Every finding on record at Quality Life Services - Sugar Creek

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to ensure foods were not held in the danger zone temperatures which are between 41 degrees Fahrenheit (F) and 135 degree F and properly store food products.Findings: Review of the facility's Food Storage policy dated 2/12/26, revealed sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is dated as it is placed on the shelves, and old stock is always used first. Date marking to indicate the date by which a ready-to-eat, potentially hazardous food should confused or discarded will be visible on all high risk food. Foods with a manufacturer use by date, must be used or discarded by the stamped date. During tray line observation of the main designated kitchen on 6/3/26, at 11:20 a.m. the following was observed:-The tomato soup was held at 89F. During an interview on 6/3/26, at 11:21 a.m. Dietary Aide, Employee E9 confirmed the tomato soup was being held at 89F. During an interview on 6/3/26, at 11:22 a.m. Director of Dietary, Employee E8 confirmed the facility failed to ensure foods were not held in the danger zone temperatures which are between 41 degree F and 135 degree F. During an observation on 6/4/26, at 10:45 a.m. of the Activity Kitchenette the following was observed: -(1) 10 oz can of pumpkin expired 4/19 -(1) 8ounce Hershey's Coca Powder Expired 8/23 -(1) box of Jell-O lime flavored expired 11/22/24-(1) Box of Jell-O orange flavored expired 2/23/25 -(1) 14 oz Pumpkin Pie Mix Expired 10/25 -(1) bottle of balsamic vinegar Expired 10/7/25 -(1) Container 8 oz Corn Meal Expired 3/7/26 Interview on 6/4/26, at 10:46 a.m. the Director of Maintenance, Employee E7 confirmed the above observations and the facility failed to properly store food products and ensure food products were discarded prior to their expiration date. During an interview on 6/4/26, at 11:16 a.m., the Nursing Home Administrator confirmed that the facility failed to properly store food products and ensure foods were not held in the danger zone temperatures which are between 41 degrees Fahrenheit (F) and 135 degree F. 28 Pa. Code: 201.18(b)(1) Management28 Pa. Code: 211.6(c) Dietary services28 Pa. Code: 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement person-centered comprehensive care plans to meet resident care needs for three of five residents (Resident R10, R17, and R98). Findings include: Review of facility policy Behavior Monitoring dated 2/16/26, indicated the licensed nursing staff will observe resident behaviors and provide documentation regarding: what behaviors are observed and the number of episodes that occur each shift, what non-pharmacological interventions are initiated to prevent or respond to the behaviors, and the effectiveness of the non-pharmacological interventions utilized. Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of anxiety, depression, and 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). Review of Resident R10's care plan dated 4/6/26, indicated the resident has the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, including becoming agitated towards staff and cursing at staff when agitation. Interventions include analyze key times, places, circumstances, triggers, and what de-escalates my behavior and document. Monitor my behavior and document the success of attempted interventions. Review of Resident R10's comprehensive care plan dated 5/29/26, indicated the resident has a behavior problem related to raising the height of my bed as high as it will go. I have been known to make false accusations against staff and family. Interventions include monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of Resident R10's behavior monitoring documentation indicated, behavior symptoms known to resident and planned interventions; flat affect, difficulty falling and staying asleep: calm environment, encourage to participate in activities and therapy. Food/fluid, TV staff to document behaviors and response to interventions each shift and as needed. Resident R10's behavior documentation failed to include the resident's behaviors of cursing, making false accusations against staff and family, and raising their bed to the highest level. During an interview on 6/3/26, at 1:41 p.m. Social Worker Employee E2 confirmed the facility failed to implement Resident R10's person-centered comprehensive care plan by failing to ensure staff are monitoring and documenting identified behaviors each shift. Review of the clinical record Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's MDS dated [DATE], indicated diagnosis of Alzheimer's disease (brain condition that slowly damages your memory, thinking, learning and organizing skills) and mild cognitive impairment (typical thinking skills and dementia). During a resident group on 6/3/26, at 11:00 a.m. residents reported that Resident R17 has a behavior of putting his hands down his pants. Residents agreed that he does this behavior consistently and in public, during activities, when he sits next to other residents (to include female residents), etc. Residents stated staff were aware, but this behavior has been on-going since his admit to the facility. During an interview on 6/3/26, with three employee's (Nurse Aide (NA) Employee E4, NA Employee E19, and Licensed Practical Nurse (LPN) Employee E20) confirmed that Resident R17 has the behavior of sticking his hands down his pants in public. It can occur when he is walking down the hallway, sitting in an activity, etc., and it is consistent. That when they tell him to stop he does but he may do it again in a 5 minutes or an hour and that they were unaware of any place to document or monitor his behavior. Review of Resident R17's comprehensive care plan dated 5/28/26, indicated: behavior problem related to putting my hand down the front of my pants. Assist me to develop more appropriate methods of coping and interacting. Educate me my family and caregivers on successful coping and interaction strategies. Ensure resident is wearing underwear under clothing. If observed not wearing underwear, remind/assist me in dressing. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time, day, persons involved and situations. Document behavior and potential causes. Review of Resident R17 behavior documentation for May 2026 and June 2026 failed to include documentation of monitoring of the above behaviors. During an interview on 6/3/26, at 1:42 p.m. Social Worker Employee E2 confirmed that the facility failed to implement Resident R17's person centered- comprehensive care plan by failing to ensure staff are monitoring and documenting identified behaviors each shift. Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE]. Review of Resident R98's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of Resident R98's behavior monitoring documentation indicated, behavior symptoms known to resident and planned interventions: yelling without provocation, restlessness, transfer without assistance; common area for close supervision, 1:1, Tv, food/fluid, toileting. Review of Resident R98's behavior documentation for May 2026 revealed the resident displayed known behaviors during 36/94 observations. Review of Resident R98's comprehensive care plan failed to include the development of person-centered goals and interventions related to the resident's known behaviors. During an interview on 6/5/26, at 10:25 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed that the facility failed to develop a person-centered comprehensive care plan to meet resident care needs for Resident R98. 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)(3)(5) Nursing services.

Based on review of facility policy, job descriptions, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services for three of four residents reviewed (Residents R10, R15, and R17). Findings include: Review of the Social Work Director job description indicated the purpose of this position is to coordinate internal and external social services counseling and education services. Review of the Psychiatric Mental Health Nurse Practitioner (PMHNP/CRNP) job description indicated the PMHNP provides comprehensive mental health care needs to residents across the care continuum. The CRNP (Certified Registered Nurse Practitioner) will assess, diagnose, and manage psychiatric and mental health conditions using evidence-based treatment modalities including psychotherapy and psychopharmacology. Key responsibilities include provide psychotherapy or supportive counseling as appropriate. Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of anxiety, depression, and 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). Review of Resident R10's clinical record from December 2025 through May 2026 revealed the following behavior documentation: 12/11/25: This writer was approached by sister, who was visibly upset. Sister stated that she was told by resident to get the F*** out. Sister told this writer she was leaving. That she did not have to put up with his abuse. He lived with her and she will not tolerate his abuse anymore. She stated that she left his room but he did not have his call bell and she was not going back in there. This writer stated they would get the call bell and give it to the resident. This writer went into the room, got his call bell and clipped it to his shirt. This writer stated to the resident, here is your call bell clipped to your shirt. The resident then began to curse at this writer. This writer told resident that they were leaving the room now. Resident then said a few more curse words and then said no more. 1/20/26: Resident was swearing at staff during a transfer via hoyer lift. Resident was instructed to cross his arms when he was in the lift so he did not hurt his arms and he would not. When staff tried to help him cross his arms he cursed at staff. 3/16/26: Resident observed with bed a high position. Resident was educated numerous times that it was a danger to have bed that high up but resident continues to raise bed to a high position. 3/18/26: Resident rang call light to ask CNA (Certified Nurse Aide) to get him up for bingo. CNA told resident that as soon as the hoyer lift and another staff member was available she would get him into his wheelchair. Resident began screaming at CNA get the fuck out of here you fucking asshole CNA removed herself from the room after telling the resident it was not appropriate and she would return when the hoyer lift was available as resident was unable to be consoled at that time. Resident had call light within reach. 2 CNAs went in and assisted resident via hoyer lift into wheelchair, during care resident was yelling at staff, one of the CNAs told resident that they were there to help, and to please stop yelling at them. Resident calmed down and was assisted down to bingo without further behaviors at this time. 4/4/26: Writer alerted at 0710 (7:10 a.m.) by nightshift CNA that resident was yelling at her to get his morning medications. Writer had just received change of shift report from nightshift, got resident's medications and asked the other LPN (Licensed Practical Nurse) on the unit to go in with this writer due to his increased behaviors. Writer and other LPN knocked and entered the resident's room, resident started screaming at staff you fucking people! writer explained that writer and LPN just came onto shift, writer realizes he is angry about nightshift not getting meds but i am here with them now. Resident continued with I don't fucking care. I am so fucking sick of you fucking people. I shouldn't be here Writer told the resident I do not appreciate the way you are talking to me, if you are going to continue, I am leaving the room and you can ring when you are cooled off resident continued screaming and cussing at writer, writer was turning to walk out of the room and resident said I'll take them resident took medications, writer asked for a finger to obtain blood glucose reading, resident put middle finger up in writer's face and said how about this one? I'm fucking pissed. This is fucking bullshit. I hate it here. I hate you people. I hate it, I shouldn't be here Writer obtained blood glucose reading and ensured call light was within reach. Resident then said, everyone just leave me the fuck alone, okay? writer explained we were there to assist him and to ring if he needs anything. 4/5/26: Resident in bed with control and put his bed high up in the air. Writer and CNA asked resident to lower his bed to a safe level. Resident stated oh fuck off and leave me the fuck alone. Resident educated on risk of falling and injury when bed is that high, resident stated No. I don't fucking care. What do you people not get? Leave me the fuck alone. Writer and CNA ensured call light within reach clipped to the resident's shirt prior to exiting the resident's room. 4/13/26: Resident yelling at staff and dumped breakfast tray this AM resident educated related he acknowledged understanding. 4/13/26: Resident yelling cuss words in common area at staff and visitors; resident taken back to room. 5/29/26: Resident has been yelling at staff and is refusing to eat out of anger. Resident refused to eat his lunch. Resident received fall mats and has been instructed to keep his bed low to the ground to prevent falls. Resident previously would keep his bed raised in the air in the highest position and would make jokes about attempting to roll out of bed. Resident is angry that he can't keep his bed in the air the way he likes it. Resident was educated that we take these precautions to keep him safe. Resident continues to yell at staff. RN (Registered Nurse) notified. Plan of care continues. 5/29/26: Resident requested to speak with SW (Social Worker). SW went to resident's room per his request accompanied by CED (Customer Experienced Director). Resident voiced he was angered regarding keeping bed in low position and having fall mats in room. SW asked if resident understood why staff were enacting these precautions. Resident stated yeah, because the head nurse thinks she knows everything. Well she don't know me. I want to know who said I was putting the bed up? SW discussed at length need for keeping resident safe at all times. Resident stated you don't know what you're talking about. I like my bed the way I like it. Offered to assist resident in adjusting bed at this time. Resident became agitated and started yelling at CED and SW that you guys don't know how to do it. So stop acting like you do and just get out. SW and CED stated to resident would leave room per request, and if needing any further assistance to press call light for hall staff to assist. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E17 stated, Patient was seen today due to being a new resident, history to anxiety/depression/PTSD and recent subdual hemorrhage. Patient was sitting at a table eating his breakfast. Patient had latent responses. Often thinking hard before responding to me. Patient reports he is sleeping good and has a good appetite. Patient did not understand the question how is your mood? He just looked at me and mumbled words. Patient repots some depression in that he feels sad at times. Patient is already on the maximum dose of lexapro (a medication used to treat depression). Patient denies anxiety and psychosis. Plan is to keep all psych medications the same and follow up in 1 month. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E17 stated, Patient was seen today due to increased depression and poor appetite. Patient states he doesn't have much of an appetite. Patient reports sleeping good. Patient reports depression but states he doesn't want any medications or medication changes. Patient denies anxiety. Patient denies psychosis. Plan is to keep all psych medications the same and follow up in 1 month. Review of a Medical assessment dated [DATE], completed by PMHNP Employee E17 stated, Patient was seen today for a follow up. Patient was laying in his bed. Patient was pleasant. Patient has trouble articulating words and it takes a while for him to speak and get his point across. Patient reports I don't know when asked how his mood is. Patient reports good for appetite and sleep. Patient reports some depression I have been sad, lonely and depressed for seven months now. Patient denies anxiety. Patient denies psychosis. Plan is to keep all psych medications the same and follow up in 1 month. Review of clinical record from November 2025 to May 2026 failed to show additional therapy services. During an interview on 6/3/26, at 1:31 p.m. Social Worker Employee E2 stated, PMHNP Employee E17 does medication management. We currently do not have a provider for counseling. We had one previously, but they had no psychologists available, so we are to utilize PMHNP Employee E17 for mental health concerns. We currently do not have any residents going to outpatient mental health services. We haven't had a provider for a few months now. During an interview on 6/3/26, at 1:41 p.m. Social Worker Employee E2 stated, We use VA (Veterans Affairs) to coordinate transportation services for Resident R10. We should be coordinating services with them so he can see outpatient psych services. We could also schedule a telehealth appointment. During this interview, Social Worker Employee E2 confirmed that the facility failed to provide sufficient and timely social services to Resident R10. 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 dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of Resident R15's physician order dated 1/6/26, through 1/13/26, indicated to administer Zyprexa (an antipsychotic medication used to treat mental illnesses) 2.5 milligrams at bedtime for schizophrenia (a chronic and severe brain disorder that affects a person's ability to interpret reality, often diagnosed in late teens). Review of Resident R15's current diagnosis list, a new diagnosis of schizophrenia was given on 1/6/26, the day the antipsychotic medication was ordered. Review of Resident R15's clinical record on 6/4/26, at 9:41 a.m. failed to reveal that other interventions were completed to rule out an acute change of condition prior to implementation of an antipsychotic medication. Review of facility provided documentation labeled Medical Assessment completed on 1/5/26, indicated plan is to diagnose patient with schizophrenia and start her on Zyprexa 2.5 milligrams twice a day for hallucinations and delusions and was completed by PMHNP Employee E17. During an interview on 6/4/26, at 11:19 a.m. Social Worker Employee E2 stated that other tests should have been completed such as urinalysis (to check for a urinary tract infection) and blood work prior to a provider ordering new mind altering medications and confirmed that Resident R15 failed to have medical testing done prior to Zyprexa medication ordered and a new diagnosis of schizophrenia given to Resident R15. Review of the clinical record Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's MDS dated [DATE], indicated diagnosis of Alzheimer's disease (brain condition that slowly damages your memory, thinking, learning and organizing skills) and mild cognitive impairment (typical thinking skills and dementia). During a resident group on 6/3/26, at 11:00 a.m. residents reported that Resident R17 has a behavior of putting his hands down his pants. Residents agreed that he does this behavior consistently and in public, during activities, when he sits next to other residents (to include female residents), etc. Residents gave example that Resident R17 had been putting his hands down his pants this past weekend at an activity was re-directed and this upset the other residents during the activity. Residents stated staff were aware, but this behavior has been on-going since his admit to the facility. Review of Resident R17's clinical record indicated: Social service note 11/10/2025: Initial care conference held this AM with resident's brother and his wife. Discussed behaviors and cognitive status with family. They requested eval by Valley Psychology to determine cognitive status r/t dx of Alzheimer's and Lewy Body Dementia to determine medical/financial decision-making ability. Reviewed referral would be sent per their request for consult. Reviewed resident was also on rounds for psych CRNP this AM as well. Family voiced appreciation for discussion. Following, SW sent referral for eval to Psychology. Health Status note: 11/11/2025: This writer spoke with resident's brother, in regard to medication changes. Resident R17's brother voiced understanding. Resident R17's brother inquired about giving resident Depo-Provera to control his urges. This writer stated that would be a decision for the MD to make but will inquire with MD if it would be a possibility. Resident R17's brother voiced understanding. Clinician order note: 11/25/2025: This order is outside of the recommended dose or frequency. Depo-Provera Intramuscular Suspension 150 MG/ML (Medroxyprogesterone Acetate (Contraceptive)) Inject 1 ml intramuscularly in the morning starting on the 28th and ending on the 28th every month for Unspecified Sexual Dysfunction - The dosing regimen of 1 mL monthly exceeds the usual dosing regimen of 0.9844 mL every 92 days to 1 mL every 90 days. - The frequency of monthly exceeds the usual frequency of every 92 days to every 90 days. Health Status note: 11/25/2025: Called Resident R17's brother and spoke with him in regard to the Depo-Provera shot. Resident R17's brother voiced understanding and was pleased that Resident R17 will be receiving the shot. Medical assessment note: 4/27/2025: Resident R17 was seen for putting his hands down his pants and upsets other residents. Resident R17 was in his room sitting in a chair. Resident R17 reports I got my Depo shot today, what does that do?. Resident R17 was educated on the purpose of the shot and Resident R17 reports it works. Resident R17 was instructed to stop putting his hands down his pants by other residents. During an interview on 6/3/26, with three employee's (NA Employee E4, NA Employee E19, and LPN Employee E20) confirmed that Resident R17 has the behavior of sticking his hands down his pants in public, it can occur when he is walking down the hallway, sitting in an activity, etc., and it is consistent. That when they tell him to stop, he does but he may do it again in 5 minutes or an hour and that they were unaware of any place to document or monitor his behavior. During an interview on 6/3/26, at 1:02 p.m. Activity Coordinator Employee E21, confirmed that Resident R17 has the behavior of sticking his hands down his pants and has done this during activities, and other residents have stated they are uncomfortable with this. Review of clinical record from January 2026 to June 2026 failed to show additional therapy services. During an interview on 6/3/26, at 1:31 p.m. Social Worker Employee E2 stated, PMHNP Employee E17 does medication management. We currently do not have a provider for counseling. We had one previously, but they had no psychologists available, so we are to utilize PMHNP Employee E17 for mental health concerns. We currently do not have any residents going to outpatient mental health services. We haven't had a provider for a few months now. During an interview on 6/3/26, at 1:33 p.m. Social Worker Employee E2 confirmed that the facility failed to provide sufficient and timely social services (counseling/therapy) for a known behavior for Resident R17. 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 policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence medication regimen reviews (MRRs) were reviewed by the resident's attending physician monthly for three of five residents (Residents R8, R56, and R98).Findings include: Review of facility policy Medication Regimen Review dated 2/16/26, 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 revealed Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/23/26, indicated diagnoses of high blood pressure, muscle weakness, and Gastro-Esophageal Reflux Disease (GERD - a chronic condition where stomach acid flows back into the esophagus). Review of Resident R8's MRR dated 1/31/26, indicated the following recommendation from pharmacist to physician:Resident is prescribed a PRN (as needed) order for Omeprazole (a medication used to treat GERD) 20 mg (milligrams) tablets. Please consider discontinuing the PRN order for Omeprazole, and ordering PRN Calcium Carbonate (500 mg - 750 mg) tablets: 2 tablets every 6 hours, as needed for treatment of GERD symptoms. Review of Resident R8's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/31/26. On 2/3/26, a facility Certified Registered Nurse Practitioner (CRNP) addressed the MRR, stating, Other, has not used, d/c (discontinue) Omeprazole. Review of the clinical record revealed Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS dated [DATE], indicated diagnoses of depression, Bipolar disorder (a mental condition marked by alternating periods of elation and depression), and Schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms).t Review of Resident R56's MRR dated 4/20/26, indicated the following recommendation from pharmacist to physician:Please consider tapering the antipsychotic order for Olanzapine (a medication used to treat mood disorders) 10 mg to 7.5 mg (daily each morning) x 7 days, then taper further to 5 mg (daily each morning) x 7 days, then discontinue. On day 8 of taper (1st day of 5 mg Olanzapine dose), consider starting Quetiapine 12.5 mg daily each morning, then reassess treatment after 14 days (at 7 days post-discontinuation of Olanzapine). Resident has experienced increased incidence of hallucinations since starting Olanzapine, with notable increase after the dose was changed from 7.5 mg to 10 mg, on 3/31/26. Review of Resident R56's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 4/20/26. On 4/27/26, a psychiatric CRNP addressed the MRR, stating, Disagree: monitor current mental health recent med changes. Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE]. Review of Resident R98's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of Resident R98's MRR dated 2/28/26, indicated the following recommendation from pharmacist to physician:Resident is prescribed a routine order for Ativan 0.5 mg (three times daily) for treatment of anxiety disorder. Prescribed PRN Ativan for treatment of resident's anxiety started on 12/8/25 and the PRN order had minimal use. Please consider decreasing the currently prescribed Ativan 0.5 mg dose to 0.25 mg. Please also consider changing the regimen back to a PRN order, due to Ativan administration history and resident's history of falls. Review of Resident R98's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 2/28/26. On 3/6/26, a facility CRNP addressed the MRR, stating, Disagree with no additional explanation provided. During an interview on 6/4/26, at 2:30 p.m. the Director of Nursing confirmed that the monthly medication regimen reviews were addressed by the facility and Psych services CRNPs and not the resident's attending physician for Residents R8, R56, and R98. 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 clinical record review, facility policy, and staff interviews, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of three residents (Resident R9 and R15). Findings include: Review of facility Antipsychotic Medication Consent Form policy dated 2/16/26, indicated it is the philosophy of this home that in cooperation with our elders, we will create and maintain an environment that fosters the minimal use of antipsychotic medications. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE], and re-admitted on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of resident needs) dated 4/13/26, indicated diagnoses of Anxiety disorder ( group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation) Depression (mood disorder that causes persistent feeling of sadness and loss of interest) , and Bipolar disorder (mental health condition that causes extreme mood swings). Review of physician order dated 12/22/25, indicated to administer: Risperdal oral tablet 0.5mg (risperidone - an antipsychotic medication) give 1 tablet by mouth two times a day for schizoaffective disorder, depressive type. Review of the admit sheet indicated a new diagnosis of schizoaffective disorder ( schizoaffective disorder - is a serious mental health condition characterized primarily by symptoms of schizophrenia. Schizoaffective disorder can be difficult to diagnosis because it has symptoms of both schizophrenia and either depression or bipolar disorder. To be diagnosed with schizoaffective disorder a person must have the following symptoms: A period during which there is a major mood disorder, either depression or mania, that occurs at the same time that symptoms of schizophrenia are present. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode) dated 11/24/25, - one year after admit. Review of Resident R9's clinical record on 6/4/26, at 11:53 a.m. failed to reveal that other interventions were completed to rule out an acute change of condition prior to implementation of an antipsychotic During an interview on 6/4/26, at 1:28 p.m. Director of Nursing confirmed that the facility failed to provide documentation that the medication regimen were free from potentially unnecessary medications for Resident R9. 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 dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of Resident R15's physician order dated 5/12/26, through 11/12/26, indicated to administer Ativan (a psychotropic medication used to treat anxiety) 0.5 milligrams every 12 hours by mouth as needed for anxiety for six months. Review of Resident R15's physician order dated 1/6/26, through 1/13/26, indicated to administer Zyprexa (an antipsychotic medication used to treat mental illnesses) 2.5 milligrams at bedtime for schizophrenia (a chronic and severe brain disorder that affects a person's ability to interpret reality, often diagnosed in late teens). Review of Resident R15's current diagnosis list, a new diagnosis of schizophrenia was given on 1/6/26, the day the antipsychotic medication was ordered. Review of Resident R15's clinical record on 6/4/26, at 9:41 a.m. failed to reveal that other interventions were completed to rule out an acute change of condition prior to implementation of an antipsychotic medication. During an interview on 6/4/26, at 11:19 a.m. Social Worker Employee E2 stated that other tests should have been completed such as urinalysis (to check for a urinary tract infection) and blood work prior to a provider ordering new mind altering medications and confirmed that Resident R15 failed to have medical testing done prior to Zyprexa medication ordered and a new diagnosis of schizophrenia given to Resident R15. During an interview on 6/4/26, at 11:29 a.m. the Director of Nursing confirmed that Resident R15 was ordered Ativan for six months and the clinical record failed to provide a rationale as to why the medication was ordered past 14 days and confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medications for Resident R15. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies

Based on review of facility policy, clinical record review, staff interviews, and observations it was determined that the facility failed to provide supervision with meals as ordered for one of three residents (Resident R6). Findings include: Review of the facility policy Restorative Nursing dated 2/16/26, indicated restorative care is an ongoing process, provided by all staff at all times for resident. Formal Restorative Nursing Programs will be initiated for residents who demonstrate a need for this service. Review of the facility policy Physician Orders dated 2/16/26, indicated 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 facility policy Activities of Daily Living (ADL) dated 2/16/26, indicated a program of ADL is provided for residents. A program of assistance is implemented. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/8/26, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety. Review of Resident R6's physician order dated 12/2/25, indicated staff to have all foods cut into small bite size pieces when setting up resident for meals, resident to be out of bed for meals and supervised by staff. Review of Resident R6's care plan dated 10/5/2023, indicated the resident has an ADL self-performance deficit related to limited mobility. Interventions include staff having all foods cut into small bite size pieces when setting up resident at meals times, resident to be out of bed for meals, and supervised by staff. During an observation on 6/2/25, at 12:35 p.m. Resident R6 was observed sitting in bed while being served lunch. Nurse Aide Employee E4 set lunch tray up and cut up food for Resident R6 and then left the room. Resident R6 failed to be out of bed for lunch and was not being supervised for lunch. During an interview on 6/2/25, at 12:47 p.m. Licensed Practical Nurse (LPN) Employee E5 stated restorative dining is to promote independence and offer assistance to residents. LPN Employee E5 confirmed that Resident R6 should have been out of bed and should have been supervised during lunch while eating in the room, per physician's orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on review of facility policy, clinical records, staff and resident interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for one of five residents (R8).Findings Include: Review of the RESmart CPAP and Auto-CPAP User Manual dated 8/3/16, revealed it is recommended that the air filter be changed every 30 days. Remove the filter cap by gently pressing on its bottom. Remove the foam filter by gently pulling around the edges of the filter. Remove filter and replace with blue side facing out. Replace filter cap so that the small opening on the cap is facing down. Insert the cap's tabs into the filter area opening. Opering a RESmart CPAP and Auto-CPAP with a dirty filter may keep the system from working properly and may cause damage to the device. Review of the facility CPAP/BIPAP policy dated 2/12/26, revealed the CPAP will be set up and monitored by a licensed nurse or respiratory therapist, as appropriate. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE], with diagnoses of dysphagia (difficulty swallowing), morbid obesity, and depression. Review of Resident R46's care plan dated 10/16/25, revealed the resident had altered respiratory status and difficulty breathing related to sleep apnea, shortness of breath and uses a C-Pap. A further review of the care plan failed to include an intervention to change the CPAP's filter. Review of Resident R46's physician order dated 12/5/25, revealed the resident utilizes the Resmed Airsense 10 CPAP Settings: 4-20cm h2o, every evening and night shift. Review of Resident R46's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/23/26, indicated diagnoses were current. Section O- Special Treatments, Procedures, and Programs revealed the resident required non-invasive mechanical ventilation while a resident. During an interview on 6/3/26, at 1:02 p.m. Resident R46 indicated the facility does not clean his CPAP machine or change the filter. Resident R46 stated he has been using the CPAP for 20 years and he can't sleep without it. During an observation on 6/3/26, at 1:03 p.m. Resident R46's CPAP filter was observed to be unclean with built up fuzzy white debris visualized on it. During an interview on 6/3/26, at 1:06 p.m. Hospitality Aide, Employee E11 confirmed Resident R46's CPAP filter was unclean. During an interview on 6/3/26, at 1:09 p.m. Licensed Practical Nurse, Employee E12 confirmed Resident R46's CPAP filter was unclean with built up debris visualized on the filter. LPN, Employee E12 stated Resident R46's CPAP filter should be cleaned once a week. During an interview on 6/3/26, at 1:12 p.m. the Nursing Home Administrator confirmed the facility failed to provide appropriate respiratory care for one of five residents (Resident R46). 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 with dementia receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of three residents reviewed (Resident R15), and failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident R98). Findings include: Review of facility policy Behavior Monitoring dated 2/16/26, indicated the licensed nursing staff will observe resident behaviors and provide documentation regarding: what behaviors are observed and the number of episodes that occur each shift, what non-pharmacological interventions are initiated to prevent or respond to the behaviors, and the effectiveness of the non-pharmacological interventions utilized. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/5/26, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of Resident R15's physician order dated 1/6/26, through 1/13/26, indicated to administer Zyprexa (an antipsychotic medication used to treat mental illnesses) 2.5 milligrams at bedtime for schizophrenia (a chronic and severe brain disorder that affects a person's ability to interpret reality, often diagnosed in late teens). Review of Resident R15's current diagnosis list, a new diagnosis of schizophrenia was given on 1/6/26, the day the antipsychotic medication was ordered. Review of Resident R15's clinical record on 6/4/26, at 9:41 a.m. failed to reveal that other interventions were completed to rule out an acute change of condition prior to implementation of an antipsychotic medication. Review of facility provided documentation labeled Medical Assessment completed on 1/5/26, indicated plan is to diagnose patient with schizophrenia and start her on Zyprexa 2.5 milligrams twice a day for hallucinations and delusions and was completed by Psychiatric Mental Health Nurse Practitioner (PMHNP) Employee E17. During an interview on 6/4/26, at 11:19 a.m. Social Worker Employee E2 stated that other tests should have been completed such as urinalysis (to check for a urinary tract infection) and blood work prior to a provider ordering new mind altering medications and confirmed that Resident R15 failed to have medical testing done prior to Zyprexa medication ordered and a new diagnosis of schizophrenia given to Resident R15 who is diagnosed with Dementia. Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE]. Review of Resident R98's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of Resident R98's active diagnosis list indicated the resident received a diagnosis of dementia in other diseases classified elsewhere, mild, with agitation on 5/11/26. Review of Resident R98's care plan on 6/3/26, failed to indicate the facility had developed and implemented an individualized person-centered care plan to address Resident R98's dementia and cognitive loss. During an interview on 6/5/26, at 10:25 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss for Resident R98. 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)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of three treatment carts (Willow Hall Treatment Cart).Findings include: Review of the facility policy Administering Medications last reviewed 1/6 /26, indicated during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. When opening a multi-dose container, the date opened shall be recorded on the container. Review of the facility policy Storage of Medications last reviewed 1/6/26, indicated the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments containing drugs and biologicals shall be locked when not in use. Medications must be stored separately from food and must be labeled accordingly. During an observation completed on 6/3/26, at 12:59 p.m. the [NAME] treatment cart was sitting in the hallway near the nursing station. The treatment cart was unlocked and unattended. During an interview completed on 6/3/26, 1:02 a.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the treatment cart was left unlocked and unattended. During an interview on 6/3/26, at 1:12 p.m. the Nursing Home Administrator confirmed the facility failed to properly secure a treatment cart while not in use for one of three treatment carts (Willow Hall Treatment Cart). 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 facility policy review, medical literature review, clinical record reviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk which resulted in an Immediate Jeopardy situation for 40 of 107 residents.Findings include: Review of facility policy Dysphagia (difficulty swallowing) Diets dated 2/16/26, indicated the following: Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food [storing food in cheeks, gums, without swallowing], inability to manipulate food in the mouth, wet gurgly voice, etc.) will be referred to the Speech Therapist (ST) for evaluation of dysphagia.The ST will evaluate the resident. Once a diagnosis has been made, the ST will work with the Registered Dietitian (RD) or designee to make appropriate recommendations to the physician for proper food and fluid consistency. Nursing care partners will notify the culinary director of needed consistency changes using the appropriate notification. The culinary department will be responsible for preparing and serving the diet and fluid consistency as ordered. Individuals needing a change in diet consistency may be placed on a mechanically altered diet. Diets should be adjusted to meet individual needs. For example, if the individual has difficulty chewing meat only, the meat may be ground or pureed, and other foods may be of regular consistency.Care will be taken to serve foods and fluids as ordered on the consistency altered diets and fluids. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework, revised July 2019, provides definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia, which include the following descriptions: Level 7 Easy to Chew foods must be able to break food apart easily with the side of a fork or spoon. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape.Level 5 Minced and Moist meats should be finely minced or chopped. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excess. Use slot between fork prongs (4 millimeters) to determine whether minced pieces are the correct or incorrect size. Food should be soft enough to squash easily with fork or spoon. Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm or sticky.Level 3 Moderately thick liquids should drip slowly or in dollops/strands through the slots of a fork. When a fork is pressed on the surface of Level 3 Moderately thick liquids, the tines/prongs of a fork do not leave a clear pattern on the surface. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/21/25, indicated diagnoses of high blood pressure, malnutrition (lack of proper nutrition), and muscle wasting. Review of Resident R1's clinical record revealed a progress note from Speech Therapy dated 10/4/25, that indicated that resident was seen for treatment of dysphagia. Review of Resident R1's clinical record revealed a physician's order date 11/11/25, to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction. Review of documentation provided by the facility dated 2/26/26, stated the following: Resident R1's 's daughter, immediately alerted nursing staff that the resident appeared to be choking. LPN (licensed practical nurse) and RN (registered nurse) were present outside the room at the medication cart and responded immediately. Upon entering the room, the resident was observed choking and unable to effectively clear food from the airway. The Heimlich maneuver (a lifesaving technique used to dislodge food or objects from a choking person's airway by forcing air up from the lungs) was immediately initiated by the RN. RN Supervisor was notified, and the CRNP (certified registered nurse practitioner) responded to bedside. Crash cart was brought to the room. Heimlich maneuver was performed for approximately one minute; however, the resident became cyanotic (a bluish discoloration of the skin resulting from inadequate oxygenation of the blood). When the obstruction was not relieved, the resident was carefully placed on a backboard, and abdominal thrusts were continued. Food material was visualized in the oral cavity, and suction was utilized to remove visible particles. Resident was on continuous oxygen via nasal cannula during the event. After the food bolus was dislodged, the resident exhibited shallow respirations with a pulse of 20 beats per minute. Daughter present at bedside. RN discussed condition and offered transfer to the emergency department. Daughter declined hospital transfer and requested comfort-focused care. Resident ceased to breathe at 12:40 p.m. with family present at bedside. At the time of the incident, the resident was served a hamburger that was not consistent with the physician-ordered diet. Review of a written statement dated 2/26/26, indicated that Dietary Aide (DA) Employee E4 was interviewed regarding the above incident and stated that she was the server who placed the food onto the plate for Resident R1. Interviewer asked DA Employee E4 if she recalled placing a 7EC 5MM (Level 7 Easy to Chew, Level 5 minced and moist meats) burger on Resident R1's plate, to which DA Employee E4 replied that I can't honestly remember. Review of a written statement dated 2/26/26, indicated that DA Employee E5 was also interviewed regarding the above incident. Interviewer asked DA Employee E5 if she could verify that Resident R1 received his appropriate diet, to which she replied, I can't remember. Review of a written statement dated 2/26/26, from Nurse Aide (NA) Employee E6 stated This writer gave resident lunch tray while family was sitting in the room with him. I did not look at what was served. I saw the burger but did not realize it was not the right texture. Review of Resident R1's plan of care did not include his physician ordered diet of to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction. Review of the facility document Diet Type Report dated 3/3/26, revealed that the facility had 40 residents on altered texture diets (Level 7 Easy to chew, Level 5 minced and moist, pureed, and thickened liquids). Review of five additional clinical records for residents that are ordered an altered texture diet revealed that four of the five did not have their altered texture diet listed as an approach in their plan of care (Resident R2, R3, R4, and R5). During an interview on 3/3/26, at 1:03 p.m. the Nursing Home Administrator (NHA) provided a written outline of what has been implemented in the facility since the incident, which included: immediate education for all staff to check tray tickets (a slip of paper used by staff to communicate a resident's diet order, dislikes, and preferences) against tray before giving to resident. Also verify diet before giving drinks/snacks. Staff then sign off on the tray ticket to ensure they are correct. All meals being plated are monitored by cook and/or dietary supervisor are matching the diet orders on the meal tickets as well. IDDSI diets posted at all nurses' stations and dietary department. Binders at each nurses' station were already in place. During an interview on 3/3/26, at 1:29 p.m. Speech Therapist (ST) Employee E7 indicated that she was aware of the above incident when Resident R1 received the wrong diet texture which resulted in him choking and dying. ST Employee E7 confirmed that she had worked with the resident in October 2025 for treatment of dysphagia, and had recommended the altered diet texture that he was ordered (Level 7 Easy to Chew with level 5 Minced and Moist Meats). ST Employee E7 confirmed that resident should not have received a regular hamburger, and that the meat should have been ground, and that the size of the meat particles should fit in between the prongs of a fork, and mixed with gravy, sauce or other condiments to make it moist and allow resident to safely chew and swallow. ST Employee E7 stated that the facility implemented the IDDSI diet system in 2019, and that staff was educated during the initiation of the new diet system, and that she made copes of the IDDSI diet to keep on the nursing units for future reference. ST Employee E4 added that staff was educated at the time the diets were implemented. During an interview on 3/3/26, at 1:40 p.m. Registered Dietitian (RD) Employee E8 indicated that she is also aware of the above fatal incident regarding Resident R1, and confirmed that his diet order was complicated RD Employee E8 went on the explain the tray line process in the kitchen and stated that the Starter is the staff member at the beginning of the tray line and that they will read the diet orders out loud to communicate them to the other staff member who will be placing the food on the plate. The food on the plate/tray is then checked by a final staff member who will ensure that the food is accurate and appropriate for the prescribed diet. If you are new, it's easy to miss, and hard to pay attention. RD Employee E8 confirmed that Resident R1 should not have received a regular hamburger because he was ordered level 5 minced and moist meats It should have been ground with gravy. When State Agency (SA) asked of residents' diet orders are listed in their plan of care RD employee E8 stated No, I just put in 'provide diet as ordered' because they are subject to change. Review of the facility's tray tickets revealed that the facility uses abbreviations to communicate this information. For example, Resident R1's tray ticket on the date of the incident stated 7EC, 5MMM, NAS, Mod. Dislikes: banana, bread (wheat), broccoli, honeydew, hot dog, potato, sausage, spinach, tomato, and watermelon. Preferences: applesauce, hamburger, honey/Mod thk apple juice. Review of the above tray ticket does not include what specific items to place on the tray such as Minced moist meat hamburger, etc. During an interview on 3/3/26, at 4:27 p.m. The NHA and Director of Nursing (DON) were made aware that diet orders are not communicated via plan of care, and that tray tickets do not include full diet orders, and food items, which may have helped to contribute to Resident R1's receiving incorrect menu items, which was confirmed by the NHA. NHA made aware that immediate jeopardy situation exists for the additional 40 residents that receive altered texture diets, and an Immediate Jeopardy Template was provided. During an interview on 3/3/26, at 4:41 p.m. Licensed Practical Nurse (LPN) Employee E9 stated that nursing staff have been doublechecking trays before they are passed to the resident. Sometimes the diets are complicated, so you may have to look it up on the sheets. LPN Employee E9 referred to the cards that are now attached to the meal cart for reference on IDDSI diets. We also have a binder at the desk with this information. During an observation on 3/3/26, at 5:16 p.m. staff were noted to be reading each residents' tray ticket, checking the food on the tray to ensure it was the correct diet texture, and initialing the tray tickets while the food remained on the delivery cart. During an interview on 3/3/26, at 5:16 NA Employee E10 stated that after someone checks the trays while still on the cart, NA are then double checking the tray to ensure its safety at the time of service. NA Employee E10 added that the incident with Resident R1 was so scary, and that everyone is taking the situation very seriously. On 3/3/26, at 7:25 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Staff passing trays are auditing food that is provided is matching the diet orders on the meal tickets. They are then signing off on the meal tickets to ensure they are correct. All meals being plated are monitored by the cook and/or dietary supervisors are matching the diet orders on the meal tickets as well. 2. All care plans will be reviewed and updated with current orders. NHA/designee will provide immediate education to RD, RNAC (Registered Nurse Assessment Coordinator), LPNAC (Licensed Practical Nurse Assessment Coordinator), and Dietary Manager on updating resident care plans with diets per physician's orders. This will be completed by Wednesday March 4th, 2026. 3. RD immediately went through current meal tickets to ensure that all residents' tickets match the physician orders to ensure the verbiage is more complete and not abbreviated for a better understanding by staff. This was completed on Tuesday Mach 3, 2026. 4. Education to be completed by NHA/designee to nursing/dietary/activities staff on diets that are used in this facility as well as any altered textures. This will be completed by Thursday, March 5th, 2026. 5. Education to be completed by RD/designee on reading and understanding the facility's tray tickets. This will be completed by Thursday March 5th, 2026. 6. Care plans will be audited against physician orders 5 times per week by NHA/designee to ensure accuracy. 7. Audits will be completed by NHA/designee to verify that staff understand the diets utilized and the altered textures. To be completed everyday times 5 days. Then 3 times per week for 4 weeks. 8. Dietary Manager and/or RD will conduct audits at time of plating meals to ensure the accuracy of diet texture per tray card/physician order. To be completed everyday times 5 days, then 3 times per week for 4 weeks. 9. Education to be completed by RD/designee to Dietary Manager on how to physically enter diets in the Food Service System (computer). This will be completed by Thursday March 5th, 2026. 10. A work group will be implemented 3/4/26 in morning to review Food Services Tray Card computer system versus other options. 11. All audits will be reviewed at an ad-hoc QAPI (quality assurance and performance improvement) meeting by Thursday March 5th, 2026. Review of medical records conducted on 3/4/26, revealed that 107 of 107 residents in the facility had an updated care plan to include the current physician prescribed diet. Review of tray tickets conducted on 3/4/26, revealed that all diet orders are written out in their entirety, (no longer abbreviated), and that they match the physician order for 107 of 107 residents. For example: 7EC is now Easy Chew, and 5MMM is now minced moist meat. Review of tray audits conducted on 3/5/26, that were completed in dietary at time of tray line service were completed as required for three of three meals reviewed. Review of tray audits conducted on 3/5/26, that were completed by nursing staff at time of service completed were completed as required for three of three meals reviewed. Review of Care plan audits conducted on 3/5/26, revealed that they were completed as required on 3/5/26. Review of Education documentation completed as follows: IDDSI education completed on 130 of 142 employees- remaining to be educated prior to start of next shift.Tray ticket education completed on 150 of 163 -remaining to be educated prior to start of next shift.Entering diets education completed on 2 of 2 employees.Care plan education completed on 5 of 5 employees. During interviews conducted from 3/4/26, at 10:58 a.m. through 3/5/26, at 12:30 p.m., 24 employees verified that they received the required education. On 3/5/25, at 1:00 p.m. the Immediate Jeopardy was lifted when the action plan implementation was verified During an interview on 3/5/26, at 1:49 p.m. NA Employee E11 stated that the revised tray tickets are very helpful and that staff have always been instructed to check trays before distributing them to a resident. During an interview on 3/5/26, at 1:57 p.m. Dietary Manager (DM) Employee E12 stated that revised meal tickets may help to avoid making mistakes in the future, and that Resident R1 should have received a hamburger with minced meat mixed with gravy to keep it moist instead of a regular texture burger. During an interview on 3/5/26, at 2:21 p.m. NA Employee E1 stated that the revised tray tickets are helpful with the complete diet order as often times families ask what the abbreviations mean. During an interview on 3/5/26, at 4:01 p.m. the NHA confirmed that facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1) placing an additional 40 residents that had similar diet needs at risk (Residents R2, through R41) 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident nutrition care needs for five of six residents reviewed (Resident R1, R2, R3, R4, and R5).Findings include: Review of the International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) Framework, revised July 2019, provides definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia, which include the following descriptions: Level 7 Easy to Chew foods must be able to break food apart easily with the side of a fork or spoon. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape.Level 5 Minced and Moist meats should be finely minced or chopped. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excess. Use slot between fork prongs (4 millimeters) to determine whether minced pieces are the correct or incorrect size. Food should be soft enough to squash easily with fork or spoon. Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked. Sample should not be firm or sticky.Level 4 Pureed food is smooth with no lumps and minimal granulation. Cohesive enough to hold its shape on the spoon.Level 3 Moderately thick liquids should drip slowly or in dollops/strands through the slots of a fork. When a fork is pressed on the surface of Level 3 Moderately thick liquids, the tines/prongs of a fork do not leave a clear pattern on the surface.Level 2 Mildly thick liquids flows off a spoon. Sippable, pours quickly from a spoon, but slower than thin drinks. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/21/25, indicated diagnoses of high blood pressure, malnutrition (lack of proper nutrition), and muscle wasting. Review of Resident R1's clinical record revealed a physician's order dated 11/11/25, to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction. Review of Resident R1's plan of care conducted on 3/3/26, did not include his physician ordered diet of to provide a diet of NAS (no added salt), low potassium, 7 EC Easy to Chew texture, level 5 minced and moist meats, 3 moderately thick consistency (liquids) and 1500 ml (milliliters) fluid restriction. Review of clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnosis of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and hyperlipidemia (excess fat in the blood). Review of Resident R2's clinical record revealed a physician's order dated 12/1/25, to provide a diet of 7 EC Easy to Chew texture, level 5 Minced and Moist Meats. Review of Resident R2's plan of care conducted on 3/3/26, did not include the above physician ordered diet. Review of clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnosis of high blood pressure, dysphagia (difficulty swallowing), and unsteadiness on feet. Review of Resident R3's clinical record revealed a physician's order dated 2/25/26, to provide a diet of Reduced Concentrated Sweets, Minced and Moist texture. Review of Resident R3's plan of care conducted on 3/3/26, did not include the above physician ordered diet. Review of clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnosis of high blood pressure, dementia, and unsteadiness on feet. Review of Resident R4's clinical record revealed a physician's order dated 12/2/25, to provide a diet of No Added Salt, level4 Pureed texture, level 2 mildly thick liquids. Review of Resident R4's plan of care conducted on 3/3/26, did not include the above physician ordered diet. Review of clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnosis of high blood pressure, hyperlipidemia, and unsteadiness on feet. Review of Resident R5's clinical record revealed a physician's order dated 1/7/25, to provide a diet of No Added Salt, 7EC Easy to Chew texture, level 5 minced and moist meats. Review of Resident R5's plan of care conducted on 3/3/26, did not include the above physician ordered diet. During an interview on 3/3/26, at 1:40 p.m. Registered Dietitian (RD) Employee E8 was asked by State Agency (SA) if residents' diet orders are listed in their plan of care RD employee E8 stated No, I just put in 'provide diet as ordered' because they are subject to change. During an interview on 3/3/26, at 4:27 p.m. The Nursing Home Administrator confirmed that the facility failed to develop comprehensive care plans to meet resident nutrition care needs for five of six residents. 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)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit).Findings include: Review of facility policy HIPAA/HITECH Administrative Policy dated 2/16/26, indicated the facility is to protect residents' privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CRF Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) and all Federal regulations and interpretive guidelines promulgated thereunder. During an observation on 3/4/26, at 2:01 p.m. the [NAME] Medication Cart at the nurses' station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an observation at 3/4/26, at 2:02 p.m. Nurse Aide (NA) Employee E1 walked up to the medication cart and closed the resident profile. NA Employee E1 stated, The nurse just walked away from the cart and is a resident's room. During an interview on 3/4/26, at 2:02 p.m. NA Employee E1 confirmed that the facility failed to maintain the confidentiality of residents' medical information on the [NAME] Nursing Unit. During an interview on 3/5/26, at 2:18 p.m. information was disseminated to the Nursing Home Administrator and Director of Nursing that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1) Nursing services.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility when the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk, and resulted in an Immediate Jeopardy situation for 40 of 107 residents. Findings include: The job description for the NHA specified the purpose of the position is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The job description for the DON specified the purpose of the position is to provide nursing management, set resident care standards for all direct care providers and provide completer supervision and management for the nursing department. Based on findings identified in this report, the facility failed to provide an altered texture diet, as prescribed by the physician for one of 40 residents. This resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents with similar diet needs at risk which resulted in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 3/3/26, at 4:27 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent a choking incident that resulted in death, which created an immediate jeopardy situation for 40 of 107 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). Findings include: Review of facility policy Food Safety and Sanitation, dated 3/17/25, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food services department. During an observation of the main designated kitchen on 5/15/25, at 11:35 a.m. the following was observed: - Wall behind Cook's preparation area, build-up of food spillage/brown debris - Wall behind Robocoupe (food processor)/blender area, build-up of food spillage/brown debris - Wall behind garbage can located next to steamer, build-up of food spillage/brown debris During an interview conducted 5/15/25, at 11:36 a.m., Registered Dietitian (RD) Employee E13 confirmed that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide residents with their quarterly banking statements for three of five residents. Findings include: During a group interview on 5/14/25, at 10:45 a.m. residents indicated that they did not get quarterly statements from the facility for their monies that the facility receives. Residents indicated that they were not aware they were to receive quarterly statements for their monies. During a review of residents quarterly statements the following was noted: Resident R500: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25. Resident R501: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25. Resident R502: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25. During an interview on 5/16/25, at 11:41 a.m. Business Office Manager Employee E12 confirmed that the facility sends out quarterly statement, and the person who receives the statement is indicated on the quarterly statement for the residents. During an interview on 5/16/25, at 1:12 p.m. Nursing Home Administrator confirmed that the facility failed to send quarterly statements to residents who had monies in the resident account and sent to their responsible parties. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106). Findings include: Review of facility Behavior Standard Index dated 3/17/25, indicated the facility will develop and implement behavior plans and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. When control is needed to prevent harm and to allow evaluation and treatment, psychotropic medication may be required. Behavioral sheets will be utilized at the time of drug initiation or admission to home with drug order. Behaviors must be quantitatively and objectively documented by the nursing staff. Non-pharmacological interventions are implemented and assessed for effectiveness prior to considering initiation of medication. 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 2/20/25, indicated diagnoses of anemia (low iron in the blood), hypertension (high blood pressure), and anxiety. Review of Resident R4's physician order dated 2/21/25, indicated to administer Ativan oral tablet (a psychotropic medication used to treat anxiety) 0.5 milligram every eight hours as needed (PRN) for anxiety for six months. Review of Resident R4's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R4's Ativan Review of Resident R4's Medication Administration Record (MAR) dated February 2025 through May 2025, indicated that resident received Ativan PRN 24 times per order. Review of Resident R4's Progress Notes dated February 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R4's Ativan. Review of the clinical record indicated Resident R86 was admitted to the facility on [DATE]. Review of Resident R86's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety. Review of Resident R86's physician order revised on 5/15/25, indicated to administer Ativan Solution (a psychotropic medication used to treat anxiety), give 0.5 milliliters (ml) under tongue every four hours PRN for anxiety. Review of Resident R86's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R86's Ativan. Review of Resident R86's Medication Administration Record dated January 2025 through May 2025, indicated that resident received Ativan PRN 11 times per order. Review of Resident R86's Progress Notes dated January 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R86's Ativan. Resident R106 was admitted to the facility on [DATE]. Resident R106 MDS dated [DATE], indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused) and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems). Review of Resident R106's physican order dated 1/30/25: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.25 mg by mouth every 8 hours as needed for anxiety -Start Date- 01/30/2025 Review of Resident R106's physician order failed to include a 14 days stop date and there was no documented rationale by the physician for the medication to extend past the 14 days for Resident R106's Ativan. Review of Resident R106 MAR's January 2025 through March 2025 indicated that resident received Ativan 10 times. Review of the progress notes dated January 2025 through March 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering PRN Ativan. During an interview on 5/16/25, at 11:04 a.m. Director of Nursing confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106). 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies

Based on review of facility policy, and resident and staff interview , it was determined that the facility failed to inform residents on the grievance policy and procedures for seven of seven residents. Findings include: Review of facility policy Communication of Resident, Family, and Staff Concerns and Grievances, stated 3/17/25, indicated: The facility offers several communication avenues for residents, family members, and staff to questions and to report any concerns related to quality of care, customer service, regulatory issue or employee matter. Resident group interview on 5/14/25, at 10:40 a.m. indicated that residents did not know who the grievance officer was, how to file a grievance, where the grievance forms were or what the process was. Residents were asked how the facility responds to grievances and the residents said that they did not know how they respond to concerns. Review of resident council minutes for six months (November, December, January, Febraury, March, and April) failed to include discussion of resident rights, how residents file grievance, where the grievances were located, who the grievance officer was, or any information about resident rights or grievances. During an interview on 5/16/25, at 10:04 a.m. Social Worker Employee E5 confirmed that they are the grievance officer and they attend resident council. During a subsequent interview on 5/16/25, at 10:58 a.m. Social Worker Employee E5 confirmed that no information could be found to support that the facility had informed residents of the grievance process, and that the facility failed to inform residents on the grievance process policy and procedures. 28 Pa. Code 201.29(a)Resident rights

Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of five residents reviewed (Resident R48 and R260) which resulted in actual harm of a skin tear (Resident R48) and a dislocation of right elbow, fracture of the right distal radius (bone near wrist) and a fractured of the right coronoid process of the ulna (bone of forearm) (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible. Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated the diagnoses of anemia (low iron on the blood), heart failure (the heart can't pump blood as well as it should), and hypertension (high blood pressure). Section GG 5.E. Chair/bed-to-chair transfer is coded as 01, (01- indicating dependent). Review of Resident R48's care plan initiated on 10/18/24, indicated: Focus: The resident is to be transferred utilizing a front wheeled walker with assist x two. Focus: I am at high risk for falls related to confusion, deconditioning, gait/balance problems, history of frequent falls and falling out of bed. Review of incident note dated 5/3/25, at 1:30 a.m. indicated Nurse Aid (NA) informed writer that when she went to put the resident into bed the resident stated, Watch my leg. NA then looked at the resident's legs and saw a skin tear on the residents lower left lateral leg. Earlier in the shift resident was in bed yelling so a different NA assisted the resident up and into her chair to bring her to the nurse's station at 9:00 p.m. Resident sat at the nurse's station and did not say anything. The resident started falling asleep and was assisted back to her room around 1:30 a.m. when skin tear was discovered. When asked what had happened resident said, It happened when I got in my chair. Skin tear measures 3cm x 3cm and is in the shape of a triangle. Skin tear was cleansed with NSS, patted dry, 3 steri-strips applied, and covered with bordered gauze. Review of undated facility provided skin impairment huddle indicates: How was skin impairment acquired? During transfer was noted with a question mark (?). Residents' description of incident: when I got in my chair. Immediate intervention initiated: cleansed, patted dry, applied steri-strips, covered with border gauze. Review of undated, unsigned, typed interview investigation completed by Registered Nurse (RN) Employee E3 indicated resident stated watch my leg when she was transferred into bed around 1:30 a.m. due to falling asleep at nurse's station. Residents front of wheelchair faced the head of bed placing her left lower leg near bed frame during transfer. When resident was in bed NA lifted pant leg and noticed fresh blood to left lower leg and skin tear. Its likely resident obtained skin tear from rubbing against bed frame with transfer back into bed. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that Resident R48 was an assist of two for transfers, a high fall risk, and that Resident R48 was transferred with an assist of one back to bed and that the facility failed to make certain a resident was free from neglect by not following transfer orders.). Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Review of physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of R260 progress note dated 10/14/24, at 5:24 p.m. indicated Nurse Aid (NA) put resident on toilet and went to answer another call light. As this writer was walking to her room, I heard an alarm going off and went to answer it. Upon returning this writer heard resident yelling for help and rushed with NA to residents' room to observe resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Tylenol given for right side arm/shoulder pain. When this writer asked resident why she didn't pull call bell and get up off toilet she stated what does it matter. Notified RN to come to residents' room to assess for injuries' notified sister-in-law and DR. Able to move all extremities except her right arm, shoulder and wrist that she is complaining of hurting and unable to move. Resident was put in bed by staff. Neuro checks all within normal range. x-ray ordered, here at facility. Review of the facility provided incident reported dated 10/15/24, indicated NA entered Resident R260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident's alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and the facility failed to make certain a resident was free from neglect. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish , or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible. Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. : Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x- ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x -ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident ' s injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible. Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression.: Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor,safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents ' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed: impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. Review of facility submitted events to the state survey agency failed to include the report of an allegation of neglect. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that that the facility failed to report an allegation of neglect for one of three residents (Resident R260). 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management 28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on Centers for Disease Control and Prevention (CDC) guidance, Pennsylvania Department of Health (PADOH) guidance, facility policy and documents, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to timely investigate and document surveillance, exclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, and failed to implement preventative measures to address an outbreak of gastrointestinal illness among residents for 10 of 17 residents (Residents R1, R2, R3, R4, R5, R6, R7, CR8, R9, and R14) The facility's failure created a situation in which all 100 of 100 residents were placed in Immediate Jeopardy related to a lack of proper infection control procedures. Findings: The CDC, Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2/15/17, indicated that healthcare settings that experience an outbreak of gastroenteritis/norovirus should implement the following: -Cohorting (residents with symptoms of illness are moved into the same room) and Isolation Precautions -Avoid exposure to vomitus or diarrhea. -Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. -If norovirus gastroenteritis infection is suspected, adherence to personal protective equipment -PPE (gloves, gowns, masks and/or face shields worn to protect the care giver from infection) use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material. -During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. -Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks. -Consider suspending group activities (e.g., dining events) for the duration of a norovirus gastroenteritis outbreak. -Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis -During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. -Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. Review of the facility PADOH Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities dated August 2019, indicated: -Implement daily active surveillance for gastroenteritis among residents and staff using DOH sample line listing. -That for the duration of the outbreak, the facility should increase the frequency of hand hygiene audits and provide written and verbal feedback to staff. -During outbreaks, use soap and water for hand hygiene (do not substitute alcohol-based hand gel). -Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Review of the facility policy Viral Gastroenteritis last reviewed 4/8/24, indicated several different viruses cause this diarrheal illness, including Norovirus. It was indicated the average incubation period is 12-48 hours and symptoms last usually from 24-60 hours. Do not wait to confirm the diagnosis before you set up infection control measures. Review of documentation submitted to the Department of Health by the facility dated 4/30/24, indicated that Registered Nurse (RN) supervisor notified the Director of Nursing on 4/30/2024, that there were several residents that had diarrhea or emesis on the Maple unit which began on 4/29/2024. Facility tracing was initiated. The Certified Registered Nurse Practitioner was in this morning and discussed. No confirmed norovirus, however, with 19 residents that are having emesis and or diarrhea, facility is treating as norovirus outbreak. It was indicated Maple residents will be contained on their hallway. Contact isolation PPE will be utilized for staff when providing care. Masks utilized. Education provided to staff regarding isolation, how the virus is spread, cleaning/disinfecting, handwashing-sanitizer use as per CDC recommendations and facility policy. Families are being updated at this time as well as MD's. Staff will continue to encourage fluids. Activity staff will provide 1:1 activities on unit. The 3 remaining hallways will have group activities on their individual units. The Infection Control (IC) nurse will also be notified as well as the local health department. Visitors are being notified when entering facility and encouraged to wash hands before and after their visit. Review of follow-up documentation submitted by the facility dated 5/2/24, indicated on 4/29/24, there were 19 (out of 42) residents with either vomiting or diarrhea noted on the Maple hallway. IC nurse tracking/trending, noted one resident with nausea on 4/25/24, then emesis/diarrhea on 4/26/24. It was indicated an additional 10 residents were identified throughout facility as of 5/1/24, and three additional residents on 5/2/24. Staff are utilizing PPE contact isolation along with hand hygiene. Residents are in contact isolation for a minimum of 48 hours after the resolution of their symptoms to prevent further exposure to other residents. Follow-up documentation submitted by the facility dated 5/3/24, indicated two additional residents and a total of four staff members developed signs and symptoms of a gastrointestinal (GI) illness. Review of Resident CR8's clinical record on 4/25/24, at 12:14 p.m. indicated the resident had three episodes of emesis and was administered 4mg Zofran (anti-nausea medication). Review of Resident CR8's progress note dated 4/25/23, at 2:19 p.m. stated the resident had four episodes of emesis and two episodes of diarrhea. Registered Nurse was notified, and Zofran was ordered and administered. Review of the resident's clinical record failed to indicate a physician was notified of Resident CR8's emesis and diarrhea. Resident CR8 remained cohorted with Resident R9 who was asymptomatic from 4/25/24, until Resident CR8 was discharged on [DATE]. Review of CR8's physician orders from 4/25/24, through 5/1/24, failed to include an order for contact precautions. Review of the facility's line list of residents who had contracted the GI illness dated 4/30/24, indicated Resident CR8 was the first resident to develop symptoms of nausea, emesis, and diarrhea on 4/26/24. The facility failed to timely and accurately complete surveillance tracking for residents with GI illness. Facility began surveillance a total of five days after the first resident (Resident CR8) developed signs and symptoms of a GI illness. Review of Resident R14's progress note dated 4/25/24, indicated the resident had 2 XL emesis this evening. It was indicated the Registered Nurse was aware. Review of the resident's clinical record failed to indicate a physician was notified of Resident R14 ' s emesis. Resident R14 remained cohorted with Resident R15 who remained asymptomatic. Review of R14's physician orders from 4/25/24, through 5/1/24, failed to include an order for contact precautions. Review of the Norovirus Surveillance Tracking dated 4/30/24, indicated 18 residents were positive of signs and symptoms of GI illness. Review of the Education rosters dated 4/30/24, revealed education was provided to staff regarding Norovirus. The education revealed staff were educated that hand sanitizer is an appropriate form of hand hygiene. No other education was provided on any other dates. Review of Resident R1's clinical record indicated the resident complained of nausea and vomiting on 5/1/24. Review of Resident R1's clinical record failed to indicate contact precautions were implemented from 5/1/24, through 5/3/24. Resident R1 was not documented on the facility's surveillance log. Resident of Resident R2's clinical record indicated the resident complained of upset stomach and loose bowel on 5/1/24. Review of Resident R2's clinical record failed to indicate contact precautions were implemented from 5/1/24, through 5/3/24. Resident R2 was not documented on the facility's surveillance log. Review of the facility's line list of residents who contracted the GI illness on 5/7/24, indicated a total of 44 residents developed signs and symptoms of GI illness. Resident R1 and Resident R2 were not identified on the surveillance log. The facility failed to complete accurate tracking and surveillance of GI illness in residents. Review of Resident R3's clinical record indicated the resident had emesis x1 and complained of an upset stomach on 5/6/24. Review of Resident R3's clinical record failed to include an order for contact precautions from 5/6/24, through 5/7/24. During an interview on 5/7/24, at 9:54 a.m. Registered Nurse (RN), Employee E2 stated for residents that display signs and symptoms of Norovirus, contact precautions must be implemented, and prior to exiting the resident's room, PPE is disposed of in the trash bin. RN, Employee E2 stated if a resident displays new symptoms of nausea, vomiting, or diarrhea, the RN Supervisor is notified, and they are the ones that put in an order for contact precautions. RN, Employee E2 confirmed the facility failed to implement contact precautions for Resident R3 on 5/6/24, and indicated the resident should be on contact precautions. During an observation on 5/7/24, at 10:13 a.m. Housekeeper, Employee E1 was observed cleaning Resident R3's bathroom with a gown, gloves, and face shield with the door open. During an observation and interview on 5/7/24, at 10:15 a.m. Housekeeper, Employee E1 failed to remove her PPE prior to her exiting Resident R3's room. Housekeeper, Employee E1 stated she was wearing PPE because my boss told me to wear it when you come in cause people have the flu. Housekeeper, Employee E1 confirmed she failed to remove PPE prior to exiting Resident R3's room. Review of the facility's Norovirus current symptoms 5/7/24 documentation revealed Resident R4, R5, and R6 were positive for norovirus symptoms. Review of the clinical record on 5/7/24, for Resident R4, R5, and R6's clinical record failed to include an order for contact precautions. Review of the facility's line list on 5/7/24, of residents who contracted the GI illness, revealed Resident R4 developed diarrhea on 5/6/24. During an observation on 5/7/24, at 9:47 a.m. Resident R4's room failed to have contact isolation signage or Personal protective equipment (PPE) observed outside of her room. Laundry aid, Employee E3 was observed entering room without PPE and putting laundry away. During an interview on 5/7/24, at 9:51 a.m. Laundry aide, Employee E3 stated staff must wear gloves and mask if entering a room with Norovirus and sanitize hands too. During an observation on 5/7/24, at 9:44 a.m. a visitor was observed entering the facility and signing in. The receptionist was observed sitting at the front desk and failed to notify the visitor of the current Norovirus outbreak. No postings were observed at the entrance that indicated the facility is currently in an outbreak for Norovirus. During an interview on 5/7/24, at 10:05 a.m. Nurse Aide (NA), Employee E4 stated she developed symptoms of GI illness on Saturday, May 4th, and returned to work Monday, May 6, 2024. Review of NA, Employee E4's time punch revealed she worked 5/6/24, from 6:53 a.m. to 3:23 p.m. The facility failed to exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Review of the facility provided list of staff members with GI illness and staff attendance records indicated the following: -LPN, Employee E6 was noted to have signs and symptoms of a GI illness on 4/28/24. LPN, Employee E6 called off for her scheduled shift on 4/28/24. LPN, Employee E6 worked returned to work on 4/30/24, at 6:53 a.m. until 7:24 p.m. LPN, Employee E6 returned to work, without having completed the 48 hours of symptom resolution before returning to work. -NA, Employee E7 was noted to have signs and symptoms of a GI illness on 5/1/24. NA, Employee E7 returned to work on 5/2/24, at 6:53 a.m. until 3:35 p.m. NA, Employee E7 returned to work, without having completed the 48 hours of symptom resolution before returning to work. -Housekeeping Aide, Employee E8 was noted to have GI illness on 5/2/24. Housekeeping Aide, Employee E8 returned to work on 5/3/24, at 7:01 a.m. until 3:30 p.m. Housekeeping Aide, Employee E8 returned to work, without having completed the 48 hours of symptom resolution before returning to work. -Maintenance Technician, Employee E9 was noted to have GI illness on 5/2/24. Maintenance Technician, Employee E9 returned to work on 5/3/24, at 7:25 a.m. until 4:00 p.m. Maintenance Technician, Employee E9 returned to work, without having completed the 48 hours of symptom resolution before returning to work. -LPN, Employee E10 was noted to have GI illness on 5/2/24. Housekeeping Aide, Employee E10 returned to work on 5/4/24, at 6:59 a.m. until 7:23 p.m. LPN, Employee E10 returned to work, without having completed the 48 hours of symptom resolution before returning to work. -IP, Employee E5 was noted to have GI illness on 5/2/24. IP, Employee E5 returned to work on 5/3/24, at 6:53 a.m. until 9:00 p.m. IP, Employee E5 returned to work, without having completed the 48 hours of symptom resolution before returning to work. During an interview on 5/7/24, at 10:21 a.m. the DON confirmed the facility failed to obtain an order for contact precautions for Resident R4, R5, and R6 who had current symptoms of Norovirus. During an observation on 5/7/24, at 10:27 a.m. a sign that stated STOP was posted on Resident R6's door. No other signage was posted that indicated the resident was in contact isolation, or to report to nurse's station. No PPE cart was observed near the resident's door. Review of the facility's Order listing Report which included all orders that were active, completed and discontinued for all residents from 4/25/24, through 5/7/24, at 12:39 p.m. failed to include an order for contact precautions for any resident for the duration of the Norovirus outbreak. During an interview on 5/7/24, at 10:54 a.m. Resident R7's family visitor confirmed he was not notified about an outbreak when he entered the facility today. During an interview on 5/7/24, at 10:57 a.m. Resident R7's family visitor stated there has been a lot of residents sick with nausea, vomiting, and diarrhea. Resident R7's family member stated he was never notified of an outbreak from the facility. Resident R7's family visitor indicated he visited Resident R7 last week on Monday, Tuesday, Wednesday, and Thursday. It was indicated he helped Resident R7 with lunch last Tuesday, then Resident R7 got sick in the afternoon, and had a loss of appetite on Wednesday. Resident R7's family member indicated he did not wear any PPE when visiting last week, then he developed symptoms of GI illness over the weekend. He indicated he was running to the bathroom and had diarrhea. Resident R7's family visitor stated he was never told it was Norovirus, and Resident R7's never had signage on her door for contact isolation. Review of Resident R7's clinical record on 5/7/24, indicated Resident R7 was very upset and restless, on 4/28/24, and indicated the resident's son was not in to visit today when she thought he was coming. During an interview on 5/7/24, at 11:04 a.m. Infection Preventionist, Employee E5 indicated the first outbreak started on 4/26/24, and she was not notified until 4/29/24, three days later. IP, Employee E5 confirmed the facility does not have signage posted that indicated the facility is in a current Norovirus outbreak, and the facility failed to screen visitors for signs and symptoms of a GI illness. IP, Employee E5 stated she educated staff that hand sanitizer is an acceptable form of hand hygiene for Norovirus. It was indicated signage must be posted on resident's doors who are in isolation that indicates the type of isolation or a sign that indicated to see nurse's station. During an interview on 5/7/24, at 12:08 p.m. the Nursing Home Administrator (NHA), indicated the DON notified the County's Health Department on 4/30/24, of the Norovirus outbreak, and left a message with no response. The NHA confirmed no follow-up was completed. The NHA and the Medical Director were made aware that an Immediate Jeopardy situation existed for residents on 5/7/24, at 1:23 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 5/7/24, at 5:42 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -All Residents will be assessed immediately for any s/s of norovirus, if identified the following will occur: a. Residents will be cohorted to a single unit when possible, by end of the day May 7, 2024. b. Resident will immediately be placed in contact isolation until symptom free for a minimum of 48 hours. c. RN Supervisor will notify MD for orders for contact isolation. d. Orders will be placed into the chart for contact isolation. e. Residents will remain in their rooms when possible, and educate on norovirus fact sheet. f. The residents who exhibit symptoms will be placed in isolation with signage on the door to indicate the appropriate PPE that is needed to provide care. g. The Registered Nurse Assessment Coordinator (RNAC) will ensure that the resident's care plan is updated with the norovirus upon identification. h. Residents will be cohorted to a single unit when possible, by end of the day May 7, 2024. -For duration of outbreak the facility will do the following. a. Residents will remain in their rooms when possible. b. Residents will be cohorted to a single unit when possible. c. Activities will be provided on each individual unit during outbreak period. d. Residents will be encouraged to have their meals in their rooms. -The IDT team will review infection control procedures and policies by end of day May 7, 2024, and update as needed. -Whole house education will be provided by DON or designees on the following: a. Hand hygiene and the use of soap and water. b. Signage on the door to indicate the appropriate PPE that is needed to provided care. c. How to protect themselves as well as other residents from being exposed to Norovirus using the Norovirus Face sheet and Tool kit. d. Initial whole house education will be completed as of today May 7, 2024 with any current employees who are working. e. Education will be provided to all current staff members before the start of their next shift including agency. A notice is placed at the time clock informing staff to report to DON or designee to complete education. -The DON, ADON, infection Preventionist, and NHA or designee will review documentation on the current residents for s/s of nausea, vomiting, and diarrhea during am clinical throughout the duration of the outbreak. a. DON, ADON, NHA, IP or designee will audit during outbreak daily, after outbreak will monitor weekly for the first month, and monthly thereafter. -Families and staff will be notified of an outbreak with the norovirus via alert media. Signs will be posted at the entrance doors indicating that there is an outbreak of the Norovirus. a. Visitor screening tool will be placed at the front desk during the outbreak. b. All visitors will be screened for signs and symptoms of the illness and instructed to speak to a member of the nursing team prior to visiting. c. Staff experiencing s/s of norovirus will notify manager immediately and will not be permitted to return to work until 48 hours after symptoms resolve. -The DON and/or the infection Preventionist will follow-up with the local department of health for further guidance and testing requirements for outbreak by end of day May 7, 2024. -Housekeeping will increase frequency by the minimum of twice a day of cleaning and disinfecting of residents rooms with active Norovirus symptoms and common areas, and high touch areas by end of day- May 7th, 2024. a. Ongoing infected resident rooms will have additional disinfecting using Rapid Multi Surface Disinfectant Cleaner. -The review of infection control procedures and policies will be reviewed during our monthly quality assurance meeting to ensure compliance. During staff interviews conducted on 5/8/24, between 10:15 a.m. and 11:01 a.m., 22 of 22 staff members confirmed that they received education on signs and symptoms of GI virus, handwashing with soap and water, infection control of a GI virus infection, and appropriate donning and doffing of PPE. 5 of 11 Agency staff were educated on Norovirus. Agency staff who were not educated will report to RN supervisor prior to start of their shift to be educated. A review of the documentation received from the facility on 5/8/24, at 12:56 p.m. revealed that all elements of the Corrective Action Plan were substantially completed. The Immediate Jeopardy was lifted on 5/8/24, at 1:32 p.m. when the Corrective Action Plan implementation was verified. During an interview on 5/8/24, at 1:32 p.m. the NHA and DON confirmed the facility failed to maintain an infection prevention and control program by failing to timely investigate and document surveillance, exclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, and failed to implement preventative measures to address an outbreak of gastrointestinal illness among residents for 10 of 17 residents (Residents R1, R2, R3, R4, R5, R6, R7, CR8, R9, and R14) The facility's failure created a situation in which all 100 of 100 residents were placed in Immediate Jeopardy related to a lack of proper infection control procedures. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, review of facility investigation and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from sexual abuse, the facility failed to identify abuse as sexual and failed to assess current and past residents that may have been sexually abused, these failures resulted in sexual abuse on one Resident of 29 cognitively impaired residents (Resident R2). This failure placed 29 residents at risk of sexual assault and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy Resident Protection from Abuse, Neglect or Exploitation dated 11/1/21, indicated: Sexual abuse means non-consensual sexual contact of any type with a resident and includes sexual harassment, sexual coercion or sexual assault. Review of CMS Guidelines S483.12 Freedom from Abuse, Neglect, and Exploitation defines sexual abuse as: Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at 42 CFR S483.5. Sexual abuse includes, but is not limited to: o Unwanted intimate touching of any kind especially of breasts or perineal area; o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; o Forced observation of masturbation and/or pornography; and o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. A review of information provided to the department indicated the following: Facility staff was notified on 4/24/22, by Resident R3 that there was a male resident with no pants on and his privates out. Nurse Aide (NA) Employee E2 entered room and observed Resident R2 on the floor with no pants or brief on and shirt unbuttoned, legs in the air with ankles being held by Resident R1 (who was naked below the waist with penis exposed) who was pulling at Resident R2. Resident R2 was scooting across floor attempting to get to roommates bed near window (other side of room away from Resident R1). NA Employee E2 and E30 asked Resident R1 what they were doing the following took place: Resident R1 (who was naked below the waist with penis exposed) was nervous and hurried over to the bed and started to pull on a pull up (depends/brief) upon Nurse Aides entering room. Room was covered in white fluff cotton that looked like it snowed, which were from Resident R2's brief. NA Employee E2 and E30 stood Resident R2 up and Resident R2 hugged the Nurse Aide and they walked him/her out of the room. The incident/event type was listed as physical abuse. Resident R2 was admitted to the facility on [DATE], with Alzheimer ' s disease which remains current as of the 4/14/22, Minimum Data Set (MDS - a brief periodic assessment of resident needs). Review of Resident R2 ' s Minimum Data Set, dated dated dated [DATE], indicated that she has no BIMS (brief interview for mental status) because her cognition is severally impaired. MDS also indicated that her Activity of Daily living (ADL's - residents ability to complete daily living skills) for dressing was a 3/3 which equals an extensive assistance and a two person assist. Review of clinical progress notes health status notes dated 4/24/22, 10:32 p.m. , indicated Staff reported another resident reported to them there is a man down the hall without any pants on. As staff going to said room observed male resident dragging this resident on the floor without pants on brief shredded on floor bed alarm sounded male resident stated to staff he unbuttoned her shirt. Staff got resident off the floor 2 small scratches noted to resident. Review of clinical progress notes Weekly Skin & Wound Note dated 04/25/22, at 1:32 a.m. indicated Resident has a wound on the right abdomen. Resident has a wound on the left abdomen. RLQ/Hip area. 04/24/22, is when the wound was found acquired in - house. The current measurements are Length 4.5 cm intact. The peri wound area is normal skin tone. There is no drainage in the wound. Abrasion Left side in middle, 04/24/22, is when the wound was found acquired in - house. The current measurements are Length: 8 cm intact. The peri- wound area is normal skin tone. Prior to 4/24/22, Resident R2 had no documented wounds on the right and left abdomen. During interviews with facility employees Nurse Aide (NA) Employee E2 on 5/6/22, at 9:23 a.m. Licensed Practical Nurse (LPN) Employee E3 on 5/6/22, at 5:40 p.m., and E30 on 5/7/22, at 7:23 a.m. the following was indicated : NA Nurse Aide (NA) Employee E2 and E30 and Licensed Practical Nurse (LPN) Employee E3 identified the above incident as a sexual abuse. NA Employee E2 and E30 and LPN Employee E3 identified that Resident R2 (alleged victim) was trying to scoot away from Resident R1(alleged perpetrator) and create further distance from Resident R1. NA Employee E2 and E30 and LPN Employee E3 indicated Resident R1 (alleged perpetrator) was acting nervous after the incident, nursing staff indicated that they did not receive training about abuse after the above incident nor did they complete assessments on other residents. During the same interviews with NA Employee E2, E30 and LPN Employee E3 all indicated that they reported the incident to the Registered Nurse on duty (RN Employee E26) and completed witness statements after the incident. NA Employee E2 and E30 and LPN Employee E3 indicated that prior to the incident Resident R2 needs assistance with taking off clothing and does not like to be touched or changed. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment A review of the prescribing information for [MEDICATION(S)], a medication used to treat symptoms of [CONDITION(S)] disease, (progressive nervous system disorder that affects movement) revised 2/15/22, indicated that [MEDICATION(S)] is a [MEDICATION(S)] agonist (medications that work by imitating the actions of [MEDICATION(S)] when levels are low) indicated that some people who take [MEDICATION(S)] have increase sexual urges. Resident R1 was admitted to the facility initially on 1/13/15, and readmitted on [DATE]. Review of Minimum Data Set (MDs, periodic review of resident needs) dated 11/10/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5, indicating severe impairment. Review of the clinical record indicated that on 4/20/22, an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1/13/15-4/20/15 4/20/15-7/25/15 8/01/15-1/30/16 2/03/16-8/17/16 8/18/16-1/02/19 1/02/19-5/02/22 Review of Resident R1's plan of care for [CONDITION(S)] medication use, originally initiated 1/27/15, and most recently updated 03/04/22, failed to include hypersexuality as a possible side effect of his medications, and failed to include goals and interventions related to hypersexuality. Review of Resident R1's clinical record indicated that he received psychological counseling services 19 times from 2019, through 2022. The psychiatry clinical note dated 1/21/22, indicated: Discharge from follow -up. We will remain available for consultation PRN (as needed). Review of Resident R1's clinical record indicated that he was reviewed by psychiatry on 6/17/21, 7/15/21, 12/21/21, and 1/14/22. Review of facility census records and progress note indicated that Resident R1 was moved to the locked memory impaired unit on 1/24/22. Review of facility census records and progress note indicated that Resident R1 would receive [MEDICATION(S)] (used to treat hallucinations and delusions in people with [CONDITION(S)] from [CONDITION(S)] disease) 34 milligrams daily. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of approximately seven years of progress notes (1/13/15-12/26/21) indicated one progress note indicated sexual behavior: 3/25/19, at 9:06 a.m. Resident asked CNA (Certified Nurse Aide) Will you play with my penis. CNA told the resident this was unacceptable [NAME] to ask the CAN. Resident's call bell was on writer went to resident's room and asked resident what he had needed, at first resident replied nothing then asked, Will you play with my dick? Review of approximately four months of progress notes (12/27/21-4/29/22) indicated eleven progress notes indicating sexual behavior. Review of a progress note written by LPN Employee E14 dated 12/27/21, at 5:27 p.m. indicated, Resident noted to be in his room naked and laying in his bed holding his pillow inappropriately. When he noticed writer he jumped from his bed and covered himself. Review of a progress note written by LPN Employee E1 dated 12/31/21, at 1:54 p.m. indicated, resident being sexually inappropriate towards staff. Resident asked if he could see her pussy and stated for LPN to take her panties off while grabbing at LPNs arm. LPN left the room after telling the resident he was being inappropriate and needed to stop resident repeated his previously stated questions. Review of a progress note written by LPN Employee E11 dated 1/1/22, at 9:45 p.m. indicated, Writer entered room to give hour of sleep meds. Writer noted him prone in bed without clothing\ or night shirt. also no brief. writer questioned him as to why he had nothing on he stated I'm playing with my butt. Review of a progress note written by LPN Employee E1 dated 1/8/22, at 12:38 a.m. indicated, resident was peeking into a female resident's room and attempted to go in even after being told that he should not go in there because it was a female resident's room. resident was stopped by staff and reminded he could not go into another person's room without their permission. resident huffed and walked down the hall peeking into other resident rooms. Review of a progress note written by LPN Employee E14 dated 1/14/22, at 2:40 p.m. indicated, Upon entering resident's room, noted curtain pulled. Called resident's name to alert him of my presence. Upon entering resident's area, he was noted to be completely naked and shuffling around on his bed. Review of a progress note written by LPN Employee E11 dated 1/18/22, at 6:59 a.m. indicated, resident spent majority of night shift masturbating and thrusting into mattress. Review of a progress note written by the Director of Nursing dated 3/15/22, at 2:05 p.m. indicated, LPN asked resident how he was feeling 3/14/22 at 4:30 p.m. due to his blood pressure being elevated the day before. Resident stated that he felt good, I wish I could go back home and have sex with that lady again. LPN asked what lady was he talking about, stated, The one that lives down the road from my dad's house. LPN asked does your father know? Resident did not answer anymore questions. Resident was on a leave of absence with father over this past weekend. Call placed to family and updated on statement. Per sister, their father lives on a desolate road and the neighbors are not close for him to walk to. He has to go down 20 plus cement stairs and walk up or down hills to get to a neighbor and would not be able to make it out of the house without assist from the father. The road is a side road that is hardly driven on and not well traveled. Sister stated that she would update the father about comment made. Review of a progress note written by LPN Employee E17 dated 3/22/22, at 1:14 p.m. indicated, while approaching pt for his afternoon meds pt said, I told you I don't want anymore. Attempted to redirect pt and he said, I'll take them if you do a dance on my [NAME]. Redirected pt and told him that was inappropriate. He then stated that the last time he was home at his dads that he was playing with his [NAME] on the street and went to the neighbor lady and asked her for sex and she called the police on him. He also stated his dad was mad at him and the cops came to talk to him. Review of a progress note written by RN Employee E24 dated 4/12/22, at 7:17 a.m. indicated, At approximately 12:00 a.m. overnight the resident was laying completely naked on his bed laying sideways. At 1:00 a.m. the resident was still laying on his bed without clothes with his legs over his head. When asked what he was doing he would not answer the question. At 2:00 a.m. the resident came running out of his room dressed in clothes swearing at the staff when he was reminded to use his walker. He said if I fall, I fall. I don't care. A few minutes later the resident came back out of his room with his walker stating that now he feels he is having trouble walking and he needed help sitting in a chair and standing up from the chair. Review of a progress note written by RN Employee E26 dated 4/25/22, at 12:19 a.m. indicated, Called to hemlock unit by the floor nurse at 2250. Got to unit in resident's room was a female resident sitting on floor no bottoms on shirt unbuttoned. Staff reported another resident reported to them there is a man down the hall without any pants on. As staff going to said room observed this male resident dragging female resident on floor without pants on brief shredded on floor bed alarm sounded this male resident stated to staff he unbuttoned her shirt. Staff got female resident off floor to safe area 2 small scratches noted to female resident. Review of a progress note written by LPN Employee E21 dated 4/25/22, at 1:04 a.m. indicated, At approx. 2250 a resident came to nurses station stating there was a male resident with no pants on with privates out. Both NAs got to this resident's room before writer. Wheelchair alarm of other resident, which was a female, sounding at this time. NA reported to writer that this resident had another resident ' s legs up in the air pulling said resident across the floor. Other resident noted to not have pants or brief on, shirt unbuttoned. Other residents brief noted to be shredded and all over the floor. Other resident noted to be trying to get away from this resident by kicking legs. This resident first stated, I didn't do it. Writer asked this resident how other residents shirt got unbuttoned. This resident said, I did it. This resident also stated to writer and NAs I was trying to put her in bed. This resident and other resident separated immediately. RN was notified immediately of situation by writer. 1:1 supervision of resident initiated immediately and will continue remainder of shift. Review of a progress note written by RN Employee E31 on 4/29/22, at 1:25 p.m. indicated Resident was then asked what kind of music he'd prefer and resident stated, anything more [OBSCENITY] able. During a follow-up interview on 5/20/22, at 3:21 p.m. Psychiatrist Employee E42 stated that all [CONDITION(S)] meds can cause hypersexuality. Psychiatrist Employee E42 confirmed that he had not been notified by facility staff that Resident R1 had displayed new sexual behaviors. Review of all progress notes since admission failed to indicate any documentation of notification to psychology, psychiatry, or facility administration of increased sexual behaviors beginning in December 2021. During an interview on 5/12/22, at 1:30 p.m. LPN Employee E1 stated that she remembered writing the above progress notes, and confirmed that Resident R1 had begun acting out sexually since December 2021, and the behaviors had escalated. LPN Employee E1 stated that the facility administration was aware of Resident R1 ' s behaviors, as he was moved from the open units to the memory impaired unit after she had asked facility administration to review his increasing behaviors. LPN Employee E1 further stated that his behaviors were disruptive to other roommates, and on multiple occasions, Resident R1's roommate would find other areas to sleep due to Resident R1's continual masturbation, [MEDICATION(S)] for hours at times. The facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from sexual abuse, the facility failed to identify abuse as sexual and failed to assess residents current and past that may have/had the potential to be sexually abused, these failures resulted in an sexual assault on one Resident of 29 cognitively impaired residents (Resident R2). An immediate jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on 5/7/22, at 3:51 p.m. related to the facility's failure to protect Resident R2 from sexual abuse by Resident R1 and 29 cognitively impaired residents from the potential of being sexually abused by Resident R1. The immediate jeopardy template was provided to the facility on [DATE], at 3:51 p.m. The corrective action plan included: All residents in the secured unit were being assessed for any signs and symptoms of trauma/sexual abuse. All incidents 60 days prior to the date of the event will be reviewed. Any incidents found will be fully investigated, and residents who have experienced such events will be assessed by a licensed provider and a sexual assault specialist will be contacted. Whole house education will be provided on sexual and physical abuse. Audit of all incident reports and progress notes will be audited by DON or designee for the next 60 days. During staff interviews on 5/8/22, between 10:00 a.m. - 10:55 a.m. 20 staff members confirmed they received reeducation on sexual abuse, including the definition of sexual and physical abuse and actions to take if it is thought to have occurred. (1 Registered Nurse, 3 Licensed Practical Nurses, 9 Nurse Aides, 3 Dietary employees, 2 Environmental Services employees, and 2 Activities Department employees). The immediate jeopardy was removed on 5/8/22, at 11:01 a.m. when the action plan was verified. During an interview on 5/8/22, at 10:55 a.m. Nursing Home Administrator (NHA) confirmed on 4/24/22, Resident R2 was found with no pants/brief on in a room on the secured unit with his/her ankles being held by Resident R1 who was standing over Resident R2 with no pants and the facility failed to protect Resident R2 from sexual abuse and failed to identify the incident as sexual abuse, and the facility did not assess other residents on the secured unit to determine if they had been sexually abused resulting in an immediate jeopardy situation. 28 Pa. Code 201.14: (a) Responsibility of licensee. Previously cited 2/11/21 28 Pa. Code 201.18: (b)(1) Management. Previously cited 6/29/20 28 Pa. Code 201.18: (e)(1) Management. 28 Pa.Code: 201.18: (d)(1)(3) Nursing services Previously cited 8/27/21, 2/11/21

Based on clinical record review and staff interview, it was determined that the facility failed to provide the necessary services to meet the psychosocial needs resulting in actual harm of the commitment of resident to resident sexual abuse for one of two residents with increased sexual behaviors. (Resident R1). Findings include: Review of the facility policy, Behavior Monitoring dated 11/1/21, indicated the facility will monitor the behaviors of residents receiving [CONDITION(S)] medications. The policy further indicated that the resident's plan of care will be reviewed and updated as appropriate with any changes. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment A review of the prescribing information for [MEDICATION(S)], a medication used to treat symptoms of [CONDITION(S)], (progressive nervous system disorder that affects movement) revised 2/15/22, indicated that [MEDICATION(S)] is a [MEDICATION(S)] agonist (medications that work by imitating the actions of [MEDICATION(S)] when levels are low) indicated that some people who take [MEDICATION(S)] have increased sexual urges. Resident R1 was admitted to the facility initially on 1/13/15, and readmitted on [DATE]. Review of Minimum Data Set (MDS, periodic review of resident needs) dated 11/10/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 8, moderately impaired. Review of MDS dated [DATE], indicated an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5, indicating severe impairment. Review of the clinical record indicated that on 4/20/22, an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician order history indicated [MEDICATION(S)] ordered in varying doses from: 1/13/15 - 4/20/15 4/20/15 - 7/25/15 8/01/15 - 1/30/16 2/03/16 - 8/17/16 8/18/16 - 1/02/19 1/02/19 - 5/02/22 Review of Resident R1's plan of care for [CONDITION(S)] medication use, originally initiated 1/27/15, and most recently updated 03/04/22, failed to include hypersexuality as a possible side effect of his medications, and failed to include goals and interventions related to hypersexuality. Review of Resident R1's clinical record indicted that he received psychological counseling services 19 times from 2019, through 2022. The psychiatry clinical note dated 1/21/22, indicated: Discharge from follow-up. We will remain available for consultation PRN (as needed). Review of Resident R1's clinical record indicted that he was reviewed by psychiatry on 6/17/21, 7/15/21, 12/21/21, and 1/14/22. Review of facility census records and progress note indicated that Resident R1 was moved to the locked memory impaired unit on 1/24/22. Review of a physician order dated 7/29/21 - 1/24/22, indicated that Resident R1 would receive [MEDICATION(S)] (used to treat hallucinations and delusions in people with [CONDITION(S)] from [CONDITION(S)]) 34 milligrams daily. Review of a physician order dated 1/25/22 - 2/9/22, indicated that Resident R1 would receive a tapered dose of [MEDICATION(S)] 34 milligrams as follows: one tablet for three days, then one tablet every other day for seven days, then one tablet every three days. Review of approximately seven years of progress notes (01/13/15 - 12/26/21) indicated one progress note indicating sexual behavior: 3/25/19, at 9:06 a.m. : Resident asked CNA (Certified Nurse Aide) Will you play with my penis. CNA told the resident this was unacceptable question to ask the CNA. Resident's call bell was on writer went to resident's room and asked resident what he had needed, at first resident replied nothing resident then asked, Will you play with my dick? Review of approximately four months of progress notes (12/27/21 - 4/29/22) indicated eleven progress notes indicating sexual behavior. Review of a progress note written by LPN Employee E14 dated 12/27/21, at 5:27 p.m. indicated, Resident noted to be in his room naked and laying in his bed holding his pillow inappropriately. When he noticed writer he jumped from his bed and covered himself. Review of a progress note written by LPN Employee E1 dated 12/31/21, at 1:54 p.m. indicated, resident being sexually inappropriate towards staff. resident asked if he could see her pussy and stated for LPN to take her panties off while grabbing at LPNs arm. LPN left the room after telling the resident he was being inappropriate and needed to stop resident repeated his previously stated questions. Review of a progress note written by LPN Employee E11 dated 1/1/22, at 9:45 p.m. indicated, Writer entered room to give hour of sleep meds. Writer noted him prone in bed without clothing\ or night shirt. also no brief. writer questioned him as to why he had nothing on he stated I'm playing with my butt. Review of a progress note written by LPN Employee E1 dated 1/8/22, at 12:38 a.m. indicated, resident was peeking into a female resident's room and attempted to go in even after being told that he should not go in there because it was a female resident's room. resident was stopped by staff and reminded he could not go into another person's room without their permission. resident huffed and walked down the hall peeking into other resident rooms. Review of a progress note written by LPN Employee E14 dated 1/14/22, at 2:40 p.m. indicated, Upon entering resident's room, noted curtain pulled. Called resident's name to alert him of my presence. Upon entering resident's area, he was noted to be completely naked and shuffling around on his bed. Review of a progress note written by LPN Employee E11 dated 1/18/22, at 6:59 a.m. indicated, resident spent majority of night shift masturbating and thrusting into mattress. Review of a progress note written by the Director of Nursing dated 3/15/22, at 2:05 p.m. indicated, LPN asked resident how he was feeling 3/14/22 at 4:30 p.m. due to his blood pressure being elevated the day before. Resident stated that he felt good, I wish I could go back home and have sex with that lady again. LPN asked what lady was he talking about, stated, The one that lives down the road from my dad's house. LPN asked does your father know? Resident did not answer anymore questions. Resident was on a leave of absence with father over this past weekend. Call placed to family and updated on statement. Per sister, their father lives on a desolate road and the neighbors are not close for him to walk to. He has to go down 20 plus cement stairs and walk up or down hills to get to a neighbor and would not be able to make it out of the house without assist from the father. The road is a side road that is hardly driven on and not well traveled. Sister stated that she would update the father about comment made. Review of a progress note written by LPN Employee E17 dated 3/22/22, at 1:14 p.m. indicated, while approaching pt for his afternoon meds pt said, I told you I don't want anymore. Attempted to redirect pt and he said, I'll take them if you do a dance on my [NAME]. Redirected pt and told him that was inappropriate. He then stated that the last time he was home at his dads that he was playing with his [NAME] on the street and went to the neighbor lady and asked her for sex and she called the police on him. He also stated his dad was mad at him and the cops came to talk to him. Review of a progress note written by RN Employee E24 dated 4/12/22, at 7:17 a.m. indicated, At approximately 12:00 a.m. overnight the resident was laying completely naked on his bed laying sideways. At 1:00 a.m. the resident was still laying on his bed without clothes with his legs over his head. When asked what he was doing he would not answer the question. At 2:00 a.m. the resident came running out of his room dressed in clothes swearing at the staff when he was reminded to use his walker. He said if I fall, I fall. I don't care. A few minutes later the resident came back out of his room with his walker stating that now he feels he is having trouble walking and he needed help sitting in a chair and standing up from the chair. Review of a progress note written by RN Employee E26 dated 4/25/22, at 12:19 a.m. indicated, Called to hemlock unit by the floor nurse at 2250. Got to unit in resident's room was a female resident sitting on floor no bottoms on shirt unbuttoned. Staff reported another resident reported to them there is a man down the hall without any pants on. As staff going to said room observed this male resident dragging female resident on floor without pants on brief shredded on floor bed alarm sounded this male resident stated to staff he unbuttoned her shirt. Staff got female resident off floor to safe area 2 small scratches noted to female resident. Review of a progress note written by LPN Employee E21 dated 4/25/22, at 1:04 a.m. indicated, At approx. 2250 a resident came to nurses station stating there was a male resident with no pants on with privates out. Both NAs got to this resident's room before writer. Wheelchair alarm of other resident, which was a female, sounding at this time. NA reported to writer that this resident had another resident ' s legs up in the air pulling said resident across the floor. Other resident noted to not have pants or brief on, shirt unbuttoned. Other residents brief noted to be shredded and all over the floor. Other resident noted to be trying to get away from this resident by kicking legs. This resident first stated, I didn't do it. Writer asked this resident how other residents shirt got unbuttoned. This resident said, I did it. This resident also stated to writer and NAs I was trying to put her in bed. This resident and other resident separated immediately. RN was notified immediately of situation by writer. 1:1 supervision of resident initiated immediately and will continue remainder of shift. Review of a progress note written by RN Employee E31 on 4/29/22, at 1:25 p.m. indicated Resident was then asked what kind of music he'd prefer and resident stated, anything more [OBSCENITY] able. During a follow-up interview on 5/20/22, at 3:21 p.m. Psychiatrist Employee E42 stated that all [CONDITION(S)] meds can cause hypersexuality. Psychiatrist Employee E42 confirmed that he had not been notified by facility staff that Resident R1 had displayed new sexual behaviors. Review of all progress notes since admission failed to indicate any documentation of notification to psychology, psychiatry, or facility administration of increased sexual behaviors beginning in December 2021. During an interview on 5/12/22, at 1:30 p.m. LPN Employee E1 stated that she remembered writing the above progress notes, and confirmed that Resident R1 had begun acting out sexually since December 2021, and the behaviors had escalated. LPN Employee E1 stated that the facility administration was aware of Resident R1 ' s behaviors, as he was moved from the open units to the memory impaired unit after she had asked facility administration to review his increasing behaviors. LPN Employee E1 further stated that his behaviors were disruptive to other roommates, and on multiple occasions, Resident R1's roommate would find other areas to sleep due to Resident R1's continual masturbation, [MEDICATION(S)] for hours at times. During an interview on 5/7/21, at 12:30 p.m. the Director of Nursing confirmed that she was unaware of Resident R1's new hypersexual behaviors beginning in December 2021, which were a change from his behavior of the prior seven years, confirmed that the psychology and psychiatry notes did not indicate that facility staff had notified the providers of the new sexual behaviors, confirmed that Resident R1 had psychology services discontinued due to a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(3)(5)Nursing services Previously cited: 2/11/21 28 Pa. Code 211.16(a)Social services

Based on review of facility policies, clinical records and facility documents, and staff interview, it was determined that the facility failed to make certain that residents are free from neglect, which resulted in actual harm (fractured ankle and fibula/calf bone) for one of eight residents (Resident R1). Findings include: The facility policy Resident Protection from Abuse, Neglect or Exploitation last revised on 9/12/18, indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the Admission Face Sheet indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 1/31/19, indicated that Resident R1 was re-admitted to the facility on [DATE], and had current [DIAGNOSES REDACTED]. A review of the initial physician order [REDACTED]. A review of the facility incident report indicated that on 5/2/19, at 3:30 p. m. Nurse Aide Employee E1 was pushing Resident R1 in her wheelchair to the dining room, when LPN Employee E2 alerted her to stop as her left foot was bent underneath her wheelchair. A review of the mobile x-ray report dated 5/2/19, indicated that Resident R1 had an acute medial malleolar (middle ankle) fracture. A review of the hospital x-ray report dated 5/3/19, indicated an acute nondisplaced bimalleolar fracture (occurring on the side and middle) of the ankle and an acute Weber A fracture (near the ankle) of the distal (end nearest the foot) fibula (the smaller of the two calf bones). A review of the statement dated 5/3/19, and signed by NA Employee E1, indicated that NA Employee E1 was aware that residents' feet are to be on the wheelchair leg rests during transport. A review of the facility's investigation of Resident R1's incident on 5/2/19, indicated that NA Employee E1 failed to follow the physician order [REDACTED]. A review of the physician order [REDACTED]. She had an order to change her transfer status to mechanical lift with assist of two staff. She also has an order for [REDACTED]. A review of the (MONTH) and (MONTH) 2019 medication administration records revealed that Resident R1 did not have an order for [REDACTED]. During an interview on 5/15/19, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that Resident R1 was free from neglect during transport to the dining room which resulted in actual harm (acute nondisplaced bimalleolar left ankle fracture and acute Weber A [MEDICAL CONDITION] distal fibula) to Resident R1. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (3) (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) (2) (3) (5) Nursing services.

Based on review of facility policies, clinical records and facility documents, and staff interview, it was determined that the facility failed to provide physician ordered assistive devices which resulted in actual harm (fractured ankle and fibula/calf bone) for one of eight residents (Resident R1). Findings include: A review of the Admission Face Sheet indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 1/31/19, indicated that Resident R1 was re-admitted to the facility on [DATE], and had current [DIAGNOSES REDACTED]. A review of the initial physician order [REDACTED]. A review of the facility incident report indicated that on 5/2/19, at 3:30 p. m. Nurse Aide Employee E1 was pushing Resident R1 in her wheelchair to the dining room, when LPN Employee E2 alerted her to stop as her left foot was bent underneath her wheelchair. A review of the mobile x-ray report dated 5/2/19, indicated that Resident R1 had an acute medial malleolar (middle ankle) fracture. A review of the hospital x-ray report dated 5/3/19, indicated an acute nondisplaced bimalleolar fracture (occurring on the side and middle) of the ankle and an acute Weber A fracture (near the ankle) of the distal (end nearest the foot) fibula (the smaller of the two calf bones). A review of the statement dated 5/3/19, and signed by NA Employee E1, indicated that NA Employee E1 was aware that residents' feet are to be on the wheelchair leg rests during transport. A review of the facility's investigation of Resident R1's incident on 5/2/19, indicated that NA Employee E1 failed to follow the physician order [REDACTED]. A review of the physician order [REDACTED]. She had an order to change her transfer status to a mechanical lift with assist of two staff. She also has an order for [REDACTED]. A review of the (MONTH) and (MONTH) 2019 medication administration records revealed that Resident R1 did not have an order for [REDACTED]. During an interview on 5/15/19, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide physician ordered assistive devices for Resident R1 which resulted in actual harm (acute nondisplaced bimalleolar left ankle fracture and acute Weber A [MEDICAL CONDITION] distal fibula) to Resident R1. 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 7/28/17. 28 Pa. Code: 201.18 (b) (1) (3) (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) (2) (3) (5) Nursing services.