Every finding on record at Quality Life Services - Apollo

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Buttercup Hall, Rehab Road, and Angel Wing) and one of one Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Rehab Road).Findings include: Review of facility Emergency Cart policy dated [DATE], indicated an emergency cart will be appropriately stocked and ready for use when attempting to resuscitate a resident. The cart will be readily available for use and its inventory maintained. Review of facility AED policy dated [DATE], indicated an AED will be available for use in emergency situations and its function maintained. Daily Maintenance includes checking the status indicator to ensure that it is green. During an observation of the facilities crash cart, located on Buttercup Hall, on [DATE], at 12:25 p.m. revealed the following: (1) bottle of Glucose Strips (used to check blood sugar) - expired [DATE].(3) 20-gauge needles - expired [DATE].Ambu bag (a handheld manual resuscitator used to provide positive pressure ventilation) was missing.Missing crash cart checklist signatures from [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE], at 12:29 p.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the above findings on Buttercup Hall's crash cart. During an observation of the facilities crash cart, located on Rehab Road, on [DATE], at 12:30 p.m. revealed the following: (2) 20-gauge needles - expired [DATE].Missing crash cart checklist signatures from [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an observation of the facilities crash cart, located on Angel Wing, on [DATE], at 12:40 p.m. revealed the following: Missing crash cart checklist signatures from [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During a review of facility provided document labeled Crash Cart Checklist of the facilities AED (Rehab Road) on [DATE], at 12:35 p.m. revealed no monitoring of the facilities AED on the flowing dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE], at 12:50 p.m. LPN Employee E1 confirmed the above findings on Rehab Road and Angel Wing's crash cart and missing signatures for the facilities AED. 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R14, R15, and Closed Resident Record CR156), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Resident R14, R15, and Closed Resident Record CR156).Findings include: Review of facility policy Transfer of Resident to Another Care Community dated 4/16/26, indicated the purpose is to promote continuity of care during transfer. Determine specific information requirements and prepare documents needed for transfer. Review of admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of the clinical record indicated Resident R14 was transferred to the hospital on 3/5/26, and returned to the facility on 3/11/26. Review of Resident R14's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/19/26, at 11:15 a.m. Social Worker Employee E4 stated that hospital transfers were not included on the Ombudsman list and confirmed that there was no evidence that the State Ombudsman office was notified for Resident R14's transfer to the hospital. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS dated [DATE], indicated diagnoses of muscles weakness, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and cancer (a large group of diseases where abnormal cells divide without control). Review of the clinical record indicated Resident R15 was transferred to the hospital on the following dates: 2/12/26, and returned to the facility on 2/16/26. 4/4/26, and returned to the facility on 4/17/26. 6/4/26, and returned to the facility on 6/15/26. 6/22/26, and returned to the facility on 6/23/26. Review of Resident R15's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/19/26, at 11:18 a.m. Social Worker Employee E4 stated that hospital transfers were not included on the Ombudsman list and confirmed that there was no evidence that the State Ombudsman office was notified for Resident R15's transfer to the hospital. Review of the clinical record indicated Closed Resident Record CR156 was admitted to the facility on [DATE]. Review of Closed Resident Record CR156's MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty walking, and need for assistance with personal care. Review of the clinical record indicated Closed Resident Record CR156 was transferred to the hospital on 7/22/26, and did not return to the facility. Review of Closed Resident Record CR156's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Closed Resident Record CR156's clinical record failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 7/22/26. During an interview on 8/19/26, at 11:18 a.m. Social Worker Employee E4 confirmed there was no evidence that the State Ombudsman office was notified of Closed Resident Record CR156's transfer to the hospital on 7/22/26. During an interview on 8/20/26, at 10:29 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to make certain that necessary resident information was communicated to the receiving health care provider for Closed Resident Record CR156. During an interview on 8/19/26, at 2:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R14, R15, and R156), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Resident R14, R15, and R156). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow Isolation Precaution protocol to prevent the spread of infections for four of five residents (Resident R9, R15, R56 and R101), and failed to conduct testing for residents displaying respiratory symptoms during an outbreak for three of eight residents (Resident R9, R31, and R54). Findings include: Review of the facility policy Droplet Precautions last reviewed 4/16/26, indicated droplet precautions should be used in addition to standard precautions for residents with infections that can be transmitted by droplets. Droplets may be generated by the resident's coughing, sneezing, talking, or during the performance of procedures such as suctioning.-The resident is placed in a private room or placed in a room with a resident who has active infection with the same organism but no other infection. Review of facility Contact Precautions policy dated 4/16/26, indicated that it is the intent of this facility to use contact precautions for residents known or suspected to have serious illness easily transmitted by direct contact or by contact with items in the residents environment. Gowns and gloves should be worn prior to entering the room. Review of facility Infection Prevention Manual dated 4/16/26, indicated the goals of the infection prevention program are to decrease the risk of infection to residents and personnel, monitor infections and implement appropriate control measures, and identify problems relating to infection prevention practices. Review of Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit dated 9/25/25, indicated a testing plan to ensure access to rapid-result respiratory viral testing. Prompt testing results can guide appropriate treatment and infection prevention and control measures. Test anyone showing signs or symptoms of a respiratory illness. At a minimum, tests should include Covid-19 and influenza viruses. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated diagnoses of depression, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and multidrug resistant organism (MDRO- bacteria that does not respond well to antibiotics). During a lunch observation on 8/17/26, at 12:10 p.m. Resident R9 was sitting on the side of his bed in the room. Resident had a contact precaution sign hanging on the wall beside the door. Personal Protective Equipment (PPE) was hanging on the door that included, gowns, gloves, masks, and sanitizer. During an observation on 8/17/26, at 12:25 p.m. Nurse Aide (NA) Employee E13 and NA Employee E14 were observed in Resident R9's room and failed to utilize PPE as required to enter the room. During an interview on 8/17/26, at 12:27 p.m. NA Employee E13 stated, We are supposed to be protected and wear gowns and gloves. We are to put it on before you enter the room, and confirmed that no PPE was worn while in Resident R9's room. During an interview on 8/17/26, at 12:28 p.m. NA Employee E14 stated, You gotta put all the stuff on. Gown and gloves, and confirmed that no PPE was worn while in Resident R9's room. During an interview on 8/17/26, at 12:30 p.m. Licensed Practical Nurse Employee E1 stated, You need to have all the PPE on. Gowns, gloves, mask if needed and you put it on prior to going into the room. If you don't, you could contract the organism that they are carrying and get sick. During a review of Resident R9's physician orders dated 8/17/26, indicated contact precautions for MRSA (methicillin-resistant Staphylococcus aureus- a type of infection that is resistive to some antibiotics and make it harder to treat) of the wound. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS dated [DATE], indicated diagnoses of muscles weakness, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and cancer (a large group of diseases where abnormal cells divide without control). During a review of Resident R15's physician orders dated 8/10/26, indicated contact isolation for VRE (vancomycin-resistant enterococci- a type of bacteria that can be hard to treat) and MRSA. During an observation on 8/17/26, at 10:30 a.m. contact isolation signage failed to be displayed on Resident R15's door to notify staff and visitors of the proper PPE to wear. During an interview on 8/17/26, at 10:33 a.m. Infection Preventionist (IP) Employee E3 confirmed that Resident R15 should have had a contact isolation signage on the door and that the facility failed to prevent cross contamination of possible infections for Resident R9 and R15. Review of the admission record indicated Resident R56 admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs dated 8/3/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R56's physician order dated 7/30/26, indicated droplet precautions related to pneumonia. Review of Resident R56's care plan dated 7/30/26, indicated a mask with a face shield should be worn by my caregiver during procedures with a risk of splashes or droplet contamination of my bodily fluids. Observation on 8/17/26, at 10:00 a.m. Resident R56's doorway failed to have a sign posted for droplet precautions. Interview on 8/17/26, at 10:05 a.m. Registered Nurse (RN) Employee E8 confirmed there was not a sign posted on Resident R56's door for droplet precautions as ordered. Review of the admission record indicated Resident R101 admitted to the facility on [DATE]. Review of Resident R101's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes. Review of Resident R101's physician order dated 8/7/26, indicated droplet precautions for respiratory infection. Review of Resident R101's care plan dated 8/14/26, indicated a mask with a face shield should be worn by my caregiver during procedures with a risk of splashes or droplet contamination of my bodily fluids. Observation on 8/17/26, at 9:56 a.m. Resident R101's door had a sign for droplet precautions. It indicated everyone must make sure their eyes, nose, mouth are fully covered before room entry. Remove face protection before room exit. Observation on 8/17/26, at 9:58 a.m. Nurse Aide (NA) Employee E11 was departing from Resident R101's room. NA Employee E11 had a gown, gloves, and mask in place, but failed to have eye protection as ordered. Interview on 8/17/26, at 10:05 a.m. RN Employee E8 confirmed NA Employee E11 should have had a face shield or goggles on as required with droplet precautions. Upon entering the facility on 8/17/26, at 9:00 a.m. signage was posted on front door alerting visitors of a respiratory outbreak at the facility. During an interview on 8/17/26, at 9:33 a.m. IP Employee E3 confirmed that the facility was experiencing a respiratory outbreak and that a surveillance and tracking of the outbreak was being completed. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated diagnoses of depression, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and multidrug resistant organism (MDRO- bacteria that does not respond well to antibiotics). Review of Resident R9's progress note dated 7/9/26, at 4:45 p.m. indicated that resident stated, beginning to feel sick with upper respiratory symptoms. Rhinitis (stuffy nose, runny nose, sneezing, or postnasal drip), malaise (tired), non-productive cough, dry scratchy sinuses. Review of Resident R9's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility. During an interview on 8/21/26, at 11:01 a.m. IP Employee E3 stated, No rapid testing done because he has chronic coughing. We were thinking about aspiration pneumonia (a respiratory infection). Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's MDS dated [DATE], indicated diagnoses of high blood pressure, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R31's progress noted dated 8/10/26, at 12:50 p.m. indicated that during medication pass resident observed not acting her normal self. Resident stated she didn't feel well and did not want to eat. Resident also had a productive cough. Resident placed on oxygen. Review of Resident R31's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility. During an interview on 8/21/26, at 11:04 a.m. IP Employee E3 stated, No rapid testing was done. We sent the chest xray to the physician and got no new orders. He didn't like using antibiotics. Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R54's progress noted dated 7/9/26, at 7:30 a.m. indicated that resident presenting with dyspnea (difficult breathing) and a non-productive wet cough. Very loud rhonci (snoring like breathing sounds). Tired with confusion. Review of Resident R54's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility. During an observation on 8/21/26, at 10:01 a.m. rapid Covid, Flu A and Flu B tests were available in the Infection Preventionist Employee E3's office. During an interview on 8/21/26, at 11:07 a.m. IP Employee stated, He was showing respiratory symptoms. He is a smoker with a chronic cough. We believed it to be from smoking. No rapid test was completed. During an interview on 8/21/26, at 11:11 a.m. IP Employee E3 stated that the above rapid tests were available and that the facility failed to test Resident R9, R31, and R54 with respiratory symptoms during an outbreak. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for three of six residents (Resident R3, R14, and R54). Findings include: Review of admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a 0- resident not up to date. During a review of Resident R3's immunization record on 8/18/26, at 11:15 a.m. indicated the last COVID -19 vaccine was offered on 11/1/22. The facility failed to include documented evidence that an updated COVID-19 vaccine was offered or refused and that education was provided to Resident R3. Review of admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a 9 indicating Resident R14 was moderately impaired. MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a 0- resident not up to date. During a review of Resident R14's immunization record on 8/18/26, at 11:21 a.m. indicated that on 8/25/25, a covid consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated covid vaccine for Resident R14. Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a 11 indicating Resident R54 was moderately impaired. MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a 0- resident not up to date. During a review of Resident R54's immunization record on 8/18/26, at 11:30 a.m. indicated that an undated covid consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated covid vaccine for Resident R54. During an interview on 8/18/26, at 1:14 p.m. Infection Preventionist Employee E3 confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine three of six residents (Resident R3, R14, and R54). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a scoop mattress (a specialized medical bed designed with a concave surface and raised or sloped perimeter edges) is a restraint for two of two residents (Residents R4 and R94) and failed to determine if a bed against the wall is a restraint for one of two residents (Resident R125). Findings include: Review of facility policy Physical Restraint Policy and Procedure last reviewed 4/16/26, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). During an observation on 8/19/26, at 9:20 a.m. Resident R4 was observed lying in bed and the mattress had bilateral (on both sides) raised perimeter. Review of Resident R4's physician order dated 5/1/26, indicated Safety Device: Scoop mattress for safety every shift for prevention. Review of Resident R4's current care plan indicated scoop mattress for safety. Further review of Resident R4's clinical record failed to identify any assessment or ongoing evaluations for the usage of a scoop mattress on the resident's bed. Review of the clinical record indicated Resident R94 was admitted to the facility on [DATE]. Review of Resident R94's MDS dated [DATE], indicated diagnoses of malnutrition (lack of sufficient nutrients in the body), depression, and need for assistance with personal care. During an observation on 8/17/26, at 10:34 a.m. Resident R94 was observed lying in bed and the mattress had bilateral raised edges on the top and bottom portions. During an interview on 8/19/26, at 12:52 p.m. Licensed Practical Nurse (LPN) Employee E1 stated, Resident R94 has a scoop mattress. There should be an order and a care plan for the scoop mattress. Review of Resident R94's clinical record failed to include a physician order for a scoop mattress or a plan of care related to the use of a scoop mattress. Further review of Resident R94's clinical record failed to identify any assessments or ongoing evaluations for the usage of a scoop mattress. During an interview on 8/20/26, at 10:29 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to obtain a physician order, develop a person-centered plan of care, and assess the functional status of the individual resident to determine if the use of scoop mattress is a restraint for Resident R94. Review of the clinical record indicated Resident R125 was admitted to the facility on [DATE]. Review of Resident R125's MDS dated [DATE], indicated diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), repeat falls. During an observation on 8/19/26, at 12:15 p.m. Resident R125 was observed in bed. The bed's right side was against the wall. Review of Resident R125's current physician orders failed to include an order for bed against the wall. Review of Resident R125's current care plan failed to include a plan for bed against the wall. Further review of Resident R125's clinical record failed to identify any assessment or ongoing evaluations for the usage of bed against the wall. During an interview on 8/21/26, at 11:43 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of two residents (Residents R4) and failed to determine if a bed against the wall is a restraint for one of two residents (Resident R125). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for two of six residents (Resident R14 and R54), and failed to provide accurate and timely documentation related to the Influenza vaccine for three of six residents (Resident R3, R14, and R54).Findings include: Review of facility policy Standing Orders for Administering Pneumococcal Vaccine to Adults dated 4/16/26, indicated the purpose is to reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria. Review of facility policy Immunizations: Influenza vaccination of residents, staff, and volunteers dated 4/16/26, indicated all residents, staff, and volunteers of our facility should receive the influenza vaccine annually, unless there is a documented contraindication. Review of admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a 9 indicating Resident R14 was moderately impaired. During a review of Resident R14's immunization record on 8/18/26, at 10:11 a.m. indicated that on 8/25/25, a pneumococcal consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated pneumococcal vaccine for Resident R14. Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a 11 indicating Resident R54 was moderately impaired. During a review of Resident R54's immunization record on 8/18/26, at 10:20 a.m. indicated that on 12/17/25, the pneumococcal consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated pneumococcal vaccine for Resident R54. During an interview on 8/18/26, at 1:14 p.m. Infection Preventionist (IP) Employee E3 confirmed that the facility failed to receive proper consents, failed to notify resident representatives, and failed to offer education for Resident R14 and R54's pneumococcal vaccinations. Review of admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). During a review of Resident R3's immunization record on 8/18/26, at 11:00 a.m. revealed that Resident R3's last Influenza refusal was from 11/1/22. No documented evidence that Resident R3's responsible party was given the choice of the last Influenza season vaccine and no evidence that education was provided. Review of admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a 9 indicating Resident R14 was moderately impaired. During a review of Resident R14's immunization record on 8/18/26, at 10:11 a.m. indicated that on 8/25/25, an influenza consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated influenza vaccine for Resident R14. Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a 11 indicating Resident R54 was moderately impaired. During a review of Resident R54's immunization record on 8/18/26, at 10:20 a.m. indicated that on 12/17/25, an influenza consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated influenza vaccine for Resident R54. During an interview on 8/18/26, at 1:05 p.m. the IP Employee E3 confirmed that the facility failed to obtain an updated influenza consent and provide education for Resident R3, R14, and R54's responsible party and that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for two of six residents (Resident R14 and R54), and failed to provide accurate and timely documentation related to the Influenza vaccine for three of six residents (Resident R3, R14 and R54). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R4, R101, R135, and R152).Findings include: Review of the facility policy Medication Regimen Review last reviewed 4/16/26, indicated the consultant pharmacist performs a comprehensive review of each resident's medication regimen (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medication director and/or the administrator. Recommendations are acted upon and documented by the facility staff or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident R4's MRR dated 7/24/26, indicated diagnosis needed to support therapy for lorazepam (anxiety medication). The form was signed and dated 8/8/26, by Licensed Practical Nurse (LPN) Employee E1, not the attending physician as required. Review of the clinical record indicated Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's MDS dated [DATE], indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R101's MRR dated 3/23/26, indicated possible duplication of therapy for Tylenol as needed for pain orders. The form was signed and dated 4/23/26, by LPN Employee E1, not the attending physician as required. Review of the clinical record indicated Resident R135 admitted to the facility on [DATE]. Review of Resident R135's MDS dated [DATE], indicated the diagnoses of heart failure, diabetes, and high blood pressure. Review of Resident R135's MRR dated 5/15/26, indicated admission MRR, Special instructions how resident takes medication. The form had not been addressed upon review on 8/19/26. Review of the clinical record indicated Resident R152 admitted to the facility on [DATE]. Review of Resident R152's MDS dated [DATE], indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), anxiety, and depression. Review of resident R152's MRR dated 6/23/26, indicated diagnosis needed to support therapy for trazadone (antidepressant medication). The form was signed and dated 8/5/26, by Licensed Practical Nurse (LPN) Employee E1, not the attending physician as required. Interview on 8/19/26, at 2:21 p.m. the Director of Nursing confirmed that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R4, R101, R135, and R152). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs for six of six residents (Residents R4, R16, R80, R92, R111, and R117). Findings include: Review of facility policy Call Lights - NU 2.2 last reviewed 4/16/26, indicated residents have a call light or alternative communication device within their reach at all times when unattended. Care partners will answer a call light as soon as possible. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:26 a.m. Resident R4 was in bed, and the call bell was noted to be on the floor out of the resident's reach. Review of the admission record indicated Resident R16 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:29 a.m. Resident R16 was in bed, and the call bell was noted to be on the bedside stand out of the resident's reach. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:35 a.m. Resident R80 was in bed, and the call bell was noted to be on the floor out of the resident's reach. Review of the admission record indicated Resident R111 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:38 a.m. Resident R111 was in bed, and the call bell was noted to be on the roommate's bedside table out of the resident's reach. Review of the admission record indicated Resident R117 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:340 a.m. Resident R80 was in bed, and the call bell was noted to be on the floor out of the resident's reach. Observation and interview on 8/17/26, at 9:42 a.m. Registered Nurse (RN) Employee E8 confirmed the call bells were not in the resident's reach for residents R4, R16, R80, R111, and R117. During call bell observations on 8/20/26, at 2:25 p.m. the following was observed: -at 2:26 p.m. observation of call bell light on for Resident R92's room. Resident R92's door to his room was open and he was observed sitting on the commode. -at 2:27 p.m. Resident R92 was interviewed and stated: I put myself on the commode. I have been waiting 30 minutes for help. -at 2:29 p.m. Certified Nurse aide (NA) Employee E17 was interviewed and stated: I did not put him on the toilet. I am not his assigned nurse aide. During an interview on 8/20/26, at 2:41 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to accommodate the call bell needs for Resident R92 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of resident clinical records, observations, and staff interview it was determined the facility failed to obtain a physician order to monitor a dialysis (treatment that helps body remove extra fluid and waste products) access site, failed to develop a comprehensive person-centered plan of care to address resident care needs, and failed provide consistent and complete communication with the dialysis center for one of one residents (Resident R163).Findings include: Review of the clinical record indicated Resident R163 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and need for assistance with personal care. Review of a physician order dated 8/12/26, indicated hemodialysis every Monday, Wednesday, and Friday. Review of Resident R163's physician orders failed to include an order to monitor the resident's dialysis access site and failed to indicate what type of dialysis access site. Review of Resident R163's comprehensive care plan dated 8/14/26, indicated the resident is receiving dialysis related to renal failure. Interventions included check my access site daily. Reinforce as needed and document. Maintain communication with my dialysis clinic. The comprehensive care plan failed to indicate what type of dialysis access site Resident R163 had. Review of Resident R163's clinical record did not include complete communication forms for two days during the period of 8/10/26, through 8/18/26. The incomplete forms were on the following dates: 8/12/26, and 8/14/26. No communication form was located for 8/17/26. During an interview on 8/18/26, at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R163. During an interview on 8/18/26, at 10:12 a.m. the Director of Nursing confirmed the facility failed to obtain a physician order to monitor a dialysis access site and failed to develop a comprehensive person-centered plan of care to address resident care needs for Resident R163.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan of care to render trauma informed care for a resident who was at risk for re-traumatization for one of three residents (Resident R116).Findings include: Review of the facility Trauma Informed Care competency checklist indicated staff are to recognize there are multiple causes of trauma and varies from person to person and verbalize that trauma informed care is individual for each person, there is not a model of care that can be followed. Review of the clinical record indicated Resident R116 was admitted to the facility on [DATE]. Review of Resident R116's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and depression. Review of a Social Service Note dated 7/18/26, indicated Resident R116 had a history of trauma/Post Traumatic Stress Disorder, resident claims he was sexually assaulted as a child by older brother and father committed suicide. Resident R116 gets angry when talking about identifying triggers of re-traumatization. Review of Resident R116's comprehensive care plan dated 4/16/26, indicated Trauma Informed Care: I have a history of actual trauma (List trauma, for example; rape, family separation, abuse, neglect, PTSD). Goals included I will have less than (name of behavior that is exhibited as a result of anxiety/PTSD from the trauma). Resident R116's trauma informed care plan of care failed to include individualized focus, goals, and interventions related to the resident's PTSD. During an interview on 8/20/26, at 12:38 p.m. Social Worker Employee E4 confirmed the facility failed to failed to develop and implement an individualized person-centered plan of care to render trauma informed care for a resident who was at risk for re-traumatization for Resident R116. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on observation and staff interview it was determined that the facility failed to provide a dignified dining experience for two of eight residents (Resident R47 and R77). Findings include: Review of facility Dining and Meal Service policy date 4/16/26, indicated the dining experience will be person centered with the purpose of enhancing each individual resident's dining quality of life and being supportive of each individual's needs during dining. Review of the face sheet indicated Resident R47 admitted to the facility on [DATE]. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and depression. Observation on 8/17/26, at 12:13 p.m. Resident R47 was in her wheelchair in the resident's room. Feeding Assistant Employee E18 was standing over her and the bedside table feeding the resident her lunch. No chair was present in the room. Interview with Registered Nurse (RN) Employee E8 on 8/17/26, at 12:15 p.m. confirmed Feeding Assistant Employee E18 was not in a seated position while feeding Resident R47 the lunch meal and failed to provide a dignified dining experience. Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE]. Review of Resident R77's MDS dated [DATE], indicated diagnoses of high blood pressure, malnutrition (lack of sufficient nutrients in the body), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section GG Functional Abilities GG0130 Eating is coded 2, indicating that resident is substantial/maximal assistance – helper does more than half the effort. During a lunch observation on 8/20/26, at 12:12 p.m. Resident R77 was lying in bed without a lunch tray. Resident R77's roommate was sitting at the edge of the bed, facing Resident R77, eating lunch. During an interview on 8/20/26, at 12:15 p.m. Licensed Practical Nurse Employee E10 stated, All the Nurse Aides are feeding other residents right now and confirmed that all qualified staff should be assisting to feed residents at lunch time. LPN Employee confirmed that Resident R77 was not being assisted in eating lunch and that the facility failed to provide a dignified dining experience for Resident R77. 28 Pa. Code 211.10(a)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, resident and staff interview, it was determined that the facility failed to maintain a safe, clean, homelike environment in one of three nursing units (Angel Wing). Findings include: Interview on 8/18/26, at 10:00 a.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. Review of the admission record indicated Resident R133 admitted to the facility on [DATE]. Observation on 8/17/26, at 9:30 a.m. the ceiling of the hallway room [ROOM NUMBER] is on, had brownish/orange water dripping into three water basins placed on the floor below the leak. Interview on 8/17/26, at 9:33 a.m. Resident R133 indicated she was afraid to come out of her room because the ceiling might fall on her. Observation and interview on 8/17/26, at 9:38 a.m. Maintenance Employee E19 indicated the leak was reported late the night before and it was going to be taken care of. Observation on 8/18/26, at 11:00 a.m. the ceiling of the hallway room [ROOM NUMBER] is on, had white plaster like debris on the floor under the previous leak area and shards of plaster approximately eight inches long hanging from the ceiling. Observation and interview on 8/18/26, at 11:05 a.m. Maintenance Employee E19 confirmed the ceiling had pieces of plaster-like substance falling from the previous leak area and shards of plaster approximately eight inches long hanging from the ceiling. 28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for one of five residents (Residents R4).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing MDS assessments, dated October 2025, indicated the following instructions:H0100 Bladder and Bowel appliances: check all that apply. The definition of an external catheter is a female external catheter, or other non-invasive urine output management device or system that routes urine to a drainage bag. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section H0100 failed to indicate an external catheter was used. Review of the Resident R4's current physician order indicated place Pure wick (a brand of external catheters) use every shift for incontinence and replace every 12 hours. Maintain proper placement every shift. Review of Resident R4's current care plan indicated ensure Pure wick is replaced every 12 hours. Replace anytime Pure wick is dislodged. Review of Resident R4's Treatment administration record dated June 2026, indicated the Pure wick was utilized daily as ordered. Interview on 8/21/26, at 10:02 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the external catheter was not indicated on the MDS dated [DATE], and the facility failed to ensure MDS accurately reflected the resident's status for one of five residents (Residents R4). 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of five residents (Residents R2 and R163).Findings include: Review of facility policy Skin Integrity and Wound Management dated 4/16/26, indicated the implementation of an individual resident's skin integrity and wound management occurs within the care delivery process. Staff continually observes and monitors residents for changes and implements revisions to the plan of care as needed. Perform skin inspection on admission and weekly by a licensed nurse. Document in the electronic medical record. Perform wound assessment and complete proper forms upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/26, indicated diagnoses of hyponatremia (low levels of sodium in the blood), chronic peripheral venous insufficiency (damaged leg veins fail to efficiently return blood to the heart, causing blood to pool in the lower extremities), and need for assistance with personal care. Review of Resident R2's admission Body Check assessment dated [DATE], indicated the resident was admitted to the facility with scaly skin to the right lower leg. Skin is intact, resident does have a cast to LLE (left lower extremity) for fractures of the tibia and fibula (two bones of the lower leg). Review of the clinical record indicated Resident R2 was transferred to the hospital on 4/24/25, and returned to the facility on 5/2/25. Review of a Skin/Wound progress note dated 5/2/25, stated, Assessed resident's right lower leg following admission. From knee to foot had a thick layer of xeroform (a sterile, non-adhesive medicated gauze dressing used to keep wounds moist and prevent infection) residue. Leg cleansed with wound cleaner, dry skin flakes are adhered with residue. 1x0.5 scabbed area to upper lateral (to the side) shin, 3 small scabbed areas to top of foot. Areas swabbed with betadine (an antiseptic solution used to prevent and treat infections), covered with non-adherent pad. Resident stated she prefers to have her leg wrapped. Loosely wrapped kerlix (woven gauze) from knee to ankle. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower extremity wound for the weeks of 5/4/25, 5/11/25, and 5/18/25. Review of the clinical record indicated Resident R2 was transferred to the hospital on 5/28/25, and returned to the facility on 6/3/25. Review of Resident R2's admission Body Check assessment dated [DATE], indicated the resident was re-admitted to the facility with a three venous stasis ulcers (a wound that occurs when there is damage to the skin and underlying tissue caused by high pressure in the veins or impaired return of blood from the legs to the heart) to the front of the left lower leg and discoloration to the front of the right lower leg. Review of a Skin/Wound note dated 6/4/25, stated, Resident reported to have pressure wound to coccyx (base of spine) present on admission. This RN (Registered Nurse) and LPN (Licensed Practical Nurse) confirmed that there is no wound present to resident's coccyx. LPN had already changed the dressing to resident's left lower leg, will assess tomorrow during dressing change. Right lower leg has dry skin and xeroform residue present. There is a small dry scabbed area to the top of the foot. Otherwise, skin is intact. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wounds from 6/8/25, to 12/16/25. Review of the clinical record indicated Resident R2 was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of Resident R2's admission Body Check assessment dated [DATE], indicated the resident was re-admitted to the facility with a blister to the front right lower leg and a blister to the front left lower leg, left calf inner aspect with multiple raised blood red appearing areas, area measures 18 cm (centimeter) long by 13 cm wide with multiple blister like area noted inside area. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower leg wound from 12/28/25, to 4/28/26. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wound from 1/11/26, to 4/28/26. Review of the clinical record indicated Resident R2 was transferred to the hospital on 4/28/26, and returned to the facility on 5/1/26. Review of Resident R2's admission Body Check assessment dated [DATE], indicated the resident was re-admitted to the facility with a vascular ulcer (venous stasis ulcer) to the front right lower leg and a vascular ulcer to the front left lower leg. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wound the week of 5/10/26 - 5/16/26. Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower leg wound from 5/3/26, to 6/6/26. During an interview on 8/19/26, at 9:32 a.m. RN Employee E3 stated, I do wound rounds every week, I only see pressure wounds and residents when they are first admitted . For a non-pressure wound, there is an assessment the floor nurse is supposed to do every week. Resident R2 goes out to the wound clinic to be seen. During an interview on 8/19/26, at 10:16 a.m. RN Employee E3 confirmed the facility failed to perform weekly wound assessments on Resident R2's right and lower leg wounds on the dates listed above. During this interview, RN Employee E3 stated, I'm still trying to figure out how often Resident R2 goes out to the wound clinic. During an interview on 8/19/26, at 11:45 a.m. LPN Employee E1 stated, Resident R2 goes out to the wound clinic every 2 to 3 weeks and sometimes refuses to go, she refused her last appointment. During an interview on 8/19/26, at 2:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that Resident R2 was provided appropriate treatment and care by failing to complete weekly wound assessments for the resident's right and left lower leg wounds. Review of the clinical record indicated Resident R163 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and need for assistance with personal care. Review of a physician order dated 8/14/26, indicated to ask resident for blood sugar and how many units given. Goes by carbs intake four times a day for type 2 diabetes mellitus. Review of Resident R163's comprehensive care plan dated 8/17/26, indicated I have diabetes mellitus related to endocrine impairment. Interventions included ask resident for blood sugar and how many units given, goes by carb intake. I have an insulin pump (a wearable device used to administer rapid and short-acting insulin continuously and can provide additional bolus doses at meal times) to use when I discharge, offer me education, advice and instructions with nursing in regards to transition to glucometer and insulin administration during my stay. Monitor my ability to manage my treatment program regarding my medications, dietary needs, glucose monitoring, exercise and knowledge of complications. During an interview on 8/18/26, at 8:45 a.m. Resident R163 stated, I have an insulin pump on, it has been wonderful and I have had no issues with it. I also have a continuous blood glucose monitor (CGM, a wearable device used to track glucose levels in real time) on. I let the facility staff know what my blood sugar reading is and how many units of insulin I am going to bolus myself. I have Novolog insulin (a rapid-acting insulin) in my pump, I manage all of it on my own. During an interview on 8/18/26, at 9:04 a.m. LPN Employee E2 stated, Resident R163 has an insulin pump and a CGM, we ask him four times a day what his blood sugar is and how many units of insulin he is going to give himself, he counts his carbs. That information is communicated to the nurses through a physician order. The physician order should state what type of insulin the resident is receiving in the insulin pump. During an interview on 8/18/26, at 9:10 a.m. LPN Employee E2 confirmed Resident R163's physician order failed to include what type of insulin the resident is receiving through the insulin pump. During an interview on 8/18/26, at 9:21 a.m. LPN Employee E1 stated, The physician order should probably state which type of insulin the resident is getting through the insulin pump. We only have an order to ask the resident what his blood sugar reading was and how much insulin he gave himself. During an interview on 8/18/26, at 10:12 a.m. the DON confirmed that the facility failed to make certain Resident R163 was provided appropriate treatment and care by failing to obtain complete physician orders for the management of the resident's insulin pump. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Resident R19 and R31).Findings include: Review of facility policy Oxygen Therapy dated 4/16/26, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air. The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Change prefilled humidification system at least weekly. Review of facility policy Small Volume Nebulizer dated 4/16/26, indicated will be administered as appropriate. The purpose is to provide a mode for the delivery of aerosolized particles of medication into the airway, improve mucous clearance, and relieve bronchospasm. When treatment is completed, place in storage bag labeled with resident name and date. Replace equipment every seven days. Date connecting tubing. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/26, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/17/26, at 10:01 a.m. Resident R19 was lying in bed with oxygen on. The nasal cannula (NC- a lightweight, flexible tube used to deliver oxygen to people with breathing difficulties) was not dated. Review of Resident R19's physician order dated 7/28/26, indicated change humidifier bottle, tubing, and wraps every week on Thursday night shift. During an interview on 8/17/26, at 10:17 a.m. Licensed Practical Nurse (LPN) Employee E12 confirmed the nasal cannula was missing a date and should be changed weekly. LPN Employee E12 confirmed that the facility failed to provide appropriate respiratory care for Resident R19. Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's MDS dated [DATE], indicated diagnoses of high blood pressure, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). During an observation on 8/17/26, at 10:07 a.m. Resident R31 was sitting at bedside with oxygen on. The nasal cannula and humidification bottle were not dated. Resident R31's nebulizer machine (used to deliver medication) was sitting on the bedside table. The nebulizer tubing was not dated and not stored in a bag when not in use. Review of Resident R31's physician order dated 6/26/26, indicated Ipratropium-Albuterol Inhalation Solution (a medication used to treat COPD) every four hours, as needed, for shortness of breath. Review of Resident R31's physician order dated 8/10/26, indicated supplemental oxygen two to five liters per minute nasal cannula, as needed, every shift. Change humidifier bottle and tube weekly on night shift every Thursday. During an interview on 8/17/26, at 10:19 a.m. LPN Employee E12 confirmed the nasal cannula, humidification bottle, and nebulizer tubing were missing dates and should be changed weekly. LPN Employee E12 confirmed the nebulizer was not stored in a bag when not in use. LPN Employee E12 confirmed that the facility failed to provide appropriate respiratory care for Resident R31. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of five residents (Resident R116).Findings include: Review of facility policy Behavior Standard dated 4/16/26, indicated the purpose is to develop and implement behavior plans and medication regimens, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. Review of the clinical record indicated Resident R116 was admitted to the facility on [DATE]. Review of Resident R116's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and depression. Review of Resident R116's comprehensive care plan dated 4/22/26, indicated I am/have potential to demonstrate verbally abusive behaviors related to. Interventions included: Evaluate me for the side effects of medications and notify my physician as necessary, evaluate my coping skills and support system, and provide me with psychiatric/psychogeriatric consult as needed. The comprehensive care plan failed to include information related to Resident R116's individualized behaviors and identified coping skills. Further review of Resident R116's comprehensive care plan dated 7/26/26 indicated I use anti-psychotic medications related to disease process. Interventions included: I am on a behavior management program with (Specify: alternative to prn (as needed) medication use). Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The comprehensive care plan failed to include information related to Resident R116's individualized behavior management program and behavior symptoms. Review of Resident R116's clinical record from October 2025 through August 2026 revealed the following behavior documentation:11/5/25: Yelling at CNA (Certified Nurse Aide) and LPN (Licensed Practical Nurse). Resident stated the nurse is incompetent and the aide is useless. Went in to see what is going on with the resident he stated the LPN is incompetent and she needs fired or he needs to be discharged . When asked what I can help the resident stated that he needs something to nasal congestion and started yelling at me due to not being able to give him something right away and stated I'm incompetent just like everyone else. Resident requests antihistamines, resident is ordered zyrtec (a medical used to treat allergy symptoms) when notified resident he was already given his medication and something to help with his nasal congestion he started yelling. Second RN in the room confirmed resident's request of mediation and he yelled at the second nurse and the nurse asked just clarifying resident then stated only thing I need is a lobotomy since he can't get out of here.11/10/25: Went to take resident his evening medication and he asked me, can you give me a hysterectomy already,11/13/25: resident stated that he does not want his hearing aids, so I tried to get him to let me to keep them in the med cart to keep track of them and he shouted at me to leave his room and to leave him alone. he stated, I hate female kind and wish my sister would find a plot and fertilize the earth. he would not let me assist him putting them in his ears either.12/2/25: Resident was using tray table as a wheel walker in the hallway, he was redirected back to his room and asked to call for help. Resident's pant was wet and when help was offered to change him, he refused and was verbally abusive to both the supervisor and the aide and asked that they get out of his room and leave him alone. Resident was left alone, but would continue to monitor and offer care and assistance as needed when he is calmed down.12/4/25: pt (patient) pushing breakfast tray into hallway. offered morning medications and pt started yelling at this writer. calling names and cussing and saying to leave the pills. explained i couldn't and pt yelled what the fuck am i going to do with them steal them. educated pt that other pt's could get a hold of them and he said good they can all just fucking die. i hope you all just fucking die then you'll leave me alone in my own misery. pt did take medications.2/6/26: This nurse took resident's medications into him this am (morning). Resident threw them on the bed stating he does not f'ing know why he has to take them as they do no good. Continued to yell about the medication and refused to take them.3/8/26: resident was ambulating out of room on own, he put dinner tray on floor. rn (Registered Nurse) supervisor went back to room and attempted to speak with him about this, he stated leave me alone. told one nurse that she is an idiot. he said to another nurse your all rulemaking fucking idiots. attempts to reassure resident ineffective.3/28/26: Pt came through resident unit hallway yelling as he came through the hall about God not being real and if he is real he's doing a spectacular job with his rapist priests and bombing children and all the sick stuff of the world and was yelling gods a frog. He then saw pt from other room sitting in her doorway with a babydoll and said now look at this one holding a babydoll jesus christ whats wrong with people and went up to resident and told her hey your baby is fucking dead you know that right pt was immediately removed by an aide and taken back to his unit while yelling at the aide he should sue her for doing such a shitty job on this side of the building.3/28/26: Reported by a CNA that was sitting in the dining room during dinner reported that resident was complaining it was too loud in there. Then made the statement if he cut their throats they would be quiet. RN aware.3/30/26: around dinner time CNA alerted this nurse resident was on nursing unit going through the dirty trash hamper. pulling out dirty briefs. around 0430 (4:30 a.m.) CNA informed his nurse resident had removed the mattress cover from his mattress and put it in the hall. his mattress is off of the bed and against the wall. i went to the residents room to ask him what he was doing. he said i made him nervous asking him questions. At the time i entered the room he was moving his nightstand. unable to redirect that he should not be moving around furniture that it increases his chances of another fall. call to RN to make aware.4/2/26: resident angry at beginning of shift, was yelling and cursing at staff about linens missing from room. was loudly cursing in hallway, calling staff names. he was yelling that he wants an xray done from fall on 3/29. progress notes state that patient denied interventions after fall on this date. when this was explained to him, he angrily said cant trust nurses. he forcefully put glass of water on night stand and continued to yell vulgarities and this nurse and can on leaving room.5/5/26: screaming that he is not happy at facility. The AC (air conditioning) unit was not working, upon investigating AC unit was warm. Resident is expressing frustration with being in the facility and his past. Resident expressed he does not want to be in facility and would rather sleep under a tree. Expressed being a decorated Marine and been through a lot and doesn't want health to decline more. Assigned LPN was able to redirect the resident and help calm him down.6/22/26: Resident came out into the hallway screaming at the CNA for going into his room and removing dirty laundry. was screaming you need to go back to the country you came from or go to hell. you owe me $28 by noon and it better not be foreign currency.7/1/26: Resident was in dining room at breakfast today cussing and stating he wanted a lawyer if he did not have regular utensils. He constantly is cussing and swearing in dining with other residents being very upset. Staff constantly try to encourage resident to be better with cussing with him not wanting to hear it.7/1/26: Resident very uncooperative this evening shift. Refused meds and tx (treatments). Yelled at this nurse that he is tired of dealing with stupid people taking meds that don't work and stick them up my ass.7/8/26: Resident came out into the hallway yelling that he's tired of waiting and wants to see the dermatologist right now. He's tired of this fucking place and we all belong in jail for not treating him better.8/13/26: Resident was self propelling in his w/c (wheelchair) throughout the building upon returning to RR (resident room) resident was yelling about having a throbbing headache. Tylenol 650 mg (milligrams) offered and given. attempted to ask resident about his headache to assess the situation and resident started yelling just give me arsenic and old lace already. this place is fucking crazy full of fake doctors collecting money and doing shit. Resident headed towards his room. complaining as he was going into his room.8/15/26: Resident refused care from staff, stating, Get the fuck out my room. I'll let you know if and when I need help. Just leave me alone. Resident later observed in hallway independently propelling self in wheelchair. Bleeding was noted to right arm; resident has a known history of picking scabs. This nurse offered to assess and provide wound care; however, resident refused and directed profane and derogatory language toward this nurse. Resident also refused redirection back to room and used derogatory language toward other residents near nurse's station. Will continue to monitor and re-approach as tolerated. Supervisor made aware.8/16/26: Resident refused meds as well as his dinner tray. Was yelling that the food needs sent to a Chinese concentration camp he's tired of being fed shit. Most people here are mentally ill and slobbery they don't know any better. Let him die before he gets that way.8/18/26: Resident refused am meds and am care today, was verbally aggressive towards staff. He stated for staff to get out of his life and go die, quickly. He is more calm and pleasant this afternoon. Will continue to monitor. Review of a Medical assessment dated [DATE], completed by Psychiatric Mental Health Nurse Practitioner (PMHNP) Employee E23 stated, Pt was seen today by this provider to determine if pt has the capacity to make decisions. According to staff, Pt was brought from a hospital to this facility for failure to thrive and malnourishment. When asked pt why he came to this facility he proclaimed last November I had heart failure and I had surgery. I then went home and slipped and fell. I got dizzy a little bit after the fall. I had a whole lot of stress at that time. Someone broke into my apartment and robbed me. Pt reports he lives with himself and his dog. Pt states he has neighbors that help him out but he lives alone. Pt states his medical diagnosis is hypertension. Pt reports his sister is his POA (Power of Attorney) but he doesnt want her. Pt states he was in the hospital and my sister brought me forms to fill out and I didnt know what was happening. Pt reports the risks of going home is anything meaning that anything could happen. Pt reports the benefits of going home is he can live where he wants, it is where I belong, I have my TV and my dog. Pt was calm and cooperative. Pt was pleasant and respectful during interaction. Pt focus was good and he was not distracted. Pt seems to be lacking details and recognition of order of events. Pt did not seem to be concerned that he fell at home once. Pt is just pressured to get out of facility. Plan is to keep pt in facility until he is deemed okay to live on his own. My concern is getting groceries, cleaning and taking care of himself if he leaves the facility. Pt has fallen in the past and does not find this a problem. Pt is fixated on getting out of the facility and nothing else. Also his mobility and ability to get around. The ability of this pt to live alone is questionable. Follow up in one month. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E23 stated, Pt was seen today due to refusing care and wanting to die. Pt was sitting on his bed watching TV. Writer asked pt to turn the TV down so we could talk and pt got angry with writer. Pt stated I dont know who you think you are. Pt then stated I shouldnt even be here this is my sisters doing. Writer tried to calm pt down and then pt told writer to leave his room. Writer then exited the room. Plan is to keep pt on psych meds and follow up in 1 month. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E23 stated, Pt was seen today due to apparently verbalizing suicide. Pt was laying in his bed, awake and alert. Pt reports I hate this place. Pt reports appetite is good and sleep is not good. When pt was asked about depression he stated who wouldn't be depressed living in America today? Pt was then asked if he was suicidal and pt responded that is none of your business, now please get out of my room. Plan is to keep pt on psych meds and follow up in 3 months. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E23 stated, Pt was seen today due to apparently having anger outbursts. Pt was sitting in his wheelchair in the hallway. Pt reports mood is alright. Pt reports sleep very poorly. I have never been much of a sleeper. I get like 3 hours a day. I have had a lot of stuff happen to me. I witnessed my fathers suicide and been in combat. Pt denies depression. Pt denies anxiety. Pt denies psychosis. Per staff if you do not mention his sister he will stay calm. His sister sets him off and he could get angry. Plan is to keep pt on psych meds and follow up in 3 months. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E23, stated, Pt was seen today due to apparently having cognitive change per staff. Per staff he has been naked in his room with a blank stare on his face. Pt was sitting on his bed in just a brief. Pt states his mood is alright but in a lot of pain due to falling face first on the floor. Pt reports sleep it doesnt matter. Pt is getting increasingly angry with questions. I want to get out of here. When writer asked pt do you feel sad at all during the day? pt responded I dont want to hear your bullshit, get out. Writer left the room. Plan is to keep pt on psych meds and follow up in 3 months. Review of Resident R116's clinical record failed to include further documentation that behavioral health services were provided to the resident from 4/2/26, through 8/20/26. During an interview on 8/20/26, at 12:22 p.m. Social Worker Employee E4 stated, PMHNP Employee E23 comes on Wednesdays and Thursdays if needed. She goes in and speaks with residents and adjusts meds, she talks quickly with residents for about five minutes. She mostly does medication management only. We currently do not have a provider for talk therapy services, we were working with an outside agency, but the job offer was declined. Resident R116 will talk with you, but you have to take time and show interest in what he's talking about and gain his trust. During an interview on 8/20/26, at 12:22 p.m. Social Worker Employee E4 confirmed that the facility failed to develop an individualized person-centered plan of care for Resident R116's behavior management program, and failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for Resident R116. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(a) Resident rights.28 Pa. Code: 211.16(a)Social services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medications carts (Angel Front Medication Cart), two of five resident rooms (Resident R56 and R78), and one of three medication rooms (Angel Medication Room). Findings include: Review of the facility policy Medication Administration - NU16.54 last reviewed 4/16 /26, indicated nurses administering medications are not to leave the medication at the resident's bedside unless it is ordered that way. Medications are properly labeled according to state regulations. Review of the facility policy Storage of Medications last reviewed [DATE], indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Observation on [DATE], at 12:30 p.m. of Angel Front Medication Cart indicated the following medications not labeled with a date:-Trelegy inhalers (treats chronic respiratory disease) - two separate inhalers.-Albuterol nebulizer solution (turns medication into a fine mist that is breathed into the lungs for quick relief/rescue breathing). Interview on [DATE], at 12:33 p.m. Licensed Practical Nurse (LPN) Employee E20 confirmed the medications were opened and not labeled with a date. Review of the admission record indicated Resident R56 admitted to the facility on [DATE]. Observation of Resident R56's room on [DATE], at 10:00 a.m. indicated a container of nystatin cream (a prescription antifungal medication used to treat skin infections) on the bedside stand and another on the windowsill of the room. Review of the admission record indicated Resident R78 admitted to the facility on [DATE]. Observation of Resident R78's room on [DATE], at 10:15 a.m. indicated a container of nystatin cream on the bedside stand. Interview and tour with Registered Nurse (RN) Employee E8 on [DATE], at 12:13 p.m. confirmed the medications were left unsecure in the residents' rooms. Observation of the Angel Medication Room on [DATE], at 11:08 a.m. with LPN Employee E7 indicated two foley catheters (thin tube used to drain urine from the bladder) with expiration dates of [DATE], and [DATE]. Interview on [DATE], at 11:09 a.m. LPN Employee E7 confirmed the foley catheters were expired on [DATE], and [DATE]. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to prepare food in a form to meet physician ordered diets for one of six residents (Resident R153).Findings include: Review of the facility policy Dining and Meal Service - CU2.2 last reviewed 4/16/26, indicated food will be at the proper texture/consistency to meet each individual's needs and desires. Mechanically altered diets, such as pureed diets (food has been ground, pressed, blended or sieved into a smooth creamy and uniform paste or liquid), are prepared and served as separate entree items. Review of the clinical record indicated Resident R153 admitted to the facility on [DATE]. Review of Resident R153's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/26, indicated diagnoses of dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat and into the esophagus), pneumonia (lung infection), and urinary tract infection. Review of Resident R153's physician order dated 7/30/26, indicated diet - Regular/General diet, Four Pureed texture, Two Mildly Thick (Nectar Thick) consistency of beverage. Review of Resident R153's care plan dated 7/30/26, indicated to provide, serve diet as ordered. Monitor intake and record every meal. Observation of the lunch service on 8/18/26, at 12:20 p.m. on the Angel Wing indicated Resident R153 asking the Survey Agency (SA) to grind her meat up. SA notified Nurse Aide (NA) Employee E21. Interview and observation on 8/18/26, at 12:22 p.m. NA Employee E21 was helping Resident R153 with the lunch meal and indicated the resident was served the incorrect diet. The resident should have had a pureed diet and the food served was two meatloaf patties, one baked potato, and regular green beans. Interview on 8/18/26, at 12:25 p.m. Dietary Director Employee E22 confirmed the incorrect diet was served to Resident R153 and that resident should have pureed meatloaf, mashed potatoes, and puree green beans. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on observation, facility documents, and staff interview it was determined that the facility failed to make certain a feeding assistant provided dining assistance only for residents who have no complicated feeding problems including difficulty swallowing for one of six residents (Resident R47). Findings include: Interview on 8/18/26, at 10:00 a.m. the Director of Nursing indicated the facility does not have a policy on which residents a feeding assistant may feed. Review of the face sheet indicated Resident R47 admitted to the facility on [DATE]. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat and into the esophagus). Further review of the clinical record failed to include documentation that Resident R47's selection was based on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. Observation on 8/17/26, at 12:13 p.m. Resident R47 was in her wheelchair in the resident's room. Feeding Assistant Employee E18 was standing over her and the bedside table feeding the resident her lunch. Interview on 8/18/26, at 10:00 a.m. the Director of Nursing confirmed the facility failed to make certain a feeding assistant provided dining assistance only for residents who have no complicated feeding problems including difficulty swallowing and could not produce documentation that Resident R47's selection was based on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.Findings include: The facility deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. Findings of the current survey ending August 21, 2026, included deficiencies that were repeated from the previous survey of May 22, 2025, which are as follows: F558, F604, F628, F695, F761, F880, and F908. During an interview on 8/21/26, at 10:01 a.m. the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies from the previous survey, and that the facility failed to correct quality deficiencies and ensure that plans to improve the delivery of care services effectively addressed those deficiencies. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code211.12(c)(d)(3) Nursing services.

Based on review of facility policy, clinical records, incident reports, hospital records, facility provided documents, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer in the facilities vehicle van, which resulted in actual physical harm (an abrasion to crown of head, abrasion to right knee, abrasion to left ankle, and three acute cervical (neck) fractures of C3, C4, and C5) for one of two residents (Resident R1).Findings include: Review of the facility Accidents and Incidents policy dated 4/16/26, indicated the facility will promote a safe environment for all residents. An accident/Incident is any happening, which is not consistent with routine operations or the routine care of the resident. Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 5/21/26, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and fractures (a broken or cracked bone). Review of documentation provided by the facility dated 5/14/26, stated the following: Resident was transported to neurology appointment 5/14/26, at 1:15 p.m. via facilities wheelchair van. CNA (certified nurse assistant) transporter and resident successfully made it to the appointment without incident. Once appointment was completed and resident was being transported back to facility, incident occurred when accelerating from a stoplight. Resident remained seated in wheelchair; however, the wheelchair had tipped backwards within van. CNA recognized issue immediately and pulled to the side of the road in a safe location. She exited the vehicle and opened the rear hatch to access the resident. She was able to successfully with the assistance of passerby lift the wheelchair and resident to an upright position. CNA reports no overt signs of substantial injury directly following incident. CNA then resecured resident with equipment after verifying the equipment was without fault. Resident and CNA report being approximately eight minutes from facility when transport was resumed following incident. At this point CNA reports resident complained of discomfort to neck and sternal area. When reentering facility at approximately 4:45 p.m. CNA immediately notified Licensed Practical Nurse assigned and Registered Nurse (RN) supervisor. Resident was assessed, observations noted include abrasion on crown of head, R knee and L ankle. RN contacted Certified Registered Nurse Practitioner (CRNP) to notify of incident. CRNP provided order to send out to hospital for further evaluation. Resident transferred to acute hospital. Description of Follow-up Action: DON (Director of Nursing) and NHA (Nursing Home Administrator) on 5/15/26, initiated investigation and internal plan of correction. Investigation included interview with CNA and obtaining of statement, inventorying and testing of securement equipment present in wheelchair van, CNA assisted re-enactment of securement and incident, visit to resident at acute hospital to obtain interview documentation, and development of education to be provided to all individuals who are permissible drivers. *UPDATE* Imaging at hospital resulted in C3-C5 fracture. *UPDATE* It is inconclusive what the root cause may have been. Transportation CNA during re-enactment displayed the correct procedure and use of securement system prior to re-education. The equipment was present and determined to function as intended during investigation. The wheelchair tipped backwards during acceleration from a stoplight. *UPDATE* All permissible drivers have received education regarding wheelchair securement system. *UPDATE* CNA displayed appropriate use of securement systems during re-enactment. CNA when questioned states she applied the securement in the same manor when transporting resident. Equipment during inspection found to be operating as intended. It is unclear how the wheelchair tipped, whether the CNA had inappropriately applied the system at that time or if the equipment faulted. Review of Physician orders dated 4/9/26, indicated Resident R1 had an appointment with a specialist on 5/14/26, at 2:00 p.m. Review of Resident R1's care plan dated 5/22/26, indicated resident has an alteration in musculoskeletal status related to fractured neck. Review of a written statement dated 5/15/26, from Nurse Aide (NA) Employee E1 stated, I had resident strapped in van with all four straps. Was at a red light when I went to pull out the van jerked a little and the chair started to move back and tipped over. Resident was against the back. Four people stopped and helped me to put him back in chair (tip chair back up). I strapped him back in and brought him back. Review of an interview conducted by Director of Nursing (DON) dated 5/15/26, with Resident R1 stated, We were driving and she stopped. When she pulled up, I went back. I was laying on my back, the chair went with me. I hit my head on the left side against the door. Then my neck and chest hurt, but they got me up pretty quick. It only took about eight minutes to get back home. She (Registered Nurse Supervisor) sent me to the hospital about 45 minutes after we got back. During a review of Resident R1's progress notes revealed the following: 5/14/26 - Resident left for apt at 1:15 p.m. with wheelchair van with escort. 5/14/26 - Was reported to this nurse by NA Employee E1that she had resident in van for an appointment. States wheelchair was secured but at a stop light the chair tipped backwards and resident hit head on van door. Upon assessment, resident states he hit his head and his neck and chest hurt. Resident has an abrasion on crown of head, right knee, and left ankle. Resident states his feet flew up in the air. Spoke with CRNP and ordered Resident R1 to be sent to emergency room for evaluation of neck. 5/15/26 - Resident admitted to hospital with acute displaced fractures of C3, C4, and C5, osteomyelitis of right toe wound, white count elevated, and elevated lactic acid. During a review of Resident R1's progress notes dated 5/21/26, indicated resident returned to facility with new orders including a cervical collar (a collar that surrounds and stabilizes neck) on at all times and a follow up appointment. During a review of Resident R1's hospital records on 6/10/26, at 12:15 p.m. indicated on 5/14/26, Resident R1 had a CT scan (an advanced medical imaging procedure that combines a series of X-ray images taken from multiple angles) completed at the hospital that indicated acute displaced fractures of C3, C4, and C5. During a review of facility provided documentation labeled, May 2026 Approved Drivers List, indicated 13 approved drivers were on the list. During an interview on 6/10/26, at 12:21 p.m. Maintenance Director Employee E3 stated, A couple weeks ago we all got educated after the incident. I was not involved in any education and did not educate anyone on the safety mechanisms in the van, and failed to provide any documentation that the safety mechanisms were evaluated on a regular basis to ensure they were in working order. During an interview on 6/10/26, at 1:24 p.m. NA Employee E1 stated, I was on the approved list of drivers but now I'm not. I did not have any education or training by the facility on how to safely lock a resident into the van. I didn't have any training at all. I had to figure out how to strap a resident in the van myself. During an interview on 6/10/26, at 12:01 p.m. Resident R1 stated, I was in our van, stopped at a light. When we pulled out, all hell broke loose. I don't know what happened. The wheelchair went sideways and I flew back and hit my head on the back. I said I think I'm alright, but I guess I wasn't. People came to help, got me back into wheelchair, came back here and then sent me to hospital. I wear collar all the time. I feel like I've been rode hard and put away wet. Pain in my chest is about gone. They had seat belts on, that's what I can't figure out. Nobody can figure it out. Something malfunctioned and the driver doesn't know. They need to look into before it happens again. During an interview on 6/10/26, at 1:24 p.m. NA Employee E1 stated, I put him in, I did all the straps and the seat belt. It was a high-back wheelchair. When the light turned green, the van jerked and then I heard the straps pulling and the chair went backwards. The resident yelled. The seat belt was across the resident. I locked him in with four straps. He had leg rests on the wheelchair. You strap the wheelchair in the front of wheelchair at the bottom like where the leg rests go on and the back gets hooked to around same area. I heard the straps pulling and resident fell backwards. I got out of van and opened the back. By standards stopped and we tilt the chair back up to where it's to be. I redid everything and checked everything. I made sure he wasn't going to move. During an interview on 6/10/26, at 2:26 p.m. the Nursing Home Administrator (NHA) confirmed that no one was educated, trained, and no competencies were completed on the proper techniques of safely securing a resident into the van prior to Resident R1's incident. NHA stated, All I can think of is that NA Employee E1 may have secured a tie down on a leg rest instead of the wheelchair frame. During an interview on 6/10/26, at 3:30 p.m. NHA confirmed that the facility van has not been serviced after the incident to ensure the safety mechanisms work appropriately and that the van will be placed out of service until a company can service the van. During an interview on 6/10/26, at 3:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that a resident was free from a preventable accident during a transfer in the facilities vehicle van, which resulted in actual physical harm (an abrasion to crown of head, abrasion to right knee, abrasion to left ankle, and three acute cervical (neck) fractures of C3, C4, and C5) for one of two residents (Resident R1). 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a) Resident rights. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three resident reviewed (Resident R1), which resulted in actual harm of a resident, resulting in a head laceration requiring transfer to the hospital. Findings include: A review of the facility policy, Resident Protection from abuse, neglect or exploitation, dated 4/17/25, indicated that the residents will be treated with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (condition when blood flow to a part of the brain is obstructed leading to death of brain cells), encephalopathy (condition that disrupts the normal functioning of the brain) and urinary tract infection. A review of physician orders dated 12/3/25 indicated Resident R1 was an assist of two staff members for transfers. A review of the care plan dated 5/31/25, indicated Resident R1 was at moderate risk for falls related to deconditioning, gait/balance problems. A review of a nurse progress note dated 12/16/25, indicated the resident had been placed in shower chair, showered, returned to room and left unattended while NA went for lift. In that time resident fell from shower chair resulting in laceration. A review of an investigative report of alleged neglect submitted by the facility, dated 12/16/25, indicated that facility nurse aide (NA) Employee E1 reports assisted resident with a shower. Resident was assisted back to room, NA Employee E1 left to secure hoyer to transfer resident back to bed. NA was asked by another NA to use hoyer, he said she could have it. Employee E1 left the room, Resident R1 sustained the fall from shower chair when left in the room unsupervised. A review of a facility witness statement dated 12/17/25, indicated the following: Review of Registered Nurse (RN) Employee E2's witness statement signed and dated 12/17/25, indicated Employee E1 acknowledged that he shouldn't have left him alone. Employee E1 stated that he didn't ask anyone to sit with Resident R1 while he got the hoyer. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement signed and dated 12/16/25, indicated Employee E1 stated Resident R1 was on the floor. LPN Employee E3 asked if someone was with resident while Employee E1 went to get the lift, he said no, he just went to get the lift and went right back to the room. Review of Nurse Aide (NA) Employee E1's witness statement sign and dated 12/17/25, indicated he left Resident R1 in the shower chair and went to get the hoyer. I was only out of the room for roughly 30 seconds. Employee E1 stated he knew that you can't leave a resident unattended in the shower chair, there is no excuse. Interview 1/6/26 at 10:15 a.m. with Nurse Aide Employee E4 indicated she knows not to leave a resident alone in a shower chair and to either look on the kardex or on their orders for care instructions. Attempts to call and interview NA Employee E1 were unsuccessful. Interview 1/6/26 at 10:20 a.m. with Nurse Aide Employee E5 indicated she would look on the kardex on how to care for a resident or ask the nurse. During an interview on 1/6/26, at 1:30 p.m., the Director of Nursing confirmed that the facility neglected to provide proper supervision for Resident R1, resulting in a fall with injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, clinical and facility record review, facility provided documents, and staff interviews, it was determined the facility failed to provide adequate supervision for two residents resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for two of 33 residents (Residents R1 and R2) identified as having a high risk for wandering.Findings include: Review of facility policy Elopement Prevention dated 4/17/25, revealed the facility properly assesses residents and plans their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial assessment. A care plan will be developed that reflects the potential for elopement and preventative measures. Admitting nurses or other staff members noting elopement risk and wandering behaviors must notify the nursing Unit Manager/Designee or the ADON (Assistant Director of Nursing). Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques. If signaling device is indicated, obtain a physician's order for use of the signaling device and document the reason for application of the device in the resident's clinical record. Once the plan of care is determined, the nursing unit manager will notify the staff of the elopement risk and the interventions to be implemented. Photographs of the resident are provided to the receptionist. The receptionist will maintain the list of all residents at risk for elopement, including the resident's name, room number. This list will be distributed to the management team of the care community. Appropriate communication should occur with staff members who may be in contact with those residents. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with active diagnoses of Metabolic Encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain), altered mental status, Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Alzheimer's Disease (progressive disease that destroys memory and other important mental functions).Review of Resident R1's progress note dated 10/1/25, at 11:52 p.m. revealed, New admission this evening, resident noted to be wandering building with [his/her] cane, continuously going in and out of other resident's rooms, yelling up hallway at staff to help [his/her] roommate who was sick, staff doing what they could until MD (physician) contacted back, [he/she] would call dtr (daughter) and walk around with her on speaker phone, was telling [his/her] dtr that roommate was sick and no one was there to help, they weren't doing anything, so [he/she] would wander around and tell [his/her] dtr different things about not just [his/her] roommate but other residents as well. Trying to help [his/her] roommate as well, staff had to redirect [his/her] not to do so, told [resident] [he/she] could hurt [himself/herself] or accidentally hurt [his/her] roommate, to please allow staff to handle [his/her] roommate's condition. Review of Resident R1's clinical record revealed an admission Wandering/Elopement Risk Evaluation completed on 10/1/25, which consisted of the following questions and documented answers:1. Does the resident have a known history of wandering?Yes2. Behavior/Mood - Select the following, all that apply to resident Loss of self-controlExperiencing feelings of anger/fear of abandonment2a. Resident is exhibiting one or more of the behaviors/moods listed under 2 that could potentially contribute to their risk for wandering.3. Select from the following, all the changes that apply to the resident Change of roommateadmission within the last monthCaregiver or staff change3a. At least one or more of the circumstances under 3 are contributing to the resident's risk for wandering.4. Walk in room: self-performance Independent5. Does the resident use a device for ambulating?No.6. Select any of the following diagnosis that apply to the resident Other Dementia7. Which of the following medications is the resident taking?None of the above8. The following interventions are recommendedRe-evaluation if there is a change in their condition or circumstances Wandering Risk Evaluation Score: 23 - High Risk Review of Resident R1's behavior note, dated 10/3/25 at 2:57 p.m. revealed, Resident seemed to have increased agitation as well as increased anxiety. Seemingly lost, stating, 'I've lost my mind!' Resident was noted to be easily redirected and reassured by staff. Will continue to monitor. Review of Resident R1's progress note, dated 10/3/25, at 5:56 p.m. revealed, RN sup (Registered Nurse Supervisor) notified that patient was located sitting out side. patient was assisted back into the facility. RN sup completed a head to toe assessment. Vss (vital signs stable). Blood pressure 138/70, pulse 68, respirations 18, temp 97.9, oxygen saturation 98% room air. no s/s (signs or symptoms) of distress. No injuries noted at this time. Wander guard (wearable electronic monitoring device) placed on patient left ankle. RN sup assisted patient into transport chair, escorted [him/her] to front entrance sensors, wander guard alarm sounded. assured that wander guard fob working at this time. RN sups educated staff on q 15 min (every 15 minutes) checks, and the risk of elopement for this patient. Review of Resident R1's progress note, dated 10/3/25, at 6:00 p.m. revealed, This nurse spoke with granddaughter regarding staff finding resident outside sitting on the bench. The granddaughter voiced concerns that this resident was supposed to have a wanderguard on, and that she felt that [resident] was not being watched over effectively and correctly. This RN explained to the granddaughter how wanderguards work. Resident had a wanderguard on at time of finding [him/her] outside. RN reported that a new wanderguard was placed on the left ankle and that it was tested and worked accurately. RN also informed granddaughter that Q 15 min checks would be initiated and that everything would be documented accordingly. Staff would also be educated on wandering risks as well as ways to redirect safely and efficiently. A full head to toe was done by 3-11 RN supervisor and documented. Each unit was educated on redirection as well as an update on this resident so that we can keep the resident safe. The granddaughter reported that resident loved going outside, drinking coffee and watching tv. RN discussed ways to involve the resident in the milieu to help decrease resident's urge to wander, and to keep [resident] safe, while also keeping [him/her] engaged on the unit. RN suggested having a staff member walk with [resident] and talk with [him/her] at times throughout the day, bringing the resident to the dining room so she can socialize as well as have coffee, and also involving activities to bring [resident] out into the courtyard with staff so [resident] can go outside and get time outside so [he/she] does not feel so sheltered. Granddaughter agreed with these possible interventions. Granddaughter had no further concerns and was reassured that she can always call if there are any concerns, and that they will be addressed appropriately. ADON notified. Safety interventions in place. All staff educated. Q 15 min checks initiated.Review of a witness statement dated 10/3/25, completed by Nurse Aide (NA) Employee E4 revealed, Assistant Administrator Employee E5 and RN Manager Employee E8 came over to Angel Wing saying that we needed to locate Resident R1, that [his/her] daughter was on the phone saying [resident] was outside. I immediately recalled a conversation I overheard earlier. She [Resident R1] was on speakerphone with a woman as [he/she] was walking from the direction of the ambulance entrance towards the nurses station, the woman said do you see the desk? Make a left at the desk [he/she] turned the corner at the nurses station and saying [he/she] wanted to go outside to clear [his/her] head. The lady on the phone was talking over [resident] and asked [him/her] if [resident] could see the fireplace from where [he/she] was, [resident] told her yes and the lady told [resident] to go in that direction. At first I assumed [he/she] was a visitor but I asked RN Manager Employee E9 just to be sure, she told me it was our new resident. I said [resident] is going to need a wanderguard if [resident] doesn't already have one. RN Manager Employee E9 said [resident] did have one so I went back to what I was doing. As soon as Assistant Administrator Employee E5 and RN Manager Employee E8 said that her daughter thinks [he/she] is outside I said crap [he/she] probably is, someone [resident] was on the phone with told [him/her] how to get to the front of the building. Resident greeter was at the front door and the receptionist was at the desk, the doors were unlocked and the alarm was not going off. I went outside and found [resident] sitting on the bench outside of PC (Personal Care). I approached [resident] and asked [him/her] if [he/she] was Resident R1 and [he/she] said yep! [Resident] was sitting on the phone with her granddaughter on speakerphone, unharmed and joyous about what a beautiful day it is and she was so happy to go outside and clear her mind. Review of witness statement dated 10/4/25, completed by NA Employee E6 revealed, Around 3 p.m. on 10/3/25 I walked over to Angel Wing to go on break with my mom. As I was looking for her I saw Resident R1 walk past me on the phone while someone was saying look for the nurses station. Roughly 20 minutes later RN Manager Employee E8 came rushing over and asking if anyone has seen [Resident R1]. My mom and I went outside to look for [him/her] and saw [resident] sitting outside of PC. We escorted [resident] back inside as [him/her] daughter was on the phone trying to fight with the aides. Review of undated witness statement completed by Assistant Administrator Employee E5 revealed, On 10/3/25 I was in my office when Receptionist, Employee E1 came into my office and told me Resident R1's daughter is on the phone and explained that [Resident R1] is outside. I immediately went back to Angel Wing with RN Manager Employee E8 to see if [he/she] was in [his/her] room first. When [he/she] was not in [his/her] room, RN Manager Employee E8, two CNAs (Certified Nurse Aides), and myself went out the front door. I went right towards the parking lot; the CNAs went left towards Personal Care. I heard the CNAs bring [him/her] back into the building as resident is able to walk on [his/her] own. I then had RN Manager Employee E8 do a complete assessment to make sure everything was okay with resident. I also instructed for resident to immediately have a wander guard placed on [him/her]. I also instructed the nurses to make sure the orders are in the computer and it is care planned as an immediate plan of action to prevent it happening again. RN Manager Employee E8 and I then called the resident representative, which is [resident] granddaughter to report the event. Review of witness statement dated 10/8/25, completed by Receptionist Employee E1 revealed, I was working in the office at the time of the incident, going back and forth from the front desk to the copy room and business office to finish end-of-day tasks. Around 4:00 p.m. or so, I received a call from Resident R1's daughter. She sounded very upset and said she had received a message from someone at our facility saying that [Resident R1] had gotten out and wanted to know what was going on. I asked her to hold while I tried to find out what had happened, then I immediately went to Assistant Administrator Employee E5's office to tell him about the call I had received. He told me to forward it to Resident R1's nurses station, so I returned to my desk to do that. I followed up with a call to the supervisor for that nurse's station just to make sure someone else was aware, just in case they somehow missed the initial call. Nobody answered, but I assume now that it was probably because they were already looking for Resident R1. After that, I decided to forego the end-of-day tasks in favor of staying at the front desk in case I was immediately needed while the nursing staff went in and out of the building searching for Resident R1. I believe [he/she] was found and returned to the building around 4:15 or 4:20. I remained at the front desk until the end of my shift at 4:30 p.m., at which point I notified Assistant Administrator Employee E5 that I was leaving since I was closing the front office and locking the front door while he was still inside. During an interview on 11/12/25, at 11:22 a.m. the Director of Nursing (DON) stated, I know Resident R1 had a wanderguard placed after the incident on 10/3/25. Multiple staff members attested to overhearing [his/her] daughter telling [resident] on the phone how to get out of the building. During an interview on 11/12/25, at 11:23 a.m. ADON Employee E7 revealed, Resident R1 had a wanderguard placed at admission and it was not on during the elopement.Review of Resident R1's clinical record failed to reveal documented evidence that elopement/wandering interventions had been developed and implemented after Resident R1 was determined to be a high wander risk at admission on [DATE].Review of a facility Resident Elopement List dated 9/24/25, revealed Resident R1's name handwritten on the list with the date 10/3/25.Review of Resident R1's physician order dated 10/3/25, revealed wanderguard on at all times, check placement and skin integrity each shift. During an interview on 11/12/25, at 11:44 a.m. the DON confirmed the facility was unable to locate orders for a wanderguard for Resident R1 prior to the resident's elopement on 10/3/25. The DON stated, The LPN (Licensed Practical Nurse) who filled out the admissions assessment denies placing a wanderguard on Resident R1 at that time. Review of Resident R2's clinical record revealed was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/18/25, indicated diagnoses of high blood pressure, Anxiety, and Depression.Review of Resident R2's progress note for Resident R2, dated 9/24/25, revealed, Resident has [his/her] belongings packed in a bag and is sitting by the exit door on the Buttercup by the nurse's station. Resident easily redirected back to [his/her] room by this RN. Resident states that [he/she] was unsure if [his/her] room was still covered by the employer. Resident assessed by this nurse. AOx2 (alert and oriented) with trouble with location. Resident denies any pain at this time. Resident sitting in room currently with call bell in reach and watching TV. Review of Resident R2's progress note, dated 9/24/25 revealed, ANHA (Assistant Nursing Home Administrator) performed BIMS (Brief Interview for Mental Status) assessment on resident due to behaviors. Resident scored a 15 which indicates resident is cognitively intact. However as ANHA was sitting with resident, [resident] made some comments that were somewhat bizarre. Resident went into political conspiracies and talking about evil spirits that are al throughout the facility, [he/she] can feel them. Even though resident is able to believe in whatever [he/she] pleases this seems to be out of the ordinary for resident. ANHA notified DON/ADON of behaviors/findings. Review of progress note for Resident R2, dated 9/24/25, revealed, Wanderguard placed on right wrist r/t (related to) exit seeking. Voicemail left with brother. Review of physician order for Resident R2, dated 9/24/25, revealed resident is to have a wanderguard at all times. Check placement and skin integrity each shift. Review of Resident R2's care plan dated 9/24/25, indicated the resident is an elopement risk/wanderer as evidenced by a history of attempts to leave my home unattended, disorientation to place. Interventions include: distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, books, etc. Identify any patterns of wandering that I exhibit: purposeful wandering, aimless, or attempting to escape. Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Issue a wandering device to me. Monitor my location frequently. Document any wandering behavior and the success of any attempted diversional interventions. Review of progress note for Resident R2, dated 9/28/25, stated, About 630pm I was walking past residents room and noticed [he/she] was attempting to transfer self from wheelchair to bed without assistance or staff present. I went into room and started to speak with resident, first about football game . I walked past room about an hour later and wheelchair was gone and resident was not in bed, bed alarm was turned off, I did turn it on during early interaction. Resident was not in bathroom. CNA and myself looked throughout facility and resident was in bathroom of another room on Angel Hall, resistive to coming out of bathroom. CNA brought to [his/her] room, [resident] said [he/she] wants the police called, RN supervisor asked [resident] why and [he/she] just said because I do. RN supervisor informed [resident] [he/she] needs to tell police nature of [his/her] call and [resident] said someone turned off [his/her] security equipment in room, [he/she] did not feel safe. Resident did propel self to other part of unit and was going into other residents rooms, with other residents being upset about intrusion. RN supervisor did talk [him/her] into taking medications with resident questioning medications and being suspicious. Resident was seen by myself to be in a male occupied room. [Resident] was sitting in the dark then came out on [his/her] own. After [Resident R1] came out, male resident said to me that he was sleeping, felt someone tapping his leg. He woke up and was being spoken to about the shirt that he has on, that resident who wandered into room was speaking to him negatively about wearing same shirt yesterday. Resident then propelled self towards her room and then wandered again through facility. CNA found resident resting in bed in a room on Angel Wing. When CNA attempted to inform that this is not [his/her] room and directed [him/her] to correct room, resident was a bit angry and said this isn't right and I want to the police. Another CNA came in and spoke with resident about situation with resident transferring out of bed into wheelchair, assigned CNA did assist [him/her] to bed with some resistance. Resident is resting in bed at this time. Review of progress note for Resident R2, dated 9/29/25, revealed, Resident wandered around, denying care from aide and medicine from this nurse. Was upset that staff would not sit in [his/her] room to keep [him/her] company. Review of progress note for Resident R2, dated 10/5/25, stated, LPN on GRU (a nursing unit in the facility) front cart called RN supervisor because resident was outside in front of building. Resident was wearing long sleeve shirt, sweatpants, and non-skid socks. ADON notified of resident being outside. Kitchen staff notified RN that resident was in parking lot upon arrival to building. Staff stayed with resident, was able to get resident to return into building upon room change. RN assessed resident, no injuries noted, wander guard placement checked and not found. New wander guard placed on resident's wheelchair. Resident will not receive knives due to possibly cutting previous wander guard off. When asked about wander guard bracelet, resident stated, I believe I cut it off. Maintenance checked wander guard system, system functioning appropriately. MD notified and family notified. Review of witness statement dated 10/5/25, completed by Dietary Aide Employee E2 stated, I was pulling into the parking lot, came through the employee entrance, went towards the kitchen and I looked out the front door and saw Resident R2 outside by the road. I stayed with [him/her] until I was able to get somebody so [he/she] wouldn't get hurt or hit by a car. I was also trying to coach [him/her] in [he/she] wouldn't come. Review of undated witness statement completed by Activity Aide Employee E3 revealed, I arrived at work at 11:15 a.m. on Sunday, October 5, 2025 and entered through the employee ramp. I walked through Rehab Road to report to the front office. Upon arriving at the front office, I noted Resident R2 in the parking lot. I recognized another staff member outside with Resident R2, but unlocked the front door to go out and check to see if everything was ok. Upon going outside, Resident R2 stated that [he/she] was trying to leave. I sent the other staff member into the building to get help while I stayed with Resident R2 to ensure safety. I stayed with Resident R2 until we were able to get her safely back into the building.Review of a witness statement dated 10/5/25, completed by NA Employee E10 stated, Have not seen resident since this morning around 8 when [he/she] was wondering around hallway. Review of a witness statement dated 10/5/25, completed by LPN Employee E11 stated, I last seen Resident R2 at approximately 8:40 a.m., when I administered her morning meds.Review of a witness statement dated 10/5/25, completed by NA Employee E12 revealed, Around 11:11 a.m. I seen Resident R2 in the kitchen area, she had the wireless cellphone, and told me she was done using it. I got the phone off [him/her] and [he/she] was still in that area near the fish tank.During an interview on 11/12/25, at 11:32 a.m. DON stated, On 10/5 an Activity Aide was covering the front desk, the receptionist was on her way in. The front door was unlocked because someone was at the desk. There is a binder at the front desk with all of the residents identified as an elopement risk. During an interview on 11/12/25, at 11:44 a.m. the DON was informed that Activity Aide Employee E3 revealed in their witness statement that Resident R2 was in the parking lot with another employee when they arrived to work at 11:15 a.m., which contradicts the previous verbal statement that Activity Aide Employee E3 had been covering the front desk at the time that Resident R2 eloped from the building. During this interview, the DON stated, I will get the ADON to try to better explain the timeline. I was on vacation at that time, I'm unsure of all of the facts. During an interview on 11/12/25, at 11:48 a.m. ADON Employee E7 revealed, Dietary Aide Employee E2 was the first person to find Resident R2 outside of the building. Resident R2 went out of the front door, not sure how they got out. During this interview, ADON Employee E7 was unable to state why the front door was unlocked while the front desk was unattended. ADON Employee E7 acknowledged previously stating to the State Agency (SA) that Activity Aide Employee E3 was covering the front desk until the receptionist arrived. When the SA showed Activity Aide Employee E3's written witness statement to ADON Employee E7, they stated, I would have to go with the witness statement. On 11/12/25, at 2:34 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) was called due to the elopement of Resident R1 on 10/3/25, and Resident R2 on 10/5/25. The NHA was provided an Immediate Jeopardy template, and a corrective action plan was requested. On 11/12/25, at 5:31 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The facility Administrator, and or designee, will review current elopement policy for accuracy and update as needed, to be completed by 11/13/25. All residents will be evaluated for risk of elopement by the facility Director of Nursing, or designee, this to be completed by 11/13/25. Any new identified residents as at risk of elopement will receive orders from physician for use of wanderguard bracelet and care plan will be updated accordingly by facility Director of Nursing, or designee, to be completed by 11/13/25. An audit of all residents identified as at risk for elopement will have their care plan reviewed to ensure resident centered interventions are in place, completed by facility Director of Nursing, or designee, this to be completed by 11/13/25. All staff, both facility and agency, will be educated by the facility Director of Nursing, or designee, regarding elopement policy, identifying residents at risk, and implementing interventions, this to be completed by 11/14/25. The facility Administrator and Director of Nursing will complete a root cause analysis as to what system failed allowing this elopement to occur, this to be completed by 11/13/25. Facility Administrator and Director of Nursing will review the procedure on the front door monitoring, this to include functionality of wanderguard system, as well as the schedule of personnel monitoring front entrance. This to be completed by 11/13/25. The front door wanderguard codes have been changed and code knowledge limited to administrative staff. Facility door will be secured and code use will be required for entry or exit. Compliance will be monitored through audits. Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee. Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA, this to be completed by 11/14/25. The facility's policy and procedures for elopements were reviewed 11/12/25, no revisions were made. On 11/13/25, at 10:34 a.m. it was confirmed 146/146 residents were reassessed for an elopement risk. 36/146 residents were identified as at risk. 5/146 residents were newly identified as at risk of elopement. 36/36 resident physician orders were verified for an electronic monitoring bracelet. 36/36 care plans were reviewed and updated to include interventions to prevent elopement. Review of facility documents on 11/13/25, revealed the facility had 126 employees and 104 agency employees. 138 employees signed they received formal education on the policy Elopement Prevention. 65 employees signed they received education via phone as they had not been working in the building.During employee interviews on 11/13/25, from 11:33 a.m. through 2:18 p.m. 38 employees confirmed they had received education on the facility's elopement policy and procedures, as indicated above. Review of an ad hoc (an unplanned meeting organized to address specific issues of urgent matters) QAPI meeting dated 11/13/25, revealed during an audit of all residents, 36 residents were identified as at risk of elopement. This audit reviewed wandering assessment, wanderguard orders, and elopement care planning. The audit revealed errors in 18 resident assessments, one care plan was found to be needing updated, and two residents were found to be needing wanderguard orders. The Immediate Jeopardy was lifted on 11/13/25, at 3:07 p.m. when the action plan implementation was verified. During an interview on 11/13/25, at 4:46 p.m. the NHA and DON confirmed the facility failed to ensure each resident received adequate supervision, which resulted in an elopement for two of 33 residents (Residents R1 and R2), resulting in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(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 provide medication as ordered by the physician for two of two residents (Resident R19 and R182), resulting in significant medication errors due to receiving another resident's medications for one of five residents reviewed (Resident R182). This created actual harm which required a transfer to the emergency department and admission to a telemetry unit (a unit of a hospital where patients receive continuous heart monitoring) for Resident R182. Findings include: Review of facility policy Specific Medication Administration Procedures dated 4/17/25, indicated to review the five Rights of medication administration (right medication, right patient, right dose, right route, right time) three times. Identify the resident using two identification methods before administering medication (e.g., photo plus verbal confirmation of last name, photo and confirmation by family member, etc.) Review of the facility policy titled, Physician Orders last reviewed 4/17/25, stated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE], with diagnoses of osteoporosis (a condition in which bones become weak and brittle), hip fracture, and arthritis (swelling and tenderness in one or more joints). Review of Resident R19's hospital discharge summary dated 4/21/25, indicated to administer 70 milligrams (mg) of Fosamax once every seven days for osteoporosis. Review of Resident R19's physician order dated 4/21/25, entered by Registered Nurse, Employee E22 indicated to administer 70 mg of Fosamax one time a day for seven days. Review of information submitted to the Department of Health on 4/28/25, stated on 4/28/25, at approximately 8:00 a.m. a Registered Nurse was alerted a medication error had occurred. Resident R19 was ordered Fosamax 70 mg every seven days and the order was entered once a day for seven days. The administration record revealed the resident received five doses of Fosamax over a seven-day period. The provider was notified and assessed the resident. The resident's family was notified and requested the resident to be sent to the hospital for further evaluation. It was indicated education will be provided to all nurses on entering orders. Review of Resident R19's April 2025 Medication Administration Record (MAR) on 5/19/25, at 9:22 a.m. revealed Resident R19 received 70 mg Fosamax on 4/22/25, 4/23/25, 4/24/25, 4/26/25, and 4/27/25. Review of the facility's investigation on 5/19/25, revealed on 4/28/25, a Nursing In Service was provided to staff of how to enter daily versus weekly orders in the electronic record. Review of the list of staff members educated failed to include evidence RN, Employee E22 was reeducated. Review of RN, Employee E22's timesheet revealed she worked on 4/28/25, from 2:07 p.m. until 10:37 p.m. and 4/30/25, from 11:00 p.m. until 7:32 a.m. During an interview on 5/20/25, at 1:05 p.m. the Director of Nursing (DON) confirmed the facility failed to reeducate RN, Employee E22 and failed to ensure Resident R19 was free from significant medication errors. Review of the clinical record indicated Resident R182 was admitted to the facility on [DATE]. Review of Resident R182's MDS dated [DATE], indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and Cerebrovascular Accident (CVA - also known as a stroke, sudden interruption of blood flow to the brain). Review of a progress note dated 4/30/25, completed by Certified Registered Nurse Practitioner (CRNP) Employee E18 stated, Resident was seen for hypoxia (the absence of enough oxygen in the tissues to sustain bodily functions) and vomiting. - After assessment, there was concern for respiratory depression and abdominal distress. Ordered CXR (chest x-ray) and Abdominal x-ray. After about an hour, it was discovered that the resident likely got another residents medications which included long acting narcotic (a controlled medication that can dull senses, relieve pain, and include sleep), beta blocker (a medication used to treat high blood pressure and heart rate), SSRI (Selective Serotonin Reuptake Inhibitor, a medication used to increase Serotonin in the brain), Anticoagulant (a medication used to prevent blood from clotting), oral diabetic med (a medication used to lower blood sugar levels), calcium channel blocker (a medication used to treat high blood pressure), and diuretic (a medication used to lower blood pressure and fluid retention). Resident sent to the hospital for evaluation. Will follow up on return. Review of an Emergency Medicine Physical Evaluation dated 4/30/25, completed by an emergency room physician stated, Altered mental status, patient was given wrong medications this morning. He was given heart medications, blood pressure medications, narcotics/opiates, Lasix (a diuretic), and blood thinners. Upon EMS (Emergency Medical Service) arrival patient was bradycardic (slow heart rate less than 60 beats per minute), hypotensive (low blood pressure), and confused. EMS gave 1 mg (milligram) of Narcan (Naloxone - a medication used to treat known or possible opioid overdose), 1 mg atropine (a medication used to treat low heart rate), and 4 mg of Zofran (a medication used to treat nausea and vomiting). EMS reports that the patient was given 18 medications in error this morning that belonged to another patient. He was then found unresponsive. EMS reports that the medications the patient had given included oxycodone among others, so the patient was given naloxone with improvement in his mental status. He was initially very bradycardic with heart rates in the 30's as well and hypotensive. EMS reports that after a 500 cc (milliliters) IV (intravenous) fluid bolus the patient's heart rate improved to the 60's in a sinus rhythm and blood pressure improved to 120s over 80's. The medications that the patient received this morning included amlodipine, extended-release oxycodone, cefadroxil, escitalopram, folic acid, furosemide, empagliflozin, metoprolol tartrate, omeprazole, saccharomyces, Senokot, thiamine, vitamin-C, rivaroxaban, and Carafate. EMS does report 1 episode of vomiting prior to their arrival. EMS administered Zofran EN route as well. The patient is unable to contribute significantly to history due to altered mental status. He denies pain. The patient will be admitted for further observation and management. Review of facility investigation documents dated 4/30/25 stated, Licensed Practical Nurse (LPN) E2 is confident he [Resident R182] received Resident R42's medications at 7:39 a.m. CNA (Certified Nurse Aide) identified resident to be not baseline at 8:56 a.m. Blood pressure 96/52 mmHg (millimeters of mercury), heart rate 48, oxygen saturation 85% on room air, respirations 16 at 8:58 a.m. 2 liters of oxygen applied immediately. Review of facility investigation documents indicated the following medications were incorrectly administered by LPN Employee E2 to Resident R182 on 4/30/25: - Senna-Docusate (a laxative) 8.6-50 mg, two tablets - Vitamin C 500 mg - Xtampza (an opioid used to treat pain) ER (extended release) 13.5 mg - Carafate (a medication used to treat ulcers in the small intestines) 1 gm (gram) - Cefadroxil (a medication used to treat infections) 1 gm - Metoprolol Tartrate (a medication used to lower blood pressure) 50 mg - MiraLAX (a medication used to treat constipation) powder 17 gm - Omeprazole (a medication used to treat acid reflux) 20 mg - Thiamine (Vitamin B1) 100 mg - One-Daily Multi Vitamins tablet - Rivaroxaban (a medication used to thin the blood and prevent clotting) 10 mg - Saccharomyces boulardii (a probiotic) 250 mg - Folic Acid 1 mg - Furosemide (a medication used to rid the body of excess water) 20 mg, give 1.5 tablet (30 mg) - Amlodipine (a medication used to lower blood pressure) 10 mg - Empagliflozin (a medication used to lower blood sugar) 10 mg - Escitalopram (a medication used to treat depression) 200 mg Review of a witness statement dated 4/30/25, completed by LPN Employee E2 stated, On Wednesday 4/30/25 I was working the medication cart on front hall of GRU. I gave Resident R182 accidentally and unknowingly another resident's medications. At approximately 7:59 a.m. a nurse aide informed me he did not look well. On my way to assess him, I saw one of the CRNPs and asked her to help me assess Resident R182 and wasn't sure yet what was wrong. Upon entering the room, he appeared tired. When I asked if he was ok he replied I need to throw up. Resident did throw up in basin. While CRNP spoke to him, I grabbed everything to assess his vitals. Pulse oxygen on room air was 85%, applied nasal cannula at 2 liters per minute and notified CRNP Employee E18. Stayed with resident to monitor for a little while. Expressed to nursing peer that I was concerned about him. CRNP Employee E18 informed me a chest x-ray was being ordered in case of the event of aspiration. When CRNP Employee E18 assessed pulse oxygenation it was 99% at 3 liters per minute and heart rate was in the upper 40's. I thought it would be ok to return to med cart briefly to get Resident R42's oxycodone after being told by staff he was asking for it. It was then when I noticed my signature of Xtampza listed on first page of narc sheet. I began to look at medication passed earlier. When I saw Resident R42's meds signed off I immediately realized I did not give them to him, and they went to Resident R182. I immediately self-reported to the Registered Nurse Supervisor when I realized what took place. Supporting staff notified physician and administration. Resident was transported to the hospital via ambulance. During an interview on 5/19/25, at 12:24 p.m. LPN Employee E2 stated, I got distracted that morning, there were a lot of people talking to me. The aide came to me and said Resident R182 didn't look well, he said he felt sick, like he needed to puke. I grabbed the Nurse Practitioner (NP), who assessed the resident. The NP thought he just had an upset stomach, but he didn't look good. I think his blood pressure was 94/48, his pulse ox (oxygen saturation) was 84%, he was sweating. The ADON (Assistant Director of Nursing) stepped in, I went back to the medication cart and the wound care nurse let me know that Resident R42 across the hall wanted his oxycodone. When I went to sign out his oxycodone, I saw his Xtampza was already signed out, that's when I realized I had given Resident R42's medications to Resident R182. I was never told the best method is to bring the medication cart with me to each resident room. During orientation, I was trained by two different LPNs, neither of them told me to use the pictures in the electronic medical record to verify residents. They must have thought that was common sense. That experience was so scary, I could have killed that person. During an interview on 5/20/25, at 1:57 p.m. the DON confirmed that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors due to Resident R182 receiving another resident's medications. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility documentation, and staff interviews, the facility failed to provide adequate supervision and assistance to prevent a fall with injuries for one of four residents reviewed (Resident R1), resulting in harm with a chronic right distal femur fracture received during care requiring transfer to the hospital. Findings include: Review of Resident R1's clinical record Admission Record Report indicated that the resident was admitted on [DATE], with [CONDITION(S)] (abnormally low activity of the [CONDITION(S)]), [CONDITION(S)] (abnormally low blood pressure), diagnosed with dementia (disease marked by memory disorders, personality changes, and impaired reasoning) 4/29/21, and was readmitted on [DATE], with chronic right distal femur fracture (a break of the thigh bone just above the knee). Review of Resident R1's physician orders with a start date of 1/5/21, active through 7/2/21, indicated Activities/Mobility: Transfer with assist of 2 staff members. Review of facility documentation Tasks (information used by Nurse aides to determine level of care for residents) indicated Resident R1 is a bed mobility assist of 2 staff members. Review of facility documentation Kardex (information used by Nurse Aides to determine level of care for residents) indicated bed mobility assist of 2 staff members. Review of the quarterly MDS (Minimum Data Set - a periodic assessment of resident needs) dated 6/12/21, Section G Activities of Daily Living - indicates Resident R1 is 3/3' (resident needs extensive assistance and requires two person physical assist) for the following activities : bed mobility, transfer, toilet use and personal hygiene. Review of facility documentation Incident Note dated 7/1/21, indicated that two nurse aides were in the room providing care to Resident R1, one Nurse Aide left the room to get supplies, the remaining Nurse Aide continued to provide care, and rolled resident to remove a soiled Chux (bed pad used to prevent soilage to the entire bed sheet) from under the resident. Resident was stable then started to slide off the bed. Nurse Aide reached across bed and lowered Resident to the floor. Review of facility documentation Health Status Note dated 7/2/21, indicated X-ray shows a femur fracture awaiting transport to Hospital. Review of facility documentation Incident Witness dated 7/1/21, from Registered Nurse (RN) Employee E3 - RN Employee E3 was summoned to Resident R1 room due to resident on the floor. Temporary Nurse Aide (TNA) Employee E1 was providing care, resident rolled off the bed and TNA Employee E1 assisted Resident R1 to the floor. Resident R1 complained of kneecap pain. Review of facility documentation Incident Witness dated 7/1/21, from RN Employee E4 - RN Employee E4 summoned to room by Nurse Aide stating resident was on the floor. Two Nurse Aides were in room providing care, when one Nurse Aide left room to retrieve supplies. The remaining Nurse Aide continued providing care and rolled resident to remove a soiled Chux from under the resident. Resident began to roll out of the bed Nurse Aide reached across the bed, grasping her arm and hip, and lowered her onto the floor. Resident was on her knees on the floor. Review of facility documentation (no title), identified as hand written witness statements dated 7/14/21, from TNA Employee E1 indicated that TNA Employee E1 and NA Employee E2 were providing care to Resident R1 , NA Employee E2 went to get more supplies and TNA Employee E1 continued providing care Resident R1 rolled and slipped off the bed. TNA Employee E1 grabbed hold of Resident R1's hip and arm and lowered to floor. Review of hospital record dated 7/2/21, under Assessment/Plan - Principal problem, indicated that Resident R1 was presenting with an Acute comminuted distal femur fracture. Review of orthopedic surgery consult dated 7/2/21, indicated Resident R1 was dropped at skilled nursing facility found to have an acute on chronic right distal femur fracture. During an interview on 7/23/21, at 12:00 p.m. Nursing Home Administrator and Director of Nursing confirmed that Resident R1's bed mobility and care was for two staff and that care was provided with one staff and Resident R1 rolled off of the bed, was lowered to the ground, and was sent to the hospital and diagnosed with a chronic right distal femur fracture, resulting in harm to Resident R1. The facility failed to maintain safety for one of four residents reviewed (Resident R1), resulting in harm with a chronic right distal femur fracture received during care requiring transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1)Management. 28. Pa. Code 201.29(d)Resident Rights. 28. Pa. Code 211.10(c)(d)Resident care policies. 28. Pa. Code 211.12(d)(1)(5)Nursing services.

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to make certain that residents were free from neglect, resulting in a left femoral (thigh bone) neck fracture, for one of four residents reviewed (Resident R1). Findings include: The facility's policy entitled, Fall Risk Reduction dated 1/1/18, indicated that staff should complete a fall risk assessment on admission, review the Minimum Data Set assessment (MDS-periodic assessment of care needs) and other appropriate assessments for information related to fall risk and develop an individualized plan of care that addresses compensation for functional deficits. The facility's policy entitled, Accidents and Incidents dated 1/1/18, indicated that the licensed nurse responsible for the resident will update the resident plan of care as necessary related to the incident/accident. Review of the physician admission history and physical note dated 6/18/18, indicated that Resident R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], indicated that Resident R1 had a history of [REDACTED]. Review of a physician order [REDACTED]. Review of the Kardex (electronic information recording data regarding resident information accessible to all health team members) indicated that Resident R1 required two persons to assist with transfer. Review of the admission MDS dated [DATE], indicated that Resident R1 was cognitively intact and required extensive assistance of two persons for transfer ambulation and toileting. Review of the plan of care dated 6/25/18, indicated that Resident R1 had Activities of Daily Living (ADLs) self performance deficits and required help from staff for transfer, dressing, bathing, toileting and bed mobility. Review of a facility incident investigation report dated 6/28/18, indicated that on 6/27/18, at 8:10 p.m. Nurse Aide (NA) Employee E1 was assisting Resident R1 to the bathroom when she turned to get supplies and the resident fell on to her left side. The resident was immediately assessed by the Registered Nurse and complained of left leg pain. The physician was contacted and ordered stat (immediate) X-rays of the spine and left hip, which confirmed a left femoral neck fracture. The physician then ordered Resident R1 to be transported to the hospital. NA Employee E1's written statement dated 6/27/18, confirmed that she failed to check the resident's transfer status in the Kardex and transferred the resident without the help of a second person. The 6/28/18 incident investigation report indicated that the root cause of Resident R1's fall and fracture was failure of staff to transfer with two staff members. During an interview on 7/31/18, at 11:05 a.m. the Director of Nursing confirmed that the staff failed to make certain that Resident R1 was free from neglect by failure to obtain two staff for transfer as ordered. The facility neglected to make certain that staff transferred Resident R1 with the assistance of two staff, resulting in a fall and a left femoral (thigh bone) neck fracture and subsequent transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/5/18. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 6/5/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 6/5/18. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 6/5/18, 6/9/17. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a resident accident, resulting in a left femoral (thigh bone) neck fracture, for one of four residents reviewed (Resident R1). Findings include: The facility's policy entitled, Fall Risk Reduction dated 1/1/18, indicated that staff should complete a fall risk assessment on admission, review the Minimum Data Set assessment (MDS-periodic assessment of care needs) and other appropriate assessments for information related to fall risk and develop an individualized plan of care that addresses compensation for functional deficits. The facility's policy entitled, Accidents and Incidents dated 1/1/18, indicated that the licensed nurse responsible for the resident will update the resident plan of care as necessary related to the incident/accident. Review of the physician admission history and physical note dated 6/18/18, indicated that Resident R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], indicated that Resident R1 had a history of [REDACTED]. Review of a physician order [REDACTED]. Review of the Kardex (electronic information recording data regarding resident information accessible to all health team members) indicated that Resident R1 required two persons to assist with transfer. Review of the admission MDS dated [DATE], indicated that Resident R1 was cognitively intact and required extensive assistance of two persons for transfer ambulation and toileting. Review of the plan of care dated 6/25/18, indicated that Resident R1 had Activities of Daily Living (ADLs) self performance deficits and required help from staff for transfer, dressing, bathing, toileting and bed mobility. Review of a facility incident investigation report dated 6/28/18, indicated that on 6/27/18, at 8:10 p.m. Nurse Aide (NA) Employee E1 was assisting Resident R1 to the bathroom when she turned to get supplies and the resident fell on to her left side. The resident was immediately assessed by the Registered Nurse and complained of left leg pain. The physician was contacted and ordered stat (immediate) X-rays of the spine and left hip, which confirmed a left femoral neck fracture. The physician then ordered Resident R1 to be transported to the hospital. NA Employee E1's written statement dated 6/27/18, confirmed that she failed to check the resident's transfer status in the Kardex and transferred the resident without the help of a second person. The 6/28/18 incident investigation report indicated that the root cause of Resident R1's fall and fracture was failure of staff to transfer with two staff members. During an interview on 7/31/18, at 11:05 a.m. the Director of Nursing confirmed that the staff failed to make certain that Resident R1 was free from neglect by failure to obtain two staff for transfer as ordered. The facility failed to provide adequate supervision to prevent a resident accident during a transfer for Resident R1, resulting in a fall and a left femoral (thigh bone) neck fracture and subsequent transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/5/18. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 6/5/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 6/5/18. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 6/5/18, 6/9/17. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on facility policy, review of a closed clinical record, staff interviews, and agency reports, it was determined that the facility neglected to continuously assess, provide interventions, and follow physician's orders which resulted in severe respiratory distress to one of one resident reviewed (Resident CR1). Findings include: Review of the facility policy, "Resident Abuse, Neglect, and Misappropriation of Resident Property" revised 6/22/12, revealed that the facility will provide a safe and secure environment for all residents...will continually monitor policies, procedures, and training programs by assessing, care planning, and monitoring of residents with needs and behaviors that may lead to a conflict or neglect. Review of the clinical record indicated that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's order dated 12/12/12, directed staff to administer oxygen to Resident CR1 at a rate of four liters per minute every shift, every day (continuous) by nasal cannula (plastic tubing hooked to oxygen which fits behind the ears, and a set of two prongs which are placed in the nose). Review of a "Management Contact Report" (a statement from an employee during an investigation of an incident) dated 12/16/12, from Licensed Practical Nurse (LPN) Employee E1 and a written statement from Nurse Aide (NA) Employee E2 dated 12/16/12, indicated that prior to lunch (approximately 12:30 p.m. - 12:40 p.m.) LPN E1 and NA E2 walked Resident CR1 down the hallway to the shower room to be toileted without using the oxygen. After using the toilet, Resident CR1 was walked back to his chair, again without the oxygen, and was having difficulty breathing. The resident's oxygen saturation level (the level of oxygen that is present in the blood and is supplied throughout the body for its smooth functioning-normal level is 97%-99%) at that time was documented in the progress notes at 83% (abnormal -indicating the red blood cells were being deprived of oxygen) without the oxygen. The nasal cannula was then reapplied and the oxygen was reconnected and administered. On 12/16/12, at approximately 1:10 p.m., following lunch, NA Employee E3 un-plugged Resident CR1's oxygen concentrator and transferred the resident in a wheeled, recliner chair to the back hall lounge without using the oxygen, then left the lounge area to retrieve the oxygen equipment. When NA E3 returned to the back lounge, she proceeded to move the furniture around while Resident R1 waited for the oxygen to be reconnected. On 12/16/12, at approximately 1:30 p.m., (20 minutes later) the Resident's Family RF1 notified LPN Employee E1 that Resident CR1 was having difficulty breathing. LPN Employee E1 assessed the resident as being pale, grey, cold to the touch, and sweating profusely with rales (rattling/crackling sounds caused by congestion in the lungs) in both sides of the chest. Resident CR1 was left unattended in the back room lounge with no interventions in place while LPN Employee E1 returned to the nursing station to call a supervisor, call the physician, and begin paperwork for transfer out to the hospital. Resident family RF1 who remained in the back lounge called 911 emergency. An ambulance report dated 12/16/12, revealed that when the ambulance arrived at the facility at 2:01 p.m., Resident CR1 was observed in the back lounge, in severe respiratory distress, was ashen in color, diaphoretic (sweating), had an altered level of consciousness, and was moving very little air (shallow respirations). Resident CR1's oxygen saturation level was 38% (a critical level). Resident CR1 was reported as grunting on expiration, and his nail beds were turning blue. The ambulance report also revealed that there were no facility staff in attendance on arrival or monitoring the resident. The ambulance attendants observed a nasal cannula was in place, but not hooked up to the oxygen. The resident was transported to the hospital and admitted in critical condition to the intensive care unit with a collapsed lung and a severe respiratory infection. During an interview on 1/4/13, at 1:30 p.m., the Director of Nursing confirmed that the facility staff neglected to administer oxygen to Resident CR1 when being assisted with transfers, failed to continuously assess and monitor a resident that was in severe respiratory distress, and failed to provide for or have in place interventions for Resident CR1 during a respiratory crisis. During a telephone interview on 1/7/13, at 11:30 a.m., LPN Employee E1 confirmed that following Resident CR1's lung assessment on 12/16/12, at approximately 1:30 p.m., Resident CR1 was in respiratory distress, that a facility staff person was not present to continuously monitor and assess the respiratory distress, and that the facility did not provide for or have in place interventions for Resident CR1 during a respiratory crisis. 483.13(c) Prohibit Mistreatment/Neglect/Misappropriation. Previously cited 11/3/11. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 6/29/12, 11/3/11, 10/3/11. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 6/29/11, 11/3/11, 10/3/11. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 6/29/12, 6/5/12, 11/3/11, 10/3/11. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 6/29/12, 6/5/12, 11/3/11, 10/3/11.

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to administer prescribed medications to seven of 16 residents (Residents R2, R3, R4, R6, R8, R9, and R14), placing these residents in Immediate Jeopardy due to danger of significant adverse consequences, and failed to administer prescribed medications to nine of 16 residents (Residents R1, R5, R7, R10, R11, R12, R13, R15, and R16). Findings include: The facility policy, "Medication errors and drug reactions" dated 4/01/10, indicated the nursing staff should make an entry of the incident on the resident's clinical record , report all errors to the attending physician and that the charge nurse should make a report of the incident, and deliver to the Director of Nursing. The clinical face sheet indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The March 2011, Medication Administration Record (MAR) indicated that the Humalog insulin was not administered as ordered to Resident R2 on 3/05/11 at 7:00 a.m., on 3/05/11, at 8:00 p.m., and on 3/06/11 at 7:00 a.m. During an interview on 4/20/11 at 11:00 a.m., Registered Nurse Employee E1 confirmed that Resident R2 did not receive the Humalog insulin as ordered on [DATE] at 7:00 a.m., and 8:00 p.m., or 3/06/11 at 7:00 a.m. The physician's history indicated Resident R3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].) every morning, [MEDICATION NAME] [MEDICATION]), 750 mg., twice daily, [MEDICATION NAME] (medication for low blood pressure)10 mg. three times daily, and [MEDICATION NAME] (medication used for the treatment of [REDACTED]. five times a day. The March 2011, MAR for Resident R3 indicated that the Aspirin was not administered on 3/19/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/18/11 at 8:00 p.m., or 3/19/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/18/11 at 8:00 p.m., 3/19/11 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., and [MEDICATION NAME] was not administered on 3/18/11 at 10:00 p.m., 3/19/11 at 8:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. The admission face sheet indicated Resident R4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 500 mg. every day, [MEDICATION NAME] (prevention of blood clots), 5,000 units every eight hours, [MEDICATION NAME] (antifungal medication) 500 mg. three times daily, [MEDICATION NAME] (medication to reduce organ rejection), 1 mg. every 12 hours. The March 2011, MAR for Resident R4 indicated [MEDICATION NAME] not administered on 3/04/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/04/11 at 12:00 a.m. or at 8:00 a.m., [MEDICATION NAME] was not administered on 3/04/11 at 8:00 a.m., or 3/05/11 at 8:00 a.m., and [MEDICATION NAME] was not administered on 3/04/11 at 8:00 a.m., or 3/05/11 at 8:00 a.m. The admission face sheet indicated Resident R6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The March 2011, MAR for Resident R6 indicated that [MEDICATION NAME] was not administered on 3/13/11 at 4:00 p.m., or on 3/14/11 at 12:00 a.m. The admission face sheet indicated Resident R8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. SQ every 24 hours, and Aspirin (for the prevention of blood clots), 81 mg., every morning. The March 2011, MAR for Resident R8 indicated that [MEDICATION NAME] was not administered on 3/15/11 at 8:00 a.m., and Aspirin was not administered from 3/15/11 through 3/21/11 (seven day period). The admission face sheet indicated Resident R9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The March 2011, MAR for Resident R9 indicated that the [MEDICATION NAME] was not administered until 3/04/11 (48 hours after scheduled administration). The admission face sheet indicated Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The March 2011, MAR for Resident R14 indicated that [MEDICATION NAME] was not administered on 3/26/11 at 8:00 a.m., or 8:00 p.m., and 3/27/11 at 8:00 p.m. The admission face sheet indicated Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]., four times daily, [MEDICATION NAME] (medication to treat high blood pressure), 3.125 mg. twice daily, Aspirin, 81 mg. daily, [MEDICATION NAME] (medication for cholesterol reduction) 160 mg. daily, [MEDICATION NAME] (medicaiton for stomach acid reduction), 20 mg. daily, [MEDICATION NAME] (medication for cholesterol reduction), 20 mg. daily, Requip (medication used for restless legs), three times daily, [MEDICATION NAME] (diuretic) 40 mg. daily, and [MEDICATION NAME] (medication for diabetic nerve pain) 400 mg. three times a day. The March 2011, MAR for Resident R1 indicated that [MEDICATION NAME] was not administered on 3/26/11 at 8:00 p.m., and 3/27/11 at 8:00 a.m. or 12:00 p.m., [MEDICATION NAME], 3.125 mg. was not administered on 3/27/11 at 8:00 a.m., Aspirin, 81 mg. was not administered on 3/27/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/27/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/27/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/26/11 at 5:00 p.m., Requip was not administered on 3/26/11 at 8:00 p.m., and 3/27/11 at 8:00 a.m. or 2:00 p.m., [MEDICATION NAME] was not administered on 3/27/11 at 8:00 a.m., and [MEDICATION NAME] was not administered on 3/27/11 at 8:00 a.m., or 2:00 p.m. The admission face sheet indicated Resident R5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, [MEDICATION NAME] (blood pressure medication), 2.5 mg. daily, and [MEDICATION NAME], 20 mg. twice daily. The March 2011, MAR for Resident R5 indicated that [MEDICATION NAME] was not administered on 3/28/11 at 6:00 p.m., or 3/29/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 3/29/11 at 8:00 a.m., and [MEDICATION NAME] 20 mg. was not administered on 3/29/11 at 8:00 a.m. The admission face sheet indicated Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, [MEDICATION NAME], 3.125 mg. twice daily, [MEDICATION NAME](antibiotic), 250 mg. twice daily. The March 2011, MAR for Resident R7 indicated that [MEDICATION NAME] was not administered on 3/31/11 at 6:00 p.m., [MEDICATION NAME] was not administered on 3/30/11 and 3/31/11 at 8:00 p.m., [MEDICATION NAME] not administered on 3/30/11 at 8:00 p.m. The admission face sheet indicated Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, and [MEDICATION NAME], 10/100 mg. at bedtime, and [MEDICATION NAME] (antianxiety medication) 10 mg. twice daily. The April 2011, MAR for Resident R10 indicated that [MEDICATION NAME] was not administered on 4/07/11 at 8:00 p.m., or 4/08/11 at 2:00 p.m., and [MEDICATION NAME] was not administered on 4/07/11 at 8:00 p.m. The admission face sheet indicated Resident R11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, and [MEDICATION NAME] (medication used for dementia), 10 mg. daily, [MEDICATION NAME] (medication for depression), 10 mg. daily, [MEDICATION NAME] (medication used for blood pressure), 10-160 mg. daily, and [MEDICATION NAME] (oral diabetic medication), 500 mg. twice daily. The April 2011, MAR for Resident R11 indicated that [MEDICATION NAME] was not administered on 4/01/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 4/01/11 at 8:00 a.m., [MEDICATION NAME] was not administered on 4/01/11 at 8:00 a.m., and [MEDICATION NAME] was not administered on 4/01/11 at 8:00 a.m. In addition, the [MEDICATION NAME] was not documented as administered on 4/6/11, 4/07/11, 4/09/11, 4/10/11, 4/12/11, 4/13/11, 4/14/11, 4/15/11, and 4/16/11. The admission face sheet indicated Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily. The April 2011, MAR for Resident R12 indicated that [MEDICATION NAME] was not administered on 4/21/11 at 8:00 p.m. The admission face sheet indicated Resident R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily. The April 2011, MAR for Resident R13 indicated that [MEDICATION NAME] was not administered from 4/01/11 through 4/07/11, a period of eight days. The admission face sheet indicated Resident R15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The April 2011, MAR for Resident R15 indicated that [MEDICATION NAME] was not administered on 4/18/11 at 10:00 p.m., which was the next scheduled administration time. The admission face sheet indicated Resident R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, [MEDICATION NAME], 80 mg. at bedtime, [MEDICATION NAME] (medication used for blood pressure), 10 mg. three times daily, [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]), 300 mg. at bedtime, and [MEDICATION NAME] (an [MEDICAL CONDITION] agent), 200 mg. twice daily. The March 2011, MAR for Resident R16 indicated that [MEDICATION NAME], and Acylovir were not administered on 3/26/11 at 8:00 p.m. During an interview on 4/20/11 at 12:30 p.m., the Director of Nursing (DON) confirmed that the [MEDICATION NAME] was not administered to Resident R13 during the period of 4/01/11 through 4/07/11. The DON also confirmed that Resident R13's [MEDICATION NAME] order was omitted on the April 2011, MAR and was also omitted from the April 2011, recapitulation of physician orders [REDACTED]. During an interview on 4/20/11 at 11:15 a.m., the DON confirmed that nursing staff failed to administer the above noted medications and that the nursing staff had not alerted the facility administration of the pattern of untimely acquisition and administration of medications from 3/01/11 to the present time. The facility failed to ensure that medications were acquired and administered in a timely manner resulting in significant and non-significant medication errors that posed a danger of significant adverse consequences to the residents, thus placing the residents in an Immediate Jeopardy situation.. Refer to F157, F425, and F490. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/16/11, 6/10/10, 7/9/09. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/16/11, 6/10/10, 10/7/09, 7/9/09. 29 Pa. Code 201.18(e)(1) Management. Previously cited 3/16/11. 28 Pa. Code 201.29(j) Resident rights. Previously cited 7/09/09. 28 Pa. Code 211.9(k) Pharmacy services. Previously cited 3/16/11, 7/9/09. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/16/11, 4/2/10, 7/9/09. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/16/11, 6/10/10, 7/9/09. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/16/11, 4/2/10, 10/7/09. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/16/11, 6/10/10, 4/2/10, 10/7/09, 7/9/09.

Based on review of facility policies, facility documents, and staff interviews, it was determined that the facility failed to maintain pharmaceutical services to obtain and administer prescribed medications on a timely basis for 16 of 16 residents reviewed (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16). Findings include: The facility Pharmacy Service Agreement for the period 1/01/11 until 1/01/12, indicated "the pharmacy will provide order processing and delivery services on an emergency basis, at any time." The facility pharmacy policy stated, "Medications and related products are received from the pharmacy on a timely basis." The clinical face sheet indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The March 2011, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During an interview on 4/20/11 at 11:00 a.m., Registered Nurse Employee E1 confirmed that Resident R2 did not receive Humalog insulin as ordered on [DATE] at 7:00 a.m. and 8:00 p.m., or 3/06/11 at 7:00 a.m. The physician's history note indicated Resident R3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].), every morning, Keppra (anti-seizure medication), 750 mg., twice daily, Proamatine (low blood pressure) 10 mg., three times daily, and Sinemet (medication used for the treatment of [REDACTED]., five times a day. The March 2011, MAR for Resident R3 indicated that the Aspirin was not administered on 3/19/11 at 8:00 a.m., Keppra was not administered on 3/18/11 at 8:00 p.m., or 3/19/11 at 8:00 a.m., Proamatine was not administered on 3/18/11 at 8:00 p.m., 3/19/11 at 8:00 a.m., 2:00 p.m., and 8:00 p.m., and Sinemet was not administered on 3/18/11 at 10:00 p.m., 3/19/11 at 8:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. The admission face sheet indicated Resident R4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 500 mg., every day, Heparin (medication for the prevention of blood clots), 5,000 units, every eight hours, Flagyl (antifungal) 500 mg. three times daily, Prograf (medication to reduce organ rejection), one mg., every 12 hours. The March 2011, MAR for Resident R4 indicated that Cipro was not administered on 3/04/11 at 8:00 a.m., Heparin was not administered on 3/04/11 at 12:00 a.m. or at 8:00 a.m., Flagyl was not administered on 3/04/11 at 8:00 a.m., or 3/05/11 at 8:00 a.m., and Prograf was not administered on 3/04/11 at 8:00 a.m., or 3/05/11 at 8:00 a.m. The admission face sheet indicated Resident R6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The March 2011, MAR for Resident R6 indicated that Heparin was not administered on 3/13/11 at 4:00 p.m., or on 3/14/11 at 12:00 a.m. The admission face sheet indicated Resident R8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]., SQ every 24 hours, and Aspirin, 81 mg., every morning. The March 2011, MAR for Resident R8 indicated that Lovenox was not administered on 3/15/11 at 8:00 a.m., and Aspirin was not administered from 3/15/11 through 3/21/11 (seven day period). The admission face sheet indicated Resident R9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The March 2011, MAR for Resident R9 indicated that the Duragesic patch was not administered until 3/04/11 (48 hours after scheduled administration). The admission face sheet indicated Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The March 2011, MAR for Resident R14 indicated that Heparin was not administered on 3/26/11 at 8:00 a.m., or 8:00 p.m., and 3/27/11 at 8:00 p.m. The admission face sheet indicated Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]., four times daily, Coreg, 3.125 mg. twice daily, Aspirin, 81 mg. daily, Fenofibrate (medication for cholesterol reduction), 160 mg. daily, Prilosec (medication for stomach acid reduction), 20 mg., daily, Zocor (medication for cholesterol reduction), 20 mg. daily, Requip (medication used for restless legs), three times daily, Lasix (diuretic) 40 mg. daily and Neurontin (medication for diabetic nerve pain), 400 mg. three times daily. The March 2011, MAR for Resident R1 indicated that Sinemet was not administered on 3/26/11 at 8:00 p.m., and 3/27/11 at 8:00 a.m. or 12:00 p.m., Coreg (medication to treat high blood pressure), 3.125 mg. was not administered on 3/27/11 at 8:00 a.m., Aspirin 81 mg. was not administered on 3/27/11 at 8:00 a.m., Fenofibrate was not administered on 3/27/11 at 8:00 a.m., Prilosec was not administered on 3/27/11 at 8:00 a.m, Zocor was not administered on 3/26/11 at 5:00 p.m., Requip was not administered on 3/26/11 at 8:00 p.m., and 3/27/11 at 8:00 a.m. or 2:00 p.m., Lasix was not administered on 3/27/11 at 8:00 a.m., and Neurontin was not administered on 3/27/11 at 8:00 a.m. or 2:00 p.m. The admission face sheet indicated Resident R5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, Lisinopril (blood pressure medication), 2.5 mg. daily. and Prilosec, 20 mg. twice daily. The March 2011, MAR for Resident R5 indicated that Coreg was not administered on 3/28/11 at 6:00 p.m., or 3/29/11 at 8:00 a.m., Lisinopril was not administered on 3/29/11 at 8:00 a.m., and Prilosec, 20 mg. was not administered on 3/29/11 at 8:00 a.m. The admission face sheet indicated Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, Coreg, 3.125 mg. twice daily, and Cipro (antibiotic), 250 mg. twice daily. The March 2011, MAR for Resident R7 indicated that Digoxin was not administered on 3/31/11 at 6:00 p.m., Coreg was not administered on 3/30/11 and 3/31/11 at 8:00 p.m., and Cipro was not administered on 3/30/11 at 8:00 p.m. The admission face sheet indicated Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, Sinemet, 10/100 mg. at bedtime, and Buspar (antianxiety medication), 10 mg. twice daily. The April 2011, MAR for Resident R10 indicated that Sinemet was not administered on 4/07/11 at 8:00 p.m., or 4/08/11 at 2:00 p.m., and Buspar was not administered on 4/07/11 at 8:00 p.m. The admission face sheet indicated Resident R11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, and Namenda (medication used for dementia), 10 mg. daily, Lexapro (medication used for depression), 10 mg. daily, Exforge (medication used for blood pressure), 10-160 mg. daily, and Metformin (oral diabetic medication), 500 mg. twice daily. The April 2011, MAR for Resident R11 indicated that Evista was not administered on 4/01/11 at 8:00 a.m., Namenda was not administered on 4/01/11 at 8:00 a.m., Lexapro was not administered on 4/01/11 at 8:00 a.m., and Exforge was not administered on 4/01/11 at 8:00 a.m. In addition, the Metformin was not documented as administered on 4/6/11, 4/07/11, 4/09/11, 4/10/11, 4/12/11, 4/13/11, 4/14/11, 4/15/11, and 4/16/11. The admission face sheet indicated Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily. The April 2011, MAR for Resident R12 indicated that Metformin was not administered on 4/21/11 at 8:00 p.m. The admission face sheet indicated Resident R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily. The April 2011, MAR for Resident R13 indicated that Aricept was not administered from 4/01/11 through 4/07/11, a period of seven days. The admission face sheet indicated Resident R15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The April 2011, MAR for Resident R15 indicated that Heparin was not administered on 4/18/11 at 10:00 p.m., which was the next scheduled administration time. Resident R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily, Zocor, 80 mg. at bedtime, Midodrine (medication used for blood pressure), 10 mg. three times daily, Neurontin (medication used to treat seizures), 300 mg. at bedtime, and Acyclovir (an antiviral agent), 200 mg. twice daily. The March 2011, MAR for Resident R16 indicated that Prilosec, Zocor, Midodrine, Neurontin, and Acylovir were not administered on 3/26/11 at 8:00 p.m. During an interview on 4/07/11 at 10:00 a.m., Registered Nurse (RN) Employee E1 and Licensed Practical Nurse (LPN) Employee E2 confirmed that the nursing staff had problems obtaining medication in a timely manner from the pharmacy since the facility changed pharmacies on 3/01/11. Employees E1 and E2 indicated that faxed medication orders don't get filled by the pharmacy even though they are faxed repeatedly and that pharmacy staff will say they didn't receive the fax. In addition, Employee E1 and E2 indicated the emergency medication supply boxes are too limited and that the supplies are used up quickly. During interviews on 4/20/11 at 1:15 p.m., RN Employee E3, LPN Employees E4, E5, and E6, confirmed problems with the pharmacy and stated that they had informed the administration of these issues. During an interview on 4/20/11 at 11:15 a.m., the Director Of Nursing (DON) confirmed that nursing staff failed to administer the above noted medications because they were not made available in a timely manner by the facility pharmacy. The DON confirmed that the nursing staff had informed the administration of ongoing problems with the delay in receiving requested medications from the pharmacy in a timely manner since 3/01/11. Refer to F 157, F333 and F490. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/16/11, 6/10/10, 7/9/09. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/16/11, 6/10/10, 10/7/09, 7/9/09. 28 Pa. Code 201.18(e)(1) Management. Previously cited 3/16/11. 28 Pa. Code 211.9(a)(1) Pharmacy services. Previously cited 3/16/11, 7/9/09. 28 Pa. Code 211.9(k) Pharmacy services. Previously cited 3/16/11, 7/9/09. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/16/11, 4/2/10, 7/9/09. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/16/11, 6/10/10, 7/9/09. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/16/11, 4/2/10, 10/7/09.

Based on review of clinical records, and facility and staff interviews, it was determined that the facility failed to provide adequate monitoring and supervision to prevent a fall which resulted in actual harm with injuries, for one of 28 residents (Resident R1). Findings include: The Minimum Data Set (MDS - periodic assessment of care needs) dated 2/19/11, indicated that Resident R1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also indicated that Resident R1 was severely cognitively impaired, confused to time and place, unable to make decisions, required assistance of two persons with bed mobility and transfers, required assistance of one person for locomotion on the unit; needed the assistance of one person for activities daily of living; and the resident had fallen within the last 30 days. The plan of care dated 3/9/11, indicated that Resident R1 was restless, resistive to care, had multiple falls, exhibited unpredictable behavior and should not be left in room by self due to falls. Review of the Monthly Summary reports dated 7/15/10, through 2/15/11, revealed that Resident R1 wandered with no purpose while in a wheelchair. The Annual Restraint Assessment form dated 9/13/10, identified Resident R1 with wandering behavior, an unstable gait, and high risk for falls. A signed statement by Occupational Therapist Employee E1 dated 3/13/11, indicated that around 9:15 a.m., "the left wing nurse gave me keys to open the offices, I went in to get a fax and pulled door shut behind me." Review of the facility's Notification of Occurrence form dated 3/13/11, at 10:15 a.m., stated, "resident made way through the office and office corridor, through side door and attempted down 2 cement steps in wheelchair, tipped over and hit right side of forehead on ramp sustaining skin tears and a laceration to right side of forehead including 2 scrapes to the right knee." The resident was transferred to the emergency roiagnom on [DATE], with a right forehead laceration that required several sutures to close. The clinical record lacked evidence that monitoring or supervision was in place prior to Resident R1's fall. Review of the facility event report dated 3/14/11, at 10:02 a.m., stated that on Sunday, 3/13/11, Resident R1, "who does not know how to turn the doorknob and could not have entered into that area (office) unless the door was left open, went through the front office door which is locked on weekends and is not key padded, continued through the office area (where two additional doors are located) traveled the length of the corridor and pushed open (and exited) the exit door." During an interview on 03/15/11, at 1:30 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to supervise Resident R1 who wandered throughout the facility to ensure resident safety, which resulted in a serious injury. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited 6/10/10 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/10/10 28 Pa. Code 211.12(d)(3) Nursing services.