Every finding on record at Rehabilitation Center at Jefferson Hills, The

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in three of three locations where grievances boxes are located (main lobby, north and south nursing units). Findings include: A review of the facility policy Grievances/Complaints, Filing reviewed 1/16/25, grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During a resident group interview, on 2/11/26 at approximately 11:30 a.m., when asked if they felt they could anonymously file a grievance in the grievance boxes, consensus from the group was no. Residents stated, there a couple of boxes they are too high to reach, they are not made for people in wheelchairs, the boxes are in view of the staff, and you have to ask someone to help you, so we just ask the staff to do it for us. During an observation and interview on 2/12/26, at 9:00 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes; the lobby height was 54 inches, north nursing unit box height was 53 inches, and south nursing unit box, height was 57 inches. The box in the lobby was in view of the reception desk and blocked by a chair, the north nursing unit box was in view of the nursing station, and the south nursing unit box was blocked by a cart with a cooler in front of it and the box is in view of the nursing station. During an interview on 2/12/26, at 9:00 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents. 28 PA Code: 201.18(e)(4) Management.28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on a review of scheduled activities, observations, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents. Findings include: Review of the activity's calendars for the facility, from September through February 2026 revealed there are no group activities on Sunday's. There are three activities a day listed on the calendar with the last activity at 1 pm following lunch in the dining room. Review of the Activities calendar from September 2025 through February 2026 revealed the following: Daily9:30 a.m. 1 on 1 visits by distributing the facility Daily Chronicle (document for residents to read).11:30 a.m. Lunch Monday through Friday1:00 p.m. group activity Saturday1:00 p.m. rotating cycle one Saturday puzzles, one Saturday coloring, and one Saturday games. Sunday1:00 p.m. residents' choice a cart with books, magazines and items is taken around the facility if residents want to select something to do independently. During a group interview on 2/11/26, at approximately 11:30 a.m., consensus from the group revealed that residents would like additional activities. Residents stated there is only one activity during the week, it's at 1 pm. Residents stated they want to do something, not just have a cart that they can pick up something to do in their room on their own. The residents verbalized that they like the socialization of the group activity. The residents stated there isn't much to do on the weekend. During an interview on 2/11/26, at 1:15 p.m. Activities Director Employee E1 stated there is no activity coverage on the weekend from the activity department at this time. The activity assistant left the department approximately six months ago. Employee E1 confirmed that there is only one group activity during the week at 1:00 p.m. and she is not in the building to confirm the weekend activities. During an interview on 2/13/26, at approximately 9:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one of five nursing units. 28 Pa. Code: 201. 18(b)(3) Management.28 Pa. Code: 207.2(a) Administrators Responsibility.

Based on review of facility policy, personnel records, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.Findings include: The facility Activities Director employee job description indicated; The primary purpose of the job position is to plan, organize, implement, evaluate and direct the Activity Programs in accordance with the current federal, state, and local standards governing the facility and as directed by administrator, to ensure that the emotional, recreational, and social needs of the residents are met and maintained on an individual basis. Review of Activities Director Employee E1's personnel record indicated she was hired on 1/9/25. Review of Activities Director Employee E1's personnel record did not include evidence that Activities Director Employee E1 had proper qualifications as an Activities Director. The personnel record did not include previous history as an Activity Director, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During an interview on 2/12/26, at 1:15 p.m. Activities Director Employee E1 confirmed that she did not have education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During an interview on 2/12/26, at 1:25 p.m. Occupational Therapist Employee E3 confirmed that she did not have any oversite or involvement with the activity program at the facility. Employee E3 confirmed that she was the only regularly scheduled Occupational Therapist for the facility. During an interview on 2/12/26, at 1:35 p.m. Certified Occupational Therapy (COTA) Rehabilitation Services Director, Employee E2 confirmed that she only completes the mobility portion of the activities assessment in the clinical record and did not have any other involvement or oversite with the facility activity department programing or employee. During an interview on 2/13/26, at 9:45 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.28 Pa Code 201.18(b)(3) Management28 Pa Code 201.189(e)(6) Management

Based on a review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide prescribed treatments and services related to the care of pressure ulcers and/or pressure ulcer prevention for three of six residents (Resident R6, R7, and R23).Findings Include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays and increased morbidity and mortality. Three critical components in preventing pressure ulcers were listed: comprehensive skin assessments, standardized pressure ulcer risk assessments, and care planning and implementation to address areas of risk. Review of the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk indicated the scale was developed to foster early identification of patients at risk for forming pressure ulcers. Review of the facility policy, Pressure Ulcers dated 12/5/25, indicated, Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time. Residents will receive skin care, repositioning, and nutritional support to assist in preventing the development of avoidable pressure ulcers. The scale consists of six subscales and the total range from 6-23, with the following distributions:-Severe Risk: Less than or equal to 9.-High Risk: 10-12.-Moderate Risk: 13-14.-Mild Risk: 15-18. Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE]. Review of the Minimum Data Sent (MDS - periodic assessment of resident care needs) dated 2/2/26, included hemiplegia (paralysis on one side of the body), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Section M: Skin Conditions indicated Resident R6 has a Stage III pressure ulcer. Review of the most recent Braden Scale for Predicting Pressure Sore Risk (tool help health professionals assess a patient's risk of developing a pressure ulcer) completed on 9/9/21, indicated Resident R6 was at risk for pressure ulcer development. Review of R6's plan of care for risk of skin integrity impairment revised on 2/11/26, indicated to offload both heels while in bed every shift, turn and reposition Q2 (every two) hours, and wear palm guard on left hand at all times except during hygiene tasks. Review of a physician order dated 9/14/22, indicated a turn and position q2 (every two) hours while in bed. Review of a physician's order 8/21/23, indicated, Please use off-loading cushion under left calf to keep pressure off of left heal. Review of a physician's order 8/23/24, indicated, off load both heels while in bed. Review of Resident R6's treatment administration record (TAR) for February 2026, revealed Resident R6's palm guard was applied on 2/11/26, and 2/12/26. During an observation on 2/11/26, at 11:30 a.m. and Resident R6 was observed lying on his back, heels not offloaded, without the palm guard in place. During observations on 2/12/26, at 9:15 a.m., 11:00 a.m., 12:52 p.m., and 2:45 p.m. Resident R6 was observed lying on his back, heels not offloaded, without the palm guard in place. During observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident R6 was observed lying on his back, heels not offloaded, without the palm guard in place. During an interview on 2/13/26, at approximately 10:45 a.m. when asked if staff assisted him to elevate his heels or apply his palm guard, Resident R6 stated, Sometimes. During an interview on 2/13/26, at approximately 11:00 a.m. Licensed Practical Nurse (LPN) Employee E17 confirmed that Resident R6's heels were not offloaded, and he did not have a palm guard in place. Review of the clinical record indicated that Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), diabetes, and muscle weakness. Section M: Skin Conditions indicated Resident R7 has a Stage IV pressure ulcer. Section GG: Functional Ability indicated that Resident R7 required assistance to roll left and right in bed. Review of the most recent Braden Scale for Predicting Pressure Sore Risk completed on 3/14/23, indicated Resident R7 was at high risk for pressure ulcer development. Review of R7's plan of care for risk of skin integrity impairment revised on 2/11/26, indicated heel pillow boots to be on when in bed, turn and reposition Q2 hours, and to use wedge cushion to offload buttocks off sides. Review of a physician order dated 3/28/23, indicated, Use wedge cushion to offload buttocks off sides Q4 (every four) hours. Review of a physician order dated 5/25/23, indicated a turn and position q2 hours while in bed. During observations on 2/12/26, at 9:15 a.m., 11:00 a.m., 12:52 p.m., and 2:45 p.m. Resident R7 was observed lying on her back, without a wedge in place. The wedge was observed in the chair next to the bed. During observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident was observed lying on her back, without a wedge in place. The wedge was observed in the chair next to the bed. During an interview on 2/13/26, at approximately 8:45 a.m. when asked if staff assist in positioning her wedge, Resident R7 shook her head negatively. Review of the clinical record indicated that Resident R23 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included hemiplegia, aphasia (language disorder that affects communication and difficulty speaking), and history of a stroke. Section M: Skin Conditions indicated Resident R23 was at risk for pressure ulcer development. Section GG: Functional Ability indicated that Resident R23 required assistance to roll left and right in bed. Review of the most recent Braden Scale for Predicting Pressure Sore Risk completed on 7/30/21, indicated Resident R23 was at moderate risk for pressure ulcer development. Review of R23's plan of care for risk of skin integrity impairment revised on 4/21/25, indicated to obtain wedge for offloading in bed and to turn and reposition Q2 hours. Review of a physician order dated 4/27/22, indicated, Turn and position q2 hours. Review of a physician order dated 1/17/25, indicated, Obtain wedge for offloading while in bed. During an observation on 2/11/26, at 11:30 a.m. and Resident R6 was observed without a wedge in place. During observations on 2/12/26, at 9:15 a.m., 11:00 a.m., 12:52 p.m., and 2:45 p.m. Resident R6 was observed without a wedge in place. During observations on 2/13/26, at 8:45 a.m. and 10:45 a.m. Resident R6 was observed without a wedge in place. During an interview on 2/13/26, at approximately 11:00 a.m. LPN Employee E17 confirmed that Resident R23 did not have a positioning wedge. During an interview on 2/13/26, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide prescribed treatments and services related to the care of pressure ulcers and/or pressure ulcer prevention for three of six residents. 28 Pa. Code: 201.29(a) Resident rights. 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, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication carts and one of two medication storage rooms (North Hall storage room and South Hall medication cart).Findings include:Review of facility policy Storage of Medications dated 12/5/25, stated that medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation of the North Unit medication room on 2/11/26, at approximately 12:00 p.m. the following was observed:59 blood collection tubes with an expiration date of 10/31/25.7 blood collection tubes with an expiration date of 1/31/25.2 vacutainers with an expiration date of 11/30/25.3 vacutainers with an expiration date of 10/31/25.8 IV start kits with an expiration date of 11/30/23.4 IV extension sets with an expiration date of 5/31/25.1 syringe with an expiration date of 9/30/24.3 syringes with an expiration date of 6/1/25.4 package antibiotic ointment with an expiration date of 05/2025.1 box of (100) cleansing towelettes with an expiration date of 6/28/25.27 oral fluid collection devices with an expiration date of 03/2025.1 vial of tuberculin solution in the medication room refrigerator, partially used and undated. During an interview on 2/11/26, at 12:15 p.m. Licensed Practical Nurse Employee E10 confirmed the above observations. During an observation of the South Unit medication cart on 2/12/26, at approximately 8:35 a.m. the following was observed:-(1) bottle of Timolol eye drops, open and undated on bottle and storage container.-(1) bottle of Dorzolamide/Timolol open and undated on bottle and storage container.-(1) bottle of Latanoprost open and undated on bottle and storage container.Employee E16 confirmed that the above observation of medications not being labeled with dates on bottles or storage containers were noted on the multi-dose bottles that were in her cart when she started medication administration.During an interview on 2/12/26, at approximately 9:15 a.m. the Director of Nursing confirmed that the facility failed to make certain that unlabeled medications were in one of two medication carts and out of date supplies were properly stored and/or disposed of in one of two medication storage rooms. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1) Management.28 Pa Code: 211.9 (a)(1) Pharmacy services.28 Pa Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of two nursing units (North Nursing Unit).Findings include: Review of the facility policy Resident Environment dated 12/5/25, indicated in part The facility will provide an environment that is safe, clean comfortable and homelike, allowing the resident to use his or her personal belongings to the extent possible. During an observation on 02/12/2026, at 8:30 a.m., the following was identified: Residents R19 and R30 had tape surrounding the ceiling air vent. The air vent and tape had dust collected on both. Residents R4 and R41 had the rubber baseboard molding pulled away from the wall, for the entire length of the wall. Residents R26 and R40 had the rubber baseboard molding pulled away from the wall, for the entire length of the wall. Resident R26 had approximately a 30.61-millimeter hole in the wall at the outlet junction box that was in use. This was located near the floor between the head of Resident 26 bed and the outside wall. Hallway outside (room [ROOM NUMBER]) the ceiling has a cracked and partially patched and unpainted area. North Hallway handrails appear to have unpainted patched spots on both sides of the hall. Physical Therapy Department has a large vent in the middle of the room that has dust weaved throughout the vent. During an interview with Resident R26 and his parents, they confirmed that the room condition have been in existence since admission. During rounds and an interview on 2/12/26, at 9:00 a.m., the Nursing Home Administrator confirmed the above findings and that the facility failed to provide a safe, clean, comfortable, and homelike environment. 28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on resident and staff interviews, it was determined that the facility failed to provide reasonable access to mail services as available in the community to all residents of the facility.Findings include: A review of the facility policy Mail last reviewed 12/5/25, indicated Delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (or facility post office box ) and delivery of outgoing mail to the postal service within 24 hours, when there is no regularly scheduled postal delivery and pick-up service. During a group interview on 2/11/26, at approximately 11:30 a.m., consensus from the group revealed that residents reported the facility did not deliver mail or provide mail services on Saturdays. Review of the facility documents (activity calendars) for the past six months from 9/25 through 2/26 reveal a statement of Mail Delivery is Monday - Friday During an interview on 2/12/26, at 1:15 p.m. Activities Director Employee E1 confirmed that she does not deliver mail on Saturday as she is not in the building on weekends and she is the only employee of the activity department. During an interview on 2/13/26, at 9:22 a.m. Business Office Manager Employee E4 stated the facility does not get mail delivered on Saturday from the postal service. During an interview on 2/13/26, at 9:45 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure mail was delivered to the residents on Saturdays. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(j) Resident rights

Based on observations and staff interview it was determined that the facility failed to provide a safe environment for residents in one of two nursing units (waste room and staff restroom). Findings include:During an observation on 2/11/26, at approximately 11:45 a.m. the biohazardous waste room was noted to be unlocked. Within the room were 13 sharps containers on a shelf and two large biohazardous waste bag with multiple sharps containers in them on the floor. During an observation on 2/11/26, at approximately 11:50 a.m. the beauty shop was noted to be unlocked. Within the room was an environmental services cart with cleaning supplies and a large putty knife on top. During an observation on 2/11/26, at approximately 11:53 a.m. the staff restroom was noted to be not fully closed. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During an observation on 2/12/26, at approximately 11:00 a.m. the biohazardous waste room and the staff restroom were noted to be unlocked and accessible to residents. During an observation on 2/13/26, at approximately 10:45 a.m. the biohazardous waste room and the staff restroom were noted to be unlocked and accessible to residents. During an interview on 2/13/26, at approximately 10:50 a.m. Licensed Practical Nurse Employee E17 confirmed the biohazardous waste room was unlocked, and at that time she engaged the locking mechanism on the interior side of the door. At approximately 10:52 a.m. LPN Employee E17 confirmed that the staff restroom was unlocked and accessible to residents and that a call light was not available for use. During an interview on 2/13/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents in one of two nursing units. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.20(a)(b) Staff development.28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for eleven of fifteen staff members (Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and E15).Findings include: Review of the facility policy, Staff Development Program most recently reviewed 12/5/25, indicated, There shall be an ongoing coordinated education program which is planned and conducted for the development and improvement of skills of the facility personnel, including training related to technology, problems, needs and rights of residents Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI Program. Nurse Aide Employee E5 had a hire date of 10/24/25, and failed to have QAPI education upon hire or thereafter.Nurse Aide Employee E6 had a hire date of 11/23/25, and failed to have QAPI education upon hire or thereafter.Nurse Aide Employee E7 had a hire date of 2/5/24, failed to have QAPI in-service education between 2/5/25, and 2/5/26.Nurse Aide Employee E8Licensed Practical Nurse Employee E9 had a hire date of 11/24/25, and failed to have QAPI education upon hire or thereafter.Licensed Practical Nurse Employee E10 had a hire date of 1/29/24, failed to have QAPI in-service education between 1/29/25, and 1/29/26.Registered Nurse Employee E11 had a hire date of 1/14/16, failed to have QAPI in-service education between 1/14/25, and 1/14/26.Therapy Employee Employee E12 had a hire date of 12/12/22, failed to have QAPI in-service education between 12/12/25, and 12/12/26.Therapy Employee Employee E13 had a hire date of 12/18/23, failed to have QAPI in-service education between 12/18/25, and 12/18/26.Dietary Employee E14 had a hire date of 12/6/25, and failed to have QAPI education upon hire or thereafter.Environmental Services Employee E15 had a hire date of 12/26/23, failed to have QAPI in-service education between 12/26/25, and 12/26/26. During an interview on 2/13/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for eleven of fifteen staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, where postings are available (first floor lobby). Findings include: The facility must display in the facility, written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During observations completed on 2/11/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During rounds and an interview with the Nursing Home Administrator (NHA) on 2/12/26, at 9:00 a.m., the NHA confirmed the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for nine of thirteen staff members (Employee E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, and E15).Findings include: Review of the facility policy, Staff Development Program most recently reviewed 12/5/25, indicated, There shall be an ongoing coordinated education program which is planned and conducted for the development and improvement of skills of the facility personnel, including training related to technology, problems, needs and rights of residents Review of facility provided documents and training records revealed the following staff members did not have documented training on the resident rights Program. Nurse Aide Employee E5 had a hire date of 10/24/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide Employee E6 had a hire date of 11/23/25, and failed to have resident rights education upon hire or thereafter.Nurse Aide Employee E7 had a hire date of 2/5/24, failed to have resident rights in-service education between 2/5/25, and 2/5/26.Nurse Aide Employee E8Licensed Practical Nurse Employee E9 had a hire date of 11/24/25, and failed to have resident rights education upon hire or thereafter.Licensed Practical Nurse Employee E10 had a hire date of 1/29/24, failed to have resident rights in-service education between 1/29/25, and 1/29/26.Registered Nurse Employee E11 had a hire date of 1/14/16, failed to have resident rights in-service education between 1/14/25, and 1/14/26.Therapy Employee Employee E12 had a hire date of 12/12/22, failed to have resident rights in-service education between 12/12/25, and 12/12/26.Therapy Employee Employee E13 had a hire date of 12/18/23, failed to have resident rights in-service education between 12/18/25, and 12/18/26. During an interview on 2/13/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on resident rights for nine of thirteen staff members 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R1). This failure created an immediate jeopardy situation for 1 of 42 residents. Review of the facility policy Resident Rights dated 12/20/24, indicated the facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility medical diagnosis list dated 4/28/25, included diagnoses of hemothorax (condition where blood collects in the space between the chest wall and lung), Atrial Fibrillation (condition where the upper chambers of the heart beat out of rhythm causing an irregular and rapid heart rate), hypertension (condition where the force of blood against the artery wall is too high), anxiety and depression. Review of an Elopement Risk Assessment completed on 4/29/25, indicated Resident R1 was cognitively impaired, had poor decision-making skills, demonstrated exit seeking behavior, and wandered oblivious to safety needs. Review of the physician's orders reviewed on 5/5/25, indicated Resident R1 was not ordered any interventions to prevent elopement. Review of Resident R1's plan of care dated 4/29/25, did not indicate risk for elopement nor did it have interventions to prevent elopement. Review of the Police report dated 5/1/25, by Police Officer E1 indicated that on 5/1/25, at 8:18 p.m., RN Supervisor (RNS) Employee E2 stated Resident R1 was placed in a recliner in the community room then later found in another resident's room. Resident R1 was then placed in a wheelchair and taken back to his room around 7:30 p.m. Further review of the police report indicated that Resident R1 was unsupervised from approximately 7:30 p.m. to 7:55 p.m., when the police arrived on site. Further review of progress notes failed to indicate Resident R1 had any wandering behaviors documented as mentioned in the police report. Review of the facility provided incident report dated 5/1/25, at 8:00 p.m. indicated, Received a call from the 911 Center asking if we had a resident with this man's name. Answered that we did and told them last time I rounded he was sitting at the nursing station for visual rounding. Was told by the dispatcher that the police and EMS were out with a man of this name. They stated he was not hurt or injured; however he stated that he had to get away from someone wash trying to shoot at me. He was located at [address provided]. EMS took the resident to the hospital for an eval and treat. Spoke with [registered nurse] a the hospital in reference to resident baseline and medication list. Head count was immediately performed throughout the building and we found at that time the resident was indeed missing, and he was our resident Resident was last seen around 1930 hours (7:30 p.m.) when he was taken back to his room in his wheelchair. Call placed to the sister-in-law who was listed as his emergency contact. She was explained the situation, and she advised, I'm not surprised, I hate to say that; however, he has done this at every facility he has been in with the exception of one and that was following a surgery.' Spoke with nurse at [hospital] approx 2200 hours (10:00 p.m.), stating they were running some test, blood work, and a CT scan, he as acting his baseline. Hospital stated the were waiting on results of UA C&S and if those were clear they would be sending resident back to the facility. Information passed along to all involved in house. Waiting resident return at this time. Further review of the incindent report failed to include the time that EMS service contacted the facility. Review of a progress note dated for 5/1/25, at 11:05 p.m. indicated that the facility received a call from the 911 call center inquiring if Resident R1 was a resident of the facility. An immediate head count was completed, and it was confirmed that Resident R1 was not in the facility. The facility was made aware that Resident R1 was currently at the Emergency Department. The progress note indicated that Resident R1 was last seen by facility staff around 7:30 p.m. Also indicated that MD and family were made aware at that time. The time of the call from the 911 Call Center was not documented within the note. Review of an employee statement dated 5/1/25, at 10:08 p.m., by Nursing Aide (NA) Employee E3 indicated, On 5/1/25 I, [NA Employee E3], was working South Hall on the 3:00-11:00 [p.m.] shift. I last observed patient [Resident R1] sitting in the recliner in the lounge area of the unit around 7:10 p.m. At that time, I started a round on my assignment. When coming out of a patient's room after doing care, I was notified that he was found by the police at 7:50 p.m. Review of an employee statement dated 5/1/25, at 10:26 p.m., by NA Employee E4 indicated, Last time I remember seeing resident was around 19:15 [7:15 p.m.]. I remember leaving a resident's room after attending to a call light on the 200 hall. I witnessed two residents standing by the side double doors to the right of the nurse's station. I then directed the resident in question to sit down in the black recliner chair and continue to watch TV. After a few minutes of completing some small random task, I then went in room [ROOM NUMBER] around 7:20-7:30ish (new admit) to check on and prepare to bed completed full bed change, emptied cath [urinary catheter], changed clothes, and completed person inventory check list with resident. While with the new admit resident about 20 min[utes] in, the nursing supervisor walked down the hall asking us to count the residents. I advised I will do count soon as soon as I finish the inventory check list I was working on. The count (comment) did not sound or feel urgent or immediate. Few moments later approximately 20:00 [8:00 p.m.] I finished with [resident in room] 201 and that's when I was told that the resident in question was gone/ had left and was found by the police. I still then walk out the front door to still check and look. And I was told that it was confirmed that resident had been picked up by police. Review of RNS Employee E2's statement written on 5/1/25, at 10:45 p.m., by the Acting-Nursing Home Administrator (NHA) indicated, I was outside in my car when I saw the resident walk outside. He had told staff he wanted to go to the ER to visit a friend. Staff reported they offered him a ride and he refused and wanted to walk. Police called and stated they took him to the ER. He returned from the ER a few hours later. During a follow-up interview on 5/5/25, at 9:38 a.m. Acting-NHA and Director of Nursing (DON) indicated that RNS Employee E2 statement was proved to be inaccurate per video footage. Acting-NHA and DON stated that RNS Employee E2 left front desk, which then left the front door unsupervised and Resident R1 left through the front door. During an interview on 5/5/25, at 10:10 a.m., the Police Officer indicated that a passer-by saw Resident R1 with no shoes on and called the police. The Police Officer stated that facility never called the local precinct or 911 call center. The Police Officer found resident one street over (approximately four blocks) in residential back yard with no shoes on and no memory of how he arrived there. Resident R1 was taken to the Emergency Department by police. The Police Officer stated while Resident R1 was in the emergency room that a complaint was filed with The Department of Aging related to a bruise on his upper left arm that appeared to be older. The NHA and the DON were made aware that an Immediate Jeopardy situation existed on 5/5/25, at 1:39 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 2:00 p.m. On 5/5/25, at 7:29 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Immediate action(s) taken for the resident(s) found to have been affected include: -On 5/1/2025 at approximately 7:30 PM the facility was in formed a resident was taken by police to the local emergency room . -On 5/1/2025 a root cause analysis was completed, and it validated the resident walked out the front door because there was no one monitoring the lobby area. -On 5/1 2025 a head count was completed all residents were accounted for. -On 5/1/2025 resident returned from the hospital at approx. 10:30PM were re assessed, no skin issues, no negative outcomes, no issues noted. The residents put on q 30 min checks. -On 5/1 2025 all elopement books were audited, and no issues were found. -All residents will be reviewed and assessed for elopement risk, wondering, and care plans and orders reviewed to include appropriate interventions. completed -Head counts completed. 2. Identification of other residents having the potential to be affected was accomplished by: -All residents in house will be assessed for elopement risk by the Director of Nursing or designee by 5/2/25. -All care plans for residents identified with elopement risks will be reviewed and updated with elopement risks will be reviewed and updated with interventions to prevent elopement by the Director of Nursing or designee by 5/2/25. -All residents identified to be elopement risk will be added to Elopement Binder per protocol by 5/2/25. -House audit on all doors and exit points will be conducted by Maintenance to ensure that facility is secure and alarms are functional by 5/2/25. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: -Facility Director of Nursing or designee will conduct education to all facility staff regarding dementia/behavior in LTC residents, Elopement risk and mitigation, and Elopement Policy and Procedures to include keeping doors secure prior to the start of the next shift. -All staff will be educated on elopement interventions such as responding to alarms, reorient wandering patients, encourage activities, monitoring the front lobby and sign in sheet, and code 10 this is the facility overhead announcement code for an elopement and safety checks. Staff will be educated that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book prior to the start of the next shift. -Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee, which has been completed. - Newly admitted residents were screened for elopement risk on admission quarterly and as needed and care plans will be updated appropriately. New admission and any resident that is assessed as an elopement risk will be placed in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor 24 hours a day 7 days a week. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: -The DON or designee will investigate all incidents perform root cause analysis and follow up with appropriate interventions. -The QAPI team will review the elopement interventions and update as required. -The RN supervisor is responsible for ensuring the front door is monitored 24 hours 7 days a week until the wander guard system is installed. -The lobby monitoring sign in sheet will be reviewed daily for 1 week then 2 times a week times 2 weeks then monthly times 2. -Door alarms will be audited daily by maintenance daily. -Elopement drills will be conducted monthly for 2 months on all shifts. -The plan of correction will be monitored by QAPI for 3 months including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk. This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews on 5/6/25, between 9:00 a.m. and 11:00 a.m. LPN Employees E23, E24, and E32, RN Employee E7, NA Employees E3, E4, E9, E10, E11, E12, E13, and E14, Occupational Therapy Employee E26, Dietary Employees E15, E16, E17, and E19, Environmental Services Employees E20, E21, E22, and E25, Business Office Manager E8, Physical Therapy Employees E27, E28, And E29, Social Work Director Employee E30, Speech Therapy Employee E31 and Activities Director E6 were provided scenarios to test their knowledge on and confirmed they received education on the elopement policy, elopement prevention and actions to take in the instance of elopement. During an observation on 5/6/25, at approximately 10:00 a.m. Resident R1's and Resident R2's pictures and information were present in the elopement book at the entrance/exit of the building. Further review of the elopement book with resident charts revealed all residents identified as elopement risks were included in the elopement book. The Immediate Jeopardy was removed on 5/6/25, at 2:30 p.m. when the action plan implementation was verified. During an interview on 5/5/25, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of three residents. This failure created an immediate jeopardy situation for 1 of 42 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and resident and staff interviews it was determined that the facility failed to make certain that showers and baths were provided for one of three residents (Resident R37). Findings include: Review of facility policy Resident Rights reviewed 12/20/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of facility policy Flow of Care reviewed 12/20/24, indicated care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. Residents are to have two bath/showers/week unless the resident states otherwise. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE], with diagnoses that included repeated falls, diabetes, and low blood pressure. Review of Resident R37' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 2/10/25, indicated the diagnoses remain current. Review of the MDS dated [DATE], Section F - Preferences for Customary Routine and Activities; Question F0400 Interview for Daily Preferences Question C. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Indicated to Resident R37 this choice was somewhat important while in the facility. Further review of the MDS Section GG - Functional Abilities and Goals Question GG0130 Self-Care E. Shower/bathe self, indicated Resident R37 needed partial/moderate assistance. Review of the ACT - Activities Evaluation completed 8/27/24, revealed Resident R37 answered it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. During an interview on 3/12/25, at 10:40 a.m. Resident R37 stated he prefers showers and was unable to recall when he last had one. A review of the clinical record indicated Resident R37 received a shower on the following dates: August 2024 - no documented showers; 19 documented bed baths September 2024 - 9/4/24, 9/7/24, 9/9/24, 9/12/24, 9/22/24; 35 documented bed baths October 2024 - 10/5/24, 10/10/24, 10/19/24, 10/25/24; 38 documented bed baths November 2024 - 11/11/24; 40 documented bed baths December 2024 - 12/5/24, 12/27/24, 12/30/24; 34 documented bed baths January 2025 - no documented showers; 34 documented bed baths February 2025 - 2/6/25; 42 documented bed baths March 2025 - 3/10/25; 17 documented bed baths Review of the care plan dated 8/21/24, indicated to keep skin clean and dry, monitor and report reddened areas to MD (doctor), assist x 1 with transfers During an interview on 3/13/25, at 10:00 a.m. the Director of Nursing confirmed the facility failed to consistently provide showers and/or baths for Resident R37. 28 Pa. Code: 211.12(1) Nursing services. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for two of five residents reviewed (Residents R20 and R24). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of facility policy Nursing Care of the Diabetic Resident reviewed 12/20/24, indicated the facility will recognize, assist, and document the treatment of complications commonly associated with diabetes. Documentation should reflect the carefully assessed diabetic resident and include vital signs, level of consciousness, assessment of the skin, emotional/mood changes, and pain/discomfort. Document results of any fingerstick blood glucose monitoring, interventions to stabilize blood glucose levels, and notification to physician. Review of facility policy Notification of Condition Change: Physician reviewed 12/20/24, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident ' s condition. Document assessment data, attempted or actual correspondence with physician, and physician ' s response in the medical record. Review of facility Hypoglycemic Protocol reviewed 12/20/24, indicated if resident ' s blood glucose is less than 70 administer rapidly absorbed simple carbohydrate such as four ounces (oz) of juice, five or six oz of regular soda, or tube of glucose gel. Repeat blood glucose in 10-15 minutes and repeat protocol if still less than 70. If resident is symptomatic, notify physician. Review of the clinical record indicated Resident R20 was readmitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure. Review of Resident R20' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 2/1/25, indicated the diagnoses remain current. Review of Resident R20 physician ' s order revealed the following orders: - On 6/10/24, Glucagon (raises blood glucose level) one milligram, inject one dose as needed - On 6/18/24, inject Novolog (begins to work about 15 minutes after injection, peaks in about one or two hours after injection, and last between two to four hours) per sliding scale, if over 401 call provider - On 9/2/24, insulin Glargine (long-acting type of insulin that works slowly, over about 24 hours) inject 38 units at bedtime Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 10/2/24, at 6:05 a.m. glucagon one milligram was administered to Resident R20. - On 10/2/24, at 6:34 a.m. the CBG was noted to be 50. - On 12/7/25, at 6:14 a.m. the CBG was noted to be 52. Review of the care plan dated 10/11/22, indicated the following interventions: diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, and monitor/document/report to doctor as needed signs and symptoms of hypoglycemia. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R24 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R24 physician ' s orders revealed the following orders: - On 11/3/22, Accucheck/CBG as needed. - On 8/14/23, CBG/Accuchecks one time daily, call provider if greater than 400. - On 1/13/24, insulin Lantus (glargine) inject 30 units at bedtime. Review of Resident 24's eMAR revealed that the resident's CBG's were as follows: - On 8/6/24, at 8:04 p.m. the CBG was noted to be 438. Review of the care plan dated 11/3/22 and 4/14/23, indicated the following interventions: Monitor/document/report to doctor as needed signs and symptoms of hyperglycemia, and follow facility protocol for hypo/hyperglycemia. Review of Resident R24's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. During an interview on 3/12/24, at 10:35 a.m. Licensed Practical Nurse (LPN) Employee E1 stated with no blood glucose parameters she would call the doctor is CBG was under 70 or over 400, she would notify the doctor. If the blood glucose was under 70, she would assess the resident, provide the resident with a snack, recheck the blood glucose in 15 minutes, notify the supervisor, and doctor. If the blood glucose was over 400, she would assess the resident, give the ordered insulin, notify the doctor, and recheck the blood glucose in 15 minutes. She would document in the eMAR and progress notes. During an interview on 3/12/25, at 1045 a.m. LPN Employee E2 stated with no blood glucose parameters she would call the doctor is CBG was under 70 or over 400-500 depending on the resident. If the blood glucose was under 70, she would follow the hypoglycemia protocol, give the resident a snack, notify the doctor, and recheck the blood glucose in 15 minutes. If the glucose was over 400, she would give the maximum amount of insulin ordered and call the doctor. She would document in the eMAR and progress notes. During an interview on 3/13/25, at 10:00 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R20 and R24. 28 Pa. Code 201.18 (b)(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 clinical records and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident R37). Findings: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE], with diagnoses that included repeated falls, diabetes, and low blood pressure. Review of Resident R37' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 2/10/25, indicated the diagnoses remain current. Review of the MDS dated [DATE], Section C - Cognitive Patterns, Question C0500 BIMS Summary Score indicated Resident R37 BIMS score was 15. Review of the MDS dated [DATE], Question C0500 BIMS Summary Score indicated Resident R37 BIMS score was 12. Review of the MDS dated [DATE], Question C0500 BIMS Summary Score indicated Resident R37 BIMS score was 10. Review of the clinical record progress notes revealed documentation of the following: On 11/19/24, Palliative Care Note - Follow-Up note indicated Resident R37 ' s BIMS Score was 15. On 12/10/24, Palliative Care Note - Follow-Up note indicated Resident 37 ' s BIMS Score was 15. On 1/4/25, Palliative Care Note - Follow-Up note indicated Resident R37 ' s BIMS Score was 15. On 2/18/25, Palliative Care Note - Follow-Up note indicated Resident R37 ' s BIMS Score was 15. On 3/11/25, Palliative Care Note - Follow- Up note indicated Resident R37 ' s BIMS Score was 15. During an interview on 3/13/25, at 10:00 a.m. the Director of Nursing (DON) confirmed the facility failed to ensure documentation was accurate and complete for Resident R37. The DON stated the facility did not have a policy specific for documentation in the clinical records. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R1). Findings include: Review of the facility policy Notification of Change Condition: Responsible Party/Guardian dated 5/1/24, indicated the responsible party or guardian is to be notified when there has been any break in the resident's skin integrity. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia and a fractured left leg. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of Resident R1's admission assessment dated [DATE], indicated the resident had a skin alteration to the coccyx (lower back) 0-0.3 cm (centimeters) with light exudate (abrasion) and granulated (healing) tissue. Review of Resident R1's nurse progress note dated 7/8/24, indicated possible [NAME] Wound (pressure ulcer that has a sudden onset and rapid progression) to coccyx 6.5 cm X 7 cm, dressing applied and wound care CRNP (certified registered nurse practitioner) sent to assist in treatment plan. There was no evidence in the clinical record that the resident's family was notified of this change in condition. During an interview on 8/22/24, at 3:0 p.m. the Director of Nursing confirmed that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R1). 28 Pa. Code: 201.29(a)(b)(c)(d)(j)(m) Resident rights. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28. Pa. Code: 211.10(a)(c)(d) Resident care policies.

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R1) Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia, and a left leg fracture. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 7/4/24, indicated the diagnoses remain current. Review of a physician order dated 7/15/24, indicated to cleanse the top of both feet with NSS (normal saline solution), apply Xeroform (a moisture dressing) to open areas, apply 4X4 gauze, and wrap with gauze daily for wound care. Review of Resident R1's Treatment Administration Record (TAR), dated July 2024, indicated the treatment was applied on 7/16, and 7/17/2024. Resident R1 was discharged to home on 7/17/24. Review of weekly skin check documentation dated, 06/28/24, 7/3/24, and 7/10/24, indicated that Resident R1 did not have open areas to the top of both feet. During an interview on 8/22/24 at 1:30 p.m., Licensed Practical Nurse (LPN) Employee E1 revealed Resident R1 did not have wounds to the feet while a resident at the facility. During a telephone interview on 8/22/24 at 2:25 p.m., LPN Employee E2 revealed the documentation on Resident R1's TAR was incorrect. During an interview on 8/22/24 at 2:15 p.m., The Director of Nursing (DON) confirmed the above findings and revealed the physician order and TAR documentation for wound care to both feet was entered on the wrong resident's chart, and the facility failed to make certain that medical records were complete and accurately documented for Resident R1. 28 Pa. Code: 211.5(f) Clinical records. 28 Pa. Code: 211.5(g)(h) Clinical records.

Based on review of facility documents, resident and staff interviews it was determined that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission for 44 of 44 admitted residents. Findings include: Review of the Admission Packet list attachments as Attachment P Voluntary Arbitration Agreement. Review of the Arbitration Agreement indicated that the agreement is voluntary. The agreement has been explained to the Resident and his or her Representative in a form and manner that he or she understands. The signature section at the end of the agreement stated THE EXECUTION PAGE MUST BE SIGNED BY EITHER THE RESIDENT OR THE RESIDENT'S REPRESENTATIVE. This section did not include options to agree or disagree to enter into the binding arbitration agreement, or a refusal to sign. Review of facility census information indicated 44 residents were admitted to the facility from 1/1/24, through 3/7/24. During an interview on 3/7/24, at 11:00 a.m. Business Office Manager (BOM) Employee E2 confirmed that all residents sign the arbitration agreement. BOM Employee E2 stated that when she was trained on admissions procedures she was told that all residents needed to sign. BOM Employee E2 confirmed that the arbitration agreement forms did not provide the option of refusing to enter into the agreement, and that the signature of the resident or the resident's representative conveyed acceptance of the arbitration agreement. During an interview on 3/7/24, at 11:14 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission. 28 Pa. Code 201.14(a)Responsibility of Licensee.

Based on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) for eleven of eleven months (April 2023 through February 2024). Findings include: A review of the facility policy Legionnaires' Disease Infection Control and Monitoring Policy dated 2/12/24, did not include a water management program based on framework outlined in ASHRAE and CDC Standards identified as per the Maintenance Director Employee E1 and confirmed with the Nursing Home Administrator to minimize risk for Legionella associated with the building water systems at The Rehabilitation Center at [NAME] Hills. During an interview on 3/7/24, at 1:00 p.m., Maintenance Director Employee E1 and the Nursing Home Administrator confirmed that the facility did not implement and effective water management program for the prevention and control of water-borne contaminants, such as Legionella since 2023. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies.

Based on a review of facility documentation and staff and resident interviews, it was determined the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. Findings include: Review of facility's scheduled meal times revealed meal times revealed greater than 14 hours between dinner and breakfast. Breakfast: North Unit 9:00 a.m.; South Unit 9:10 a.m. Lunch: North Unit 1:00 p.m.; South Unit 1:10 p.m.; Dining Hall 1:15 p.m. Dinner: North Unit 5:00 p.m.; South Unit 5:10 p.m. During a resident group interview on 3/5/24, at 2:00 p.m. the residents stated that snacks at night are usually potato chips or snack puddings. On 3/7/24, at approximately 10:30 a.m. documentation was requested from Activities Director Employee E3 that the resident group agreed to this meal span. During an interview on 3/7/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. 28 Pa. Code 211.6(a)(b) Dietary services