surface-to-surface transfers, and had diagnoses that included dementia and repeated falls. A care plan for the resident, dated June 14, 2023, revealed that the resident was at risks for falling related to weakness and history of falls. The resident was to wear hipsters (padded hip underwear for preventing hip fractures in the elderly) at all times and that staff may take off for hygiene. A nursing note for Resident 1, dated June 15, 2023, revealed that an interdisciplinary team review of the resident's admission was completed. The resident's risk score is a 12, indicating that the resident was a high risk for falls. The resident was to have gripper socks on while in bed, a kid's cushion to her night stand and heater, anti-rollbacks to her wheelchair, and hipsters to be worn at all times, which staff may take off for hygiene. A nursing note for Resident 1, dated July 15, 2023, at 2:34 p.m. revealed that the writer was called to the second floor dining room for a report that the resident was found on the floor. The resident was lying flat on her back with her wheelchair behind her. The resident had slipper socks on, was fully dressed, and was clean and dry. Her right lower extremity was rotated with edema (swelling) noted to her hip. The resident yelled out in pain upon movement. There were no other injuries noted. The resident's son, daughter, and physician were notified. Orders were obtained to send the resident to the emergency room for evaluation and treatment. Emergency 9-1-1 was called and the resident was transported at 2:40 p.m. The resident was unable to explain how the fall happened. Another resident, who is alert and oriented, stated that the resident stood up and took a few steps, at which time he told her to sit back down. He stated that she turned and then fell on her right side. A nursing note at 5:41 p.m. revealed that the resident was being admitted with a right proximal femur (part of the bone of the thigh near the hip) fracture. The resident's physician and family were updated. A statement completed by the Director of Nursing, undated, revealed that after submitting the event for Resident 1 into the Department of Health's Event Reporting System on July 16, 2023, she began to question how the resident obtained a hip fracture if the resident had hipsters on. She then called the registered nurse who was present for the post-fall assessment of Resident 1 on July 15, 2023. The registered nurse reported that she did not see hipsters on the resident when she completed her assessment. She then questioned the nurse aide that was assigned to the resident on the day of the incident and asked if she had placed the hipsters on Resident 1. The nurse aide reported No, I didn't know she had them. A witness statement completed by Registered Nurse 1, dated July 16, 2023, revealed that she did not see hipsters on Resident 1 when she completed her post-fall assessment on July 15, 2023. A witness statement completed by Nurse Aide 2, dated July 16, 2023, revealed that she was not aware that Resident 1 was to be wearing hipster protective briefs during the days she provided care and that she was not aware she was acknowledging via electronic charting that this resident wore hip protective briefs. Interview with the Director of Nursing on July 28, 2023, at 1:15 p.m. confirmed that during the incident on July 15, 2023, Resident 1 was not wearing the hipsters as care planned. She indicated that through her investigation it was determined that there was a system failure in the way staff obtains resident care information. Once it was identified, the Director of Nursing began audits of all residents that were care planned for hipsters, as well as starting staff education on how and where to see/find the information when a resident is care planned for hipsters. Following the incident on July 15, 2023, the facility's corrective actions included: On July 16, 2023, a full facility audit of all residents that were care planned to wear hipsters was completed to ensure that the hipsters were care planned appropriately, as well as appropriately linked in the resident's care plan. Audits of the residents that were care planned to wear hipsters was started to ensure that the hipsters were present. Education was initiated on July 16, 2023, with facility care staff regarding how and where to see/find the information when a resident is care planned for hipsters. Education was completed on July 17, 2023. The results of the audits were to be discussed during the monthly QA meeting. The date of compliance was July 17, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents not identified as an elopement risk for one of three residents reviewed (Resident 2) and failed to develop and implement new interventions to prevent the elopement of residents not identified as an elopement risk, placing the safety of current residents not identified as a risk for elopment in Immediate Jeopardy. Findings include: The facility's policy regarding elopment, dated January 11, 2022, indicated that when a resident is found, immediately formulate plans to protect resident from further elopment and to resolve any problems arising from the elopment. Steps to prevent others from eloping must be initiated immediately. Investigation must be comprehensive and include mechanisms to prevent others from eloping due to the same reason. A progress note for Resident 2, dated January 14, 2022, at 6:46 p.m. revealed that the resident arrived at 3:30 p.m. via wheelchair. The resident's daughter brought the resident from home. The resident had a diagnosis which included [CONDITION(S)] (inflammation or swelling that occurs in the bone) of her right foot after a tumor removal. The resident is alert and oriented. The resident is pleasant, cooperative, with a bright affect. An Elopement Risk Evaluation for Resident 2, dated January 14, 2022, revealed that the resident's Total Elopement Risk Score was a one. Which indicated that a score of zero (0) to five the resident was no risk for elopment and a score of six and above indicated that the resident was at risk for elopement. A progress note for Resident 2, dated January 15, 2022, at 12:28 p.m. revealed that this was an admission note. Resident makes her wishes known to staff. Resident enjoys spending time outside when the weather is nice, often sitting on her porch at her apartment. A progress note for Resident 2, dated January 23, 2022, at 10:31 a.m., which was recorded as a late entry at 3:00 a.m., revealed that the resident was found in room wandering around yelling out. She was saying there are children running all around the room and that someone needs to take care of it. She was standing at the wall yelling at it because she thought it was a child. Attempted to reorient and de-escalate resident. Resident was agitated because she thought I did not believe her. After reassuring her that she was safe and the doors are locked, she settled down and was resting comfortably. The resident rested comfortably the rest of the shift. A progress note for Resident 2, dated January 25, 2022, at 7:09 p.m. revealed that the resident was up sitting at the bedside during the time of this assessment. The resident was in good spirits, no hallucinations at this time. A progress note for Resident 2, dated January 26, 2022, at 4:12 a.m. revealed that the resident eloped from the facility. At approximately 12:15 a.m. the licensed practical nurse (LPN) went to hang intravenous (IV) antibiotics. She was having difficulty flushing her line, so this registered nurse (RN) went in and repositioned the resident and the IV was flushed and the antibiotics were hung. At approximately 1:00 a.m. Nurse Aide 1 came to the nurse's station to tell LPN that the IV was done. The resident did tell Nurse Aide 1 that after her IV was unhooked that she needed to use the bathroom. Until the LPN got there and unhooked her, Nurse Aide 1 was in room 103. After Nurse Aide 1 was done in room 103, she came to the nurse's station to check the schedule and look in her mailbox. Nurse Aide 1 spent no more than 10 to 13 minutes in nurse's station. At approximately 1:25 a.m. to 1:28 a.m. Nurse Aide 1 went back to the unit and saw that the front sliding glass door was open, just enough for a body to go through. She went to room 102 because she knew that the resident was independent and had been hallucinating earlier and said the resident was not there. Nurse Aide 1 checked the bathroom and then reported to the nurse's station immediately to tell the RN that the resident was missing and the door was open. Licensed Practical Nurse 2 and Nurse Aide 1 ran outside circling the block looking for the resident. This RN phoned the Director of Nursing (DON) at 1:31 a.m. 9-1-1 was called at 1:33 a.m. Staff continued searching for the resident and Licensed Practical Nurse 2 was in her vehicle searching the area. At 1:38 a.m. the 9-1-1 center called me back on my cell phone to tell me that the Police Department had found the resident and that they were bringing her back to facility. Went back into facility to call the resident's son. The son was surprised, but very understanding and was on his way to facility to assist. At approximately 1:55 Officer 3 from Police Department pulled up with the resident in the back of the police car. Officer 3 said that the neighbors phoned 9-1-1 saying that there was a woman on the sidewalk yelling for help. Officer 3 was on his way to search the area when the other 9-1-1 call came across and the resident was seen on the sidewalk waving the officer down. The resident was wearing a hospital gown, cardigan, gripper socks, one sneaker, and one boot, which was on her right foot. Officer 3 stated that she was willing to get into the back of the police car. He said that she wanted him to take her to the State Police barracks and she would not tell him why. He said she wasn't happy when they crossed over the railroad tracks. When they arrived at the facility Officer 3 and myself attempted to get her out of the police car and she was resistant and said she was not getting out. When the resident's son arrived he was able to talk her into coming into facility. While we were in the lobby, a head-to-toe assessment was completed as much as the resident would allow. No apparent injuries were found. The resident's left knee was slightly red, and there were no open areas. Officer 3 did report that when he rolled up to her there was snow on her sweater and it appeared as though she fell . The resident also stated that she fell because she did not have her walker. She also stated that she did not have any injuries. While in the lobby the resident was talking about things coming from the ceiling, people coming in and out of her room, music playing, children and their friends were running around, people coming out of trap doors and taking things, and having audio and visual hallucinations. The resident's son stated this is not like his mother. I did speak with the resident's son regarding these things at the beginning of the shift at approximately 10:15 p.m. right at shift change as Licensed Practical Nurse 2 walked in and heard part of the conversation. The resident's son had called in to ask if anything was going on in the hallways or anything like that because his mother called him concerned and scared because of things she was hearing. It was at this time that I told the resident's son I was here for a couple nights and that these hallucinations were starting to happen and that the resident's physician was aware. The physician previously said to monitor her and if the hallucinations persist to inform him and he will look at her medications to see if that was the route of the problem. Despite the resident not having any apparent injuries, the son was agreeable to have resident sent to emergency department for evaluation and treatment for altered mental status. The resident left with EMS via litter at approximately 2:30 a.m. without resistance. The emergency department was called and report was given. Upon a thorough investigation the doors were indeed switched to off and the orange light on the top left was also off. It appears that the resident unlocked the front twist lock and pried the doors open enough to exit. A phone call was placed to maintenance to have them inspect doors in the morning to assure it was not faulty equipment. A progress note for Resident 2, dated January 27, 2022, revealed that the Interdisciplinary Team reviewed the incident that involved the resident on January 26, 2022, at 1:25 a.m. At approximately 1:25 a.m. to 1:28 a.m. Nurse Aide 1 went back to the unit and saw that the front sliding glass door was open, just enough for a body to go through. She went to room 102 because she knew that the resident was independent and had been hallucinating earlier and said the resident was not there. Nurse Aide 1 checked the bathroom and then reported to the nurse's station immediately to tell Registered Nurse 4 that the resident was missing and that the door was open. 9-1-1 was called. The resident was found 0.3 miles away from the facility by local police department. The resident returned to facility and then was transported to the emergency department. The resident was discharged from the emergency department with no injuries noted. The family chose to discharge the resident home straight from emergency department with home health. The facility investigation documents, undated, revealed that at approximately 12:15 a.m. the LPN went to hang IV antibiotics. At approximately 1:00 a.m. Nurse Aide 1 came to nurse's station to tell the LPN that the IV was done. After Nurse Aide 1 was done in room 103 she came to the nurse's station to check the schedule and look in her mailbox. Nurse Aide 1 spent no more than 10-13 minutes an the nurse's station. At approximately 1:25 a.m. to 1:28 a.m. Nurse Aide 1 went back to the unit and saw that the front sliding glass door was open, just enough for a body to go through. She went to room 102 because she knew that the resident was independent and had been hallucinating earlier and said resident was not there. Nurse Aide 1 checked the bathroom and then reported to the nurse's station immediately to tell the RN that the resident was missing and the door was open. Licensed Practical Nurse 2 and Nurse Aide 1 ran outside circling the block looking for the resident. Registered Nurse 4 phoned the DON at 1:31 a.m. 9-1-1 was called at 1:33 a.m. At approximately 1:55 a.m. Officer 3 from the Police Department pulled up with the resident in the back of the police car. The resident was wearing a hospital gown, cardigan, gripper socks, one sneaker, and one boot, which was on her right foot. The temperature was noted to be 8 degrees Fahrenheit at this time. A head-to-toe assessment was completed as much as resident would allow. No apparent injuries were found. Despite the resident not having any apparent injuries, the son was agreeable to have resident sent to emergency department for evaluation and treatment for altered mental status. The resident left with EMS via litter at approximately 2:30 a.m. Upon a thorough investigation the doors were indeed switched to off and the orange light on the top left was also off. It appears that resident unlocked the front twist lock and pried the doors open enough to exit. A phone call was placed to maintenance to have them inspect doors in the morning to assure it was not faulty equipment. Maintenance inspected the sliding front doors in the a.m. and confirmed that they were not faulty. Received confirmation from the emergency department that Resident 2 was picked up from the emergency department by the resident's daughter and son. Daughter was requesting that her mother be discharged home with the services of home health. Receptionist 5 was called by the Nursing Home Administrator and confirmed that the front doors were locked when she left on January 25, 2022, at 7:00 p.m. Review of the receptionist schedule for January 25-31, 2022, revealed that the receptionist area at the front sliding doors was staffed at 8:00 a.m. to 7:00 p.m. on January 25 and 26, 2022; staffed 8:00 a.m. to 6:00 p.m. on January 27, 28, and 31, 2022; and staffed 8:00 a.m. to 5:00 p.m. on January 29 and 30, 2022. Review of the facility's visitor logs on January 25, 2022, revealed that a visitor left the facility at 7:30 p.m. and another visitor left the facility at 8:00 p.m. An email by the Executive Director, dated January 26, 2022, at 12:55 p.m. revealed that the facility will be evaluating options for an alarm on the front entrance to the facility to alert when the door is opened after hours. The inquiry into options is not due to a failure, but rather a preventive safety measure. We will contact the local vendor that services our current door system. Observations of the front sliding door on January 31, 2022, at 7:10 p.m. revealed that the receptionist was not at the receptionist desk at the front entrance. Interview with the Executive Director on January 31, 2022, at 7:12 p.m. revealed that the receptionist leaves at 7:00 p.m. and would lock the front sliding door prior to leaving. Interview with the Director of Nursing on Janaury 31, 2022, at 7:15 p.m. revealed that the lobby area does not have any cameras. There is a camera outside of the front sliding doors for staff to see who is ringing the doorbell after the receptionist leaves. She indicated that the front sliding door is alarmed with a wanderguard alarm (specifically designed for Alzheimer and dementia patients allowing them to have freedom within their resident facilities while giving them essential security. By utilizing the patient wandering system, medical staff is able to monitor these patients while attending to other responsibilities) only. So only residents that were identified as wanders and/or an elopement risk would have a wanderguard bracelet on that would activate the alarm at the front door. However, as of January 31, 2022, there was no documented evidence that the facility developed and/or implemented any new interventions to prevent the elopement of residents not identified as an elopement risk. Interview with the Director of Nursing on January 31, 2022, at 8:21 p.m. revealed that they are waiting for their local vendor to come later this week to look at the front sliding doors to see if there would be an option to add an alarm to the doors. She confirmed that they did not develop and/or implement any new interventions to prevent the elopement of residents not identified as an elopement risk until the local vendor could come and evaluate the front sliding doors. On January 31, 2022, at 9:36 p.m. the Executive Director, Director of Nursing, and Assistant Director of Nursing were informed that the health and safety of current residents that were not identified as an elopement risk were in Immediate Jeopardy due to the lack of the development and/or implementation of any new interventions to prevent the elopement of residents not identified as an elopement risk after Resident 2, who was not identified as an elopment risk, eloped from the facility. The facility submitted and implemented an immediate action plan that included ensuring that the front desk area at the main entrance will have a team member present monitoring the area 24 hours a day, seven days a week to ensure constant visual monitoring of individuals exiting the facility until additional mechanical safety mechanisms to prevent exit are able to be installed. The education included the new process of monitoring the main entrance. Audits will be completed by the Nursing Home Administrator and/or designee to ensure that staff are following the process. The Immediate Jeopardy was lifted on February 1, 2022, at 7:40 p.m. when it was confirmed that the facility had team members monitoring the main entrance as well as having a temporary alarm installed on the front doors. Educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.