Every finding on record at River's Bend Health & Rehab Center

Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1) who displayed aggressive behavior and physically pushed another resident (Resident 2), causing a fall with a hip fracture. This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy, titled Resident Observation Policy, with a last revised date of May 28, 2021, and a last review date of January 28, 2026, revealed, in part, Procedure: A. The charge nurse will contact the DON (Director of Nursing) who, if necessary, will consult with administrative staff and/or the Director of Mental Health, if applicable, to determine the appropriate observation/interventions if the resident meets on of the following criteria: 2. Resident is a danger to others, to include but not limited to, homicidal comments/threats/actions; 4. Resident is acting out behaviorally, to include but not limited to, throwing items, continuous screaming/disruptive behavior; B.) DON will assign a staff member to complete the appropriate observation/interventions which may include but are not limited to, every 15 or 30 minute checks or 1:1 monitoring. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (an ongoing, progressive lung condition that restricts airflow and makes breathing difficult) and hyperlipidemia (high amounts of fats in the blood). Review of Resident 1's care plan revealed a problem focus area for behavioral symptoms, which included the following behaviors: Resident experiences wandering in hallways and into other rooms, Resident has behaviors of taking roommate's clothing and wearing them despite name tag on clothing, aggressor in resident-to-resident altercation, perception of missing money; makes accusatory statements towards staff and peers; Resident has behaviors of yelling out; Resident refuses care and medications; with a start date of January 27, 2026, and an edited date of June 30, 2026. Interventions included 1:1 Nursing Supervision. Review of Resident 1's clinical record revealed a progress note on May 7, 2026, at 7:16 PM, where the Resident had to be re-directed from hitting another resident in the evening, calling the other resident names using profane language. Resident 1 followed an employee to the medication cart and started pushing the employee and stated, I'm going to punch you in the face. Review of Resident 1's clinical record revealed a progress note on May 10, 2026, at 8:11 PM, that stated Resident 1 was aggressive towards staff and residents, in which a 1:1 was initiated for safety measures. Resident was stating that other residents stole his money, and went to another resident who was standing by the door to her room and stated, where is my money you b***h and walked to where she was standing and kicked her on her left thigh, leaving a red mark. Review of Resident 1's clinical record revealed a progress note on May 23, 2026, at 11:46 PM, that revealed he was noted with some episodes of anxiety, several exit seeking behaviors and being verbally aggressive towards other residents. Review of a nursing progress note on June 3, 2026, at 2:20 PM, revealed Resident 1 was being monitored for close supervision and 15-minute checks. Resident 1 was noted to have increased aggression towards staff and residents, and was also noted to have increased exit seeking behaviors with attempts made to exit the facility. Resident 1 has since been placed on a 1:1 supervision. IDT (interdisciplinary team) in agreement that the Resident to be removed from 1:1 monitoring to close observation with 15-minute checks. Review of the facility provided incident report revealed a resident-to-resident altercation between Resident 1 and Resident 2 on June 15, 2026, at approximately 8:00 PM. Further review of the incident report revealed Resident 1 became agitated perceiving he was missing money. Resident 1 approached Resident 2 and became verbally aggressive and subsequently pushed Resident 2 prior to staff being able to intervene. Resident 2 sustained a fall and complained of leg pain and was transferred to the hospital for evaluation and treatment. Hospital imaging revealed that Resident 2 sustained a right hip fracture that required surgical intervention. Review of a nursing progress note on June 15, 2026, at 11:32 PM, revealed Resident 1 had entered into Resident 2's room and pushed her into the wall, causing her to fall to the floor. Staff reported Resident 1 had become agitated, exit-seeking, and was swearing at staff and other residents for some time prior to this event. Staff were monitoring Resident 1 as he walked toward his room. Resident 1 saw Resident 2 in the next room looking out the door to see who was causing the commotion, Resident 1 entered the room and pushed Resident 2. Resident 2 fell and needed to be transported to the emergency department. Review of Resident 2's clinical record revealed a nursing progress note on June 17, 2026, at 8:56 PM, that Resident 2 returned from the hospital after surgical repair of her hip with a dressing and a bruise on her right hip. In a written statement dated June 15, 2026, by Employee 1 (Nurse), revealed that they were at the nursing station around 5:00 PM when Resident 1 was being uneasy and started exit seeking behavior, stating that he was waiting for a bus. Resident 1 started escalating without any provocations and was noted at one point cursing out a nursing aid who was doing her charting on the computer. Resident 1 attempted to grab a gown from another aid who was passing by the station. Resident 1 started accusing staff of stealing his money at this point. Around 6:00 PM he escalated, walking to other resident rooms when staff re-directed him. Attempts to redirect Resident 1 were not effective. In a written statement dated June 15, 2026, by Employee 2 (Nurse Aide [NA]), revealed around dinner time Resident 1 was very wandering and aggressive with other residents and workers. In a written statement dated June 15, 2026, by Employee 3 (NA), revealed they witnessed Resident 1's behavior around 5:30 PM when he started cursing at the residents and staff, walking around grabbing anything in his way, and when stopped he would abuse and curse and got so aggressive he was trying to fight. In a written statement dated June 15, 2026, by Employee 4 (Nurse), revealed around 7:00 PM Resident 1 was agitated and walking up and down the hallways. Resident 1 attempted to enter other resident rooms and was cursing using inappropriate language. Resident 1 had a 1:1 Nursing Supervision order from May 26, 2026 and it was discontinued on June 2, 2026. Review of Resident 1's June 2026 Medication Administration Record (MAR) revealed 15 minute checks with a start date of June 3, 2026, and discontinued on June 11, 2026. Additional review revealed an order for a 1:1 Nursing observation, with a start date of June 19, 2026, after the resident-to-resident abuse. There were no orders for the Resident to be on 15 minute checks or on a 1:1 on June 15, 2026. On June 30, 2026, at 12:36 PM, the Nursing Home Administrator (NHA) and the DON were notified that the facility failed to put effective interventions in place for Resident 1 to ensure the safety of other residents and prevent physical abuse, which resulted in an Immediate Jeopardy situation. The Immediate Jeopardy template was provided. The facility was informed that a correction action plan was required. The facility initiated immediate interventions on June 15 and 16, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included the following: On June 15, 2026, both parties were immediately separated, and initial psycho-social support was provided by nursing staff. On June 15, 2026, head-to-toe assessment on Resident 2 revealed right leg pain with limited range of motion (ROM), new orders were provided to transfer Resident 2 to the emergency room to evaluate and treat status post-fall. On June 15, 2026, an investigation was initiated and witness statements were obtained. On June 15, 2026, the Medical Director and Responsible Parties for both residents were notified of the event. On June 15, 2026, Resident 1 was placed on a 1:1 at all times until further notice. On June 16, 2026, a psychiatric consult with medication review was requested from in-house psych providers. On June 16, 2026, the DON/designee interviewed all capable residents with a BIMS (brief interview for mental status) of 12 or greater, to determine if they were ever abused or handled roughly by any staff or resident in the facility and if they felt safe. On June 16, 2026, the DON/designee completed house-wide body audits on all incapable resident with a BIMS less than 12 to assess for signs and symptoms of abuse. On June 16, 2026, the IDT team identified other residents that experience aggressive behaviors to ensure their care plan contains the behaviors and effective behavioral interventions. On June 16, 2026, the NHA/designee educated all staff on the abuse policy and closely monitoring any resident experiencing agitation to prevent a verbal/physical altercation. To monitor and maintain on-going compliance NHA/designee will complete an audit on five random capable residents, BIMS of 12 or greater, to ensure they were not abused or rough handled in the facility and feel safe. The DON/designee will complete an audit on five random incapable resident, BIMS less than 12, body audits to ensure there are no areas of concern consistent with abuse, The Social Service Director (SSD)/designee will complete an audit of three random residents that experience agitation behaviors to ensure their care plans contain the behavior and effective behavioral interventions, any care plans lacking information will be updated immediately. Any areas of concern will be reported immediately. Audits will continue weekly x4 and then monthly x2. The results of the audits were forwarded to the facility QAPI committee for further review and recommendations. The facility demonstrated past non-compliance by initiating immediate interventions, audits and education, which was completed by June 16, 2026. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed and no concerns were identified. Audits were reviewed to ensure the above appropriate measures and actions were in place. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of the education. Observations made during the on-site survey on June 30, 2026, revealed there were no additional physical resident-to-resident altercations that had occurred in the facility. The Immediate Jeopardy was lifted on June 30, 2026, at 3:56 PM, after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1), who displayed aggressive behavior and physically kicked another resident (Resident 2).Findings include: Review of the facility policy, titled Resident Observation Policy with a last revised date of May 28, 2021, and a last review date of January 28, 2026, revealed, in part, Procedure: A.) The charge nurse will contact the DON (Director of Nursing) who, if necessary, will consult with administrative staff and/or the Director of Mental Health, if applicable, to determine the appropriate observation/interventions if the resident meets on of the following criteria: 2. Resident is a danger to others, to include but not limited to, homicidal comments/threats/actions; 4. Resident is acting out behaviorally, to include but not limited to, throwing items, continuous screaming/disruptive behavior; B.) DON will assign a staff member to complete the appropriate observation/interventions which may include but are not limited to, every 15 or 30 minute checks or 1:1 monitoring. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (an ongoing, progressive lung condition that restricts airflow and makes breathing difficult) and hyperlipidemia (high amounts of fats in the blood). Review of a facility provided incident report revealed a resident-to-resident altercation between Resident 1 and Resident 2 on May 9, 2026, at 8:08 PM. Further review of the incident report revealed Resident 1 started being aggressive towards other residents, going to their rooms and using curse words when asked to leave by staff. Resident 1 was hard to redirect, stating that other residents and staff stole his money; he pushed an aide as she was doing care to another resident. Resident 1 was asked to go back to his seat, where he went further to another resident who was standing by her room's door and stated where is my money you bitch. When Resident 2 said she didn't know what Resident 1 was talking about, Resident 1 walked to where she was standing and kicked her in her left thigh, leaving a reddish mark. Staff then intervened and Resident 2 was taken back to her room out of harms way. Review of Resident 1's physician order history revealed an order for 1:1 nursing supervision every shift, with a start date of May 10, 2026, that was created at 9:01 PM, which was more than 24 hours after the initial Resident-to-Resident incident had occurred. Review of Resident 1's care plan revealed a problem focus area for behavioral symptoms, with an approach for 1:1, 15- or 30-minute monitoring checks for safety, as needed, with a start date of June 25, 2025. During an interview with the Nursing Home Administrator (NHA) on June 9, 2026, at approximately 11:30 AM, she revealed that she would have expected Resident 1 to have been placed on a 1:1 nursing observation as soon as the Resident-to-Resident incident occurred, and that the RN (Registered Nurse) Supervisor on duty during the incident failed to notify her or put appropriate interventions in place and was therefore terminated. The facility demonstrated past non-compliance by initiating immediate interventions starting May 10, 2026, following the incident. Documents and actions provided by the facility to address the concern were reviewed on June 9, 2026, during the onsite survey and included: Residents were immediately separated, Psychosocial Support was provided by Nursing Department Head-to-toe assessment was completed Witness statements were obtained from staff members Resident 1 was placed on close supervision, when agitated behaviors continued, he was changed to 1:1 Nursing observation Medical Director/Resident Representative were notified of occurrence Local police department and Area Agency on Aging (AAA) were notified of occurrence Psychology evaluation was completed, with new medication adjustment provided for Risperdal 0.25 by mouth twice daily Social Service Department provided a follow-up Psychosocial visit to ensure all needs were currently being met To identify others with the likelihood to be affected, the Director of Nursing (DON)/designee will complete a house-wide body audit on those residents with a BIMS (Brief Interview for Mental Status) less than 12 to ensure those residents did not have any signs or symptoms consistent with abuse, any inconsistencies identified will be investigated immediately. To identify others with the likelihood to be affected, the NHA/designee will complete a house-wide interview audit on those residents with a BIMS of 12 or greater to ensure they have not experienced a Resident-to-Resident altercation that was not investigated, any inconsistencies identified will be investigated immediately. To identify others with the likelihood to be affected, the Regional Director of Clinical Services (RDCS)/designee will complete a progress note review to ensure any other Resident-to-Resident altercations were managed and reported timely, any inconsistencies identified will be investigated immediately. To prevent a further recurrence, the NHA/designee educated all facility staff on the PA abuse policy and the proper process to follow if a Resident-to-Resident altercation transpires. The aforementioned corrective actions were completed on May 11, 2026. To monitor and maintain ongoing compliance, with DON/designee will complete a body audit of 5 random residents with a BIMS less than 12 to ensure they are free of signs or symptoms of abuse, any inconsistencies identified will be investigated immediately, weekly x 4 then monthly x 2 To monitor and maintain ongoing compliance, the NHA/designee will complete an interview audit on 5 random residents with a BIMS of 12 or greater to ensure they have not been involved in a Resident-to-Resident altercation that was not investigated, any inconsistencies identified will be investigated immediately, weekly x 4 then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. During the onsite survey on June 9, 2026, no additional concerns related to Resident-to-Resident physical abuse were identified based on observations, clinical record review, interviews with staff, review of audits, and review of education provided to staff. 28 Pa. Code 211.12(d)(3)(5)Nursing services.28 Pa. Code 201.29(j) Resident rights

Based on facility policy review, clinical record review, review of select facility documentation, observation, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards; and failed to provide adequate supervision and assistance devices to prevent accidents for two of 32 residents reviewed (Residents 10 and 51), which resulted in actual harm for Resident 51 as evidenced by scapholunate widening, suggesting a ligamentous injury.Findings include: Review of facility policy, titled Fall Prevention and Management Policy last reviewed July 7, 2025, read, in part, Fall risk assessments are to be completed at admission, quarterly, and as needed. Individualized interventions will be implemented based on this assessment and care planned accordingly. Providers will be consulted regarding risks and interventions, feedback, and any further approaches recommended. A fall will trigger a referral to Rehab Therapy. Review of Resident 10's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and lack of coordination. Review of Resident 10's clinical record revealed that she had a room change on October 16, 2025. Review of Resident 10's clinical record progress notes revealed a nurse's note dated December 20, 2025, at 7:14 PM, which indicated that Resident 10 was noted to have discoloration on the right forehead and the right eye, asked resident what happened she said she bumped her head on the side rails. Review of Resident 10's clinical record progress notes revealed that she was receiving warfarin (an anticoagulant or blood thinner to help reduce risk of clot formation) daily at the time the bruising was noted, and that Resident 10's physician gave an order to hold the warfarin for one day. Review of Resident 10's clinical record failed to reveal any assessments for the safe use of enabler bars, a consent for the use of an enabler, or a physician order for an enabler. Review of Resident 10's clinical record progress notes revealed a nurse's note dated December 21, 2025, at 12:07 PM, which indicated that Resident 10 was noted to be unsteady on her feet, her pupils were not reactive to light, and that she was not responding to physical stimuli. The note further indicated that Resident 10 was sent to the emergency room for evaluation at 12:00 PM. Review of facility provided incident report for Resident 10 recorded on December 26, 2025, at 12:14 PM, indicated that on December 20, 2025, at 8:11 PM, Resident 10 was noted to have a bruise to the right side of her forehead and that Resident 10 reported that she had hit her head on the siderails. The incident report also included an interdisciplinary team note dated December 26, 2025, at 12:42 PM, that indicated Resident 10 returned to the facility on December 23, 2025, and that all testing at the hospital failed to reveal any abnormalities or acute injuries. In addition, the note indicated that physical therapy had evaluated Resident 10 upon her return to the facility and that the enabler bars were removed from the bed as Resident 10 did not demonstrate a need for them and to prevent her from hitting her head against the enabler again. During a staff interview with the Director of Nursing (DON) and Employee 5 (Regional Director of Clinical Services) on March 12, 2026, at 10:32 AM, Employee 5 confirmed that she had no enabler assessments to provide for Resident 10. She further indicated that she believed that when Resident 10 was moved upstairs that the enablers were already on the bed. Employee 5 confirmed that the enablers should not have been on the bed. Review of Resident 51's clinical record revealed diagnoses that included age-related osteoporosis (a bone disease characterized by weak and fragile bones, increasing the risk of fractures), hypertension (high blood pressure), and abnormalities of gait and mobility (unusual patterns of walking or movement caused by injuries, neurological, musculoskeletal, or environmental factors, affecting balance, coordination, and overall mobility). Observation of Resident 51 in her room on March 9, 2026, at 10:43 AM, revealed she was wearing a brace on her right arm. Review of Resident 51's clinical record revealed she sustained a fall on February 17, 2026. Review of Resident 51's fall report dated February 17, 2026, read, in part, Resident had a fall in the shower room. The resident stated she was trying to transfer from shower chair to wheelchair. When the resident went to stand up from the shower chair it slid out and she hit the floor landing on her back. Resident has complaints of pain on right thumb. MD notified. RP notified. Nurse called into shower room for report of witnessed fall. Upon arriving, resident was noted lying flat on the floor, shower chair was to her left and the wheelchair was in front of her to the left as well. Resident initially denies any new pain other what she stated was chronic pain to her left side/hip. Resident reassessed for pain, this time complains of pain 8/10 to right hand, wrist and forearm. New orders noted to obtain STAT (immediate) 2 view X-ray of right hand, wrist and forearm. Immediate intervention was to offer resident pain medication and apply ice pack. A staff member was in the shower room with resident and was unable to stop the fall. At the time of the fall, only the front brakes of the shower chair were locked, not the back. Immediate nursing intervention was to educate staff on ensuring all brakes are locked on shower chair prior to transfers. After review, additional intervention of maintenance to inspect shower chair brakes to ensure appropriate functionality. X-ray results showed scapholunate widening suggesting a ligamentous injury (Increased distance between the scaphoid and lunate bones in the wrist. This widening typically suggests a ligamentous injury, particularly to the scapholunate ligament, which is crucial for maintaining wrist stability). Resident was immediately seen by occupational therapy to issue a brace for right wrist. Right wrist cock up splint was issued for stabilization and pain management during healing process of ligamentous injury. Review of Occupational Therapy Evaluation dated February 18, 2026, read, in part, Reason for Referral: Patient is a long term care resident seen for screening and evaluation due to Scapholunate widening s/p fall. Nurse practitioner is requesting a brace. Patient presents with deficits in range of motion, strength, fine motor and activity tolerance resulting in a decrease in a participation in ADLs (activities of daily living). Reason for Skilled Services: Patient requires skilled OT services to maximize independence w/ADLs, facilitate sitting tolerance and postural control and increase functional activity tolerance. Review of Occupational Therapy Treatment Encounter Note on February 18, 2026, read, in part, Orthotic management and training, including design and fitting, instruction in proper use, care and wearing time of prosthetic device, therapeutic stretch techniques, techniques to decrease and manage pain, techniques to improve functional skill performance and edema (fluid accumulation) reduction. Provided patient right wrist cock-up splint to stabilize wrist and prevent further injury. Patient report 10/10 pain at rest. Patient was dependent to don/doff [splint] due to pain. Review of Resident 51's physician orders revealed an active order for a brace to her right arm and an order for routine acetaminophen (pain medication). Review of Resident 51's comprehensive care plan revealed a care plan focus area Problem: Falls. History/at risk of falls, last revised March 6, 2026, with an intervention for Staff education to ensure shower chair brakes are locked prior to transfers. Interview with Employee 4 (Nurse Aide) on March 11, 2026, at 12:20 PM, revealed she was assisting Resident 51 during a transfer out of the shower chair on February 17, 2026, and as she stood up, the shower chair shot backwards and the Resident fell backwards as that happened. She further revealed she forgot to lock the back brakes of the shower chair because everything was happening very fast that day, and they absolutely should have been locked. During an interview with the DON on March 12, 2026, at 10:20 AM, she revealed she would expect the shower chair brakes to be locked as appropriate, and she would expect that the resident environment remains as free of accident hazards as is possible to prevent accidents. The facility failed to ensure that the resident environment remains as free of accident hazards as is possible and failed to provide adequate assistance devices to prevent accidents, which resulted in actual harm for Resident 51 as evidenced by scapholunate widening, suggesting a ligamentous injury. 201.14(a) Responsibility of licensee201.18(b)(1) Management211.10(d) Resident care policies211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, resident and staff interviews, observation, and record review, the facility failed to assist residents in obtaining timely dental services to obtain dentures for one of three residents reviewed (Resident 3), resulting in phyco-social harm and weight loss. Findings include:Review of the facility policy, titled Dental Services Policy with a last review date of January 21, 2026, revealed 12. Facility will promptly, within 3 days, refer residents with lost or damaged dentures for dental services.Review of Resident 3's clinical record revealed diagnosis that included dementia (loss of cognitive functioning that interferes with daily life) and chronic kidney disease (a long- term condition in which the kidneys gradually lose their ability to function properly).During an observation of Resident 3 on March 10, 2026, at 12:49 PM, it was revealed she was sitting in the dining room eating lunch, without her upper denture in.During an interview conducted with Resident 3 on March 12, 2026, at 1:31 PM, she revealed that it is difficult for her to eat meals due to the texture of her diet and that she would like whatever she needs done to be able to get new dentures so she can eat regular food again. Resident 3 said that she just fights through it because she doesn't know what else to do.Review of Resident 3's clinical record revealed a progress note written on December 22, 2025, at 3:36 PM, that stated her upper denture could not be located. Staff checked her room and were unable to find her denture. Review of Resident 3's care plan revealed a focus area that the resident requires assistance with oral hygiene, with an intervention to obtain a dental consult as needed, created on December 17, 2024.Review of Resident 3's physician orders revealed an order that the resident may see dentist as needed, with a start date of November 20, 2024.Review of Resident 3's clinical record revealed a speech therapy treatment encounter note on December 29, 2025, that the resident had decreased meal intake, due to dentures missing, and states to staff inability to masticate (chew) solid textures without dentures. The resident was downgraded to a puree diet (smooth, lump-free, pudding-like foods that require no chewing) at this time.Review of Resident 3's clinical record revealed a speech therapy treatment encounter note on December 30, 2025, that the resident was presented with puree diet and mechanical soft diet (nutrient-dense foods that are cooked, ground, mashed, or blended to a soft texture, requiring minimal chewing to prevent choking or aspiration) during breakfast meal, and picked to consume mechanical soft diet, however, is still without dentures and complained about inability to consume mechanical soft textures throughout session.Review of Resident 3's clinical record revealed a speech therapy treatment encounter note on December 31, 2025, that the resident was upgraded to mechanical soft diet.Review of Resident 3's clinical record revealed a speech therapy treatment encounter note on January 6, 2026, that the resident is stating to family dislike for softer diet, and that family is requesting upgrade to regular diet. Dentures continue to be missing, and trial of regular textures occurred during session. The resident expelled textures stating I can't chew that, I don't have dentures.Review of Resident 3's clinical record revealed a speech therapy treatment encounter note on January 16, 2026, that the resident prolonged mastication throughout entire session and expelled textures.Review of Resident 3's speech therapy discharge summary on January 27, 2026, revealed that mechanical soft diet is safest and least restrictive due to lack of dentures.Review of Resident 3's clinical record revealed a dental referral was not made until January 23, 2026, for the resident to receive a new top denture.Review of Resident 3's clinical record revealed that they were seen by the dentist on February 2, 2026, and had an impression done for upper complete denture.Review of Resident 3's clinical record revealed that on January 9, 2026, the resident weighed 191.6 pounds. On February 3, 2026, the resident weighed 185.4 pounds. On March 2, 2026, the resident weighed 184.2 pounds, indicating a 7.4 weight loss since her missing dentures.Interview conducted with Employee 8 (Speech Language Pathologist) on March 12, 2026, at 1:30 PM, revealed that when Resident 3's dentures first went missing the resident said she couldn't chew well. Employee 8 revealed she downgraded the residents' diet to pureed and that the resident then refused to eat. Employee 8 then changed the diet to mechanical soft, and said Resident 3 is no longer on speech but she has noted when the resident is in the therapy room with other therapists if someone talks about dentures the resident will bring up the fact that she wants new dentures to eat regular food.Interview conducted with the Director of Nursing (DON) on March 12, 2026, at approximately 10:20 AM revealed she would expect residents to receive timely dental consultations for missing dentures.Pa.Code 211.5(a) - Dental Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 31 residents reviewed (Residents 10, 11, and 66).Findings include: Review of Resident 10's clinical revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and depression. Review of Resident 10's physician order history revealed an order for Rexulti (an antipsychotic medication) 1 mg administer one tablet daily, dated August 26, 2025. Review of Resident 10's psychiatry consult note dated October 24, 2025, which indicated that no gradual dose reduction (GDR) of Resident 10's antipsychotic medication should be attempted as the benefits of the medication outweigh the risks. Review of Resident 10's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of December 29, 2025, indicated in Section N. Medications at question N0450. Antipsychotic Medication Review that Resident 10's physician had not documented a GDR as clinically contraindicated. During a staff interview with Employee 5 (Regional Director of Clinical Services) on March 11, 2026, at 11:37 AM, Employee 5 indicated that Resident 10's MDS was not coded accurately and that she would expect the MDS to be an accurate reflection of the Resident's status. Employee 5 further indicated that a modification to the assessment would be completed. Review of Resident 11's clinical record revealed diagnoses that included hypertension (high blood pressure) and obesity. Review of Resident 11's clinical record revealed that she was readmitted to the facility on [DATE], after a hospital stay and that she was noted to have a Stage 2 pressure ulcer (a partial-thickness skin injury presenting as shallow open wound with a red or pink moist wound bed without exposure of fat or deeper tissues), a Stage 3 pressure ulcer (full-thickness skin injury with visible subcutaneous fat or dead tissue that appears yellow, white, or gray called slough), and a Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle and may have slough or dry black firm tissue adhered to the wound bed called eschar present). Review of Resident 11's Quarterly MDS with the assessment reference date of December 2, 2025, revealed in Section M. Skin Conditions that Resident 11 had a Stage 2 and a Stage 3 pressure ulcer present upon admission and a Stage 4 pressure ulcer that was not present upon admission. Review of Resident 11's Quarterly MDS with the assessment reference date of January 22, 2026, revealed in Section M. Skin Conditions that Resident 11 had a Stage 4 pressure ulcer that was not present upon admission. During a staff interview with the Director of Nursing (DON) and Employee 5 on March 11, 2026, at 11:47 AM, Employee 5 confirmed Resident 11's pressure ulcers were present upon admission and that Resident 11's MDS's were coded inaccurately. Employee 5 further indicated that she would expect the MDS to be an accurate reflection of the Resident's status and that modifications would be completed. Review of Resident 66's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and dementia. Review of Resident 66's Medication Administration Record for May 2025, revealed that he received his ordered antipsychotic, antidepressant, anticonvulsant, and diuretic medications. Review of Resident 66's Annual MDS with the assessment reference date of May15, 2025, revealed in Section N. Medications that he only received an antibiotic and insulin during the reference period. Review of Resident 66's psychiatry consult note dated October 24, 2025, which indicated that no GDR of Resident 66's antipsychotic medication should be attempted as the benefits of the medication outweigh the risks. Review of Resident 66's Quarterly MDS with the assessment reference date of December 29, 2025, indicated in Section N. Medications at question N0450. Antipsychotic Medication Review that Resident 66's Physician had not documented a GDR as clinically contraindicated. During a staff interview with the DON and Employee 5 on March 11, 2026, at 10:29 AM, Employee 5 confirmed that Resident 66's MDS's were not coded accurately and that she would expect the MDS to be an accurate reflection of the Resident's status. Employee 5 further indicated that modifications to the assessments would be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for three of five residents reviewed for psychotropic medication use (Residents 7, 10, and 66).Findings include: Review of facility provided policy, titled Psychoactive Medication Policy, last reviewed April 30, 2025, failed to reveal any expectation of obtaining consent prior to starting psychoactive medications. Review of Resident 7's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 7's physician orders revealed an order for Trazodone (medication used to treat depression) 75 mg, given by mouth three times daily for depression, starting on February 13, 2026. Further review revealed an order for Lorazepam (antianxiety medication) 0.5 mg twice daily for anxiety, starting on December 16, 2025. Review of Resident 7's Care plan revealed a focus of: Psychotropic drug use, Resident receives antidepressant and antianxiety medication, with a start date of July 9, 2024. Review of Resident 7's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 7 or their representative. Interview with the Director of Nursing (DON) on March 12, 2026, at 10:45 AM, revealed that Resident 7 did not have the appropriate notifications made prior to starting psychotropic medications. Review of Resident 10's clinical revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and depression. Review of Resident 10's physician orders from admission through current revealed orders for: quetiapine (an antipsychotic medication) 25 mg administer one tablet at bedtime from July 19, 2025-August 19, 2025; Rexulti (an antipsychotic medication) 0.5 mg started on August 20, 2025, increased to 1 mg on August 26, 2025, and discontinued on January 8, 2026; mirtazapine (medication used to treat depression) 15 mg administer one tablet daily from July 18, 2025, through current; and trazodone (medication used to treat depression) 50 mg give half a tablet three times a day dated January 14, 2026. Review of Resident 10's care plan revealed a focus of: Psychotropic drug use, Resident receives antipsychotic medication, with a start date of July 29, 2025; and Psychotropic drug use, resident receives antidepressant medication, with a start date of November 11, 2025. Review of Resident 10's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 10 or their representative. During a staff interview with the DON and Employee 5 (Regional Director of Clinical Services) on March 12, 2026, at 11:03 AM, Employee 5 indicated that the facility had no psychotropic medication consents to provide for Resident 10. Review of Resident 66's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and dementia. Review of Resident 66's physician orders revealed orders for aripiprazole (an antipsychotic medication) 2 mg one tablet give with aripiprazole 5 mg one tablet for a total dose of 7 mg at bedtime, dated March 6, 2026; bupropion (medication used to treat depression) 300 mg extended release tablet give one tablet daily in the morning, dated December 4, 2025, and escitalopram (medication used to treat depression) 10 mg give one tablet daily, dated December 4, 2025. Review of Resident 66's care plan revealed a focus of: Psychotropic drug use, Resident receives antidepressant, antipsychotic, and mood stabilizer, with a start date of March 20, 2025. Review of Resident 66's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 66 or their representative. During a staff interview with the DON and Employee 5 on March 12, 2026, at 11:03 AM, Employee 5 indicated that the facility had no psychotropic medication consents to provide for Resident 66. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, resident interviews, facility documentation review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve grievances the resident may have for six grievances reviewed (Residents 35, 41, 43, 59, 66, and 157).Findings include: Review of the facility policy, titled Resident Grievances and Concerns Policy with a last review and revision date of May 8, 2025, revealed 4. The grievance review will be completed in a reasonable time frame consistent with the type of grievance, but in no event will the review exceed thirty (30) days. If the grievance committee / Grievance official determines that a resident rights violation has occurred, the violation must be corrected within ten (10) days. If the resident right violation cannot be corrected within 10 days, the Grievance official shall refer the matter to the State Department of Health. Interview conducted with Residents 4, 41, 59, 108, and 157 during Group with Resident Council on March 10, 2026, at 11:00 AM, revealed that grievances do not always get resolved timely or at all by the facility. Residents reported missing clothing items that they have filed a grievance for and have not been found or replaced. During Group, Resident 41 revealed the Resident has been missing a pair of pants since January 2026, and Resident 157 revealed the Resident was missing three pairs of slacks and two shirts, which were brand new. Resident 157 revealed staff took them out of his room and never returned them. Interview conducted with the Nursing Home Administrator and Director of Nursing (DON) on March 11, 2026, at 11:17 AM, revealed they will follow up with Resident 41 and Resident 157 on their missing clothing concerns. Review of a Concern Form completed on November 11, 2025, pertaining to Resident 35, 43, 59, and 66, revealed they are not getting clothes back. Documentation of the concern revealed that most, if not all of the clothes, were labeled with the resident's name, which included the following: Resident 35- one sweat suit with a zip top and five sports bras; Resident 43- two pajama sets and four pairs of gripper socks; Resident 59- two long sleeve sweat shirts and two pairs of dress pants; Resident 66- one pair of new jeans. Resolution of the grievance, dated November 13, 2025, revealed that the concern was not resolved, and only some laundry was returned and was still in search of others. The residents voicing concern were not satisfied with the resolution as they were still missing items. Interview conducted with DON on March 12, 2026, at approximately 10:20 AM, revealed they were unable to provide any further information on whether any additional efforts were made to locate the Residents' reported missing clothing or that they have been replaced. The DON was unable to provide any information on whether there was any follow-up completed or grievance made for Resident 41 and 157 related to their missing clothing concerns. 28 Pa code 201.18(b)(2)(3) Management28 Pa code 201.29(a) Resident rights

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in two of two pantry refrigerators (first and second floors). Findings include: Review of facility policy, titled Food Brought in From Outside the Facility, last reviewed November 18, 2024, read, in part, when residents or their friends or family bring food into the facility the container will be labeled with name of the food item, resident name, dated and placed in an appropriate refrigerator. Review of facility policy, titled Storing Dry Food, last reviewed March 28, 2025, read, in part, food will be stored six inches above the floor. When original packaging is opened, food must be stored in containers that can be sealed and covered. Observation in the dry storage room on March 9, 2026, at 9:44 AM, revealed one package of dried chicken gravy wasn't securely closed or date marked. At that time, Employee 9 (Food Service Director) revealed that the package should've been securely closed and marked with an open date. Observation in the walk-in refrigerator on March 9, 2026, at 9:49 AM, revealed one plastic container of fresh sweet potatoes not marked with a date. At that time, Employee 9 revealed the container of sweet potatoes should be date marked. Observation in the walk-in freezer on March 9, 2026, at 9:48 AM, revealed one case of crescent rolls was on the floor, open with one tray removed from the case. At that time, Employee 9 revealed the case of crescent rolls should not be on the floor. Observation in the first-floor nourishment refrigerator on March 9, 2026, at 10:00 AM, revealed one plastic container of soup, one Styrofoam container of French fries with cheese sauce, one Styrofoam container with a chicken fajita, and one plastic container of taco salad were not marked with a resident identifier or date. At that time, Employee 9 revealed the aforementioned items should've been marked with a resident identifier and a date. Observation in the second-floor nourishment refrigerator on March 9, 2026, at 10:06 AM, revealed two 32-ounce containers of Med Pass 2.0 (high calorie nutritional supplement) were open with contents partially removed and weren't date marked. At that time, Employee 10 (Regional Registered Dietitian) revealed the containers should've been marked with a date when opened. Interview with the Nursing Home Administrator (NHA) on March 11, 2026, at 11:00 AM, the surveyor discussed the aforementioned concerns pertaining to food storage, and the NHA provided no further information. 28 Pa code 211.6(f) - Dietary Services

Based on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of two employees observed during medication pass (Employee 2) Findings Include: Review of facility policy, titled General Dose Preparation and Medication Administration, revised November 15, 2024, revealed that, prior to preparing or administering medications, facility staff should complete appropriate hand hygiene. Observation of Employee 2 (Registered Nurse) on March 10, 2026, at 9:41 AM, revealed Employee 2 administering medications to Resident 92, then Resident 100, then Resident 93, and finally Resident 12 without completing hand hygiene at any time during the observation. Interview with the Director of Nursing on March 3, 2026, at 12:15 PM, revealed that she would expect Employee 2 to complete hand hygiene as needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 32 residents reviewed (Residents 10, 99, and 149). Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, last reviewed February 24, 2026, revealed, An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. Review of Resident 10's clinical revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and atrial flutter (abnormal heart rhythm that occurs when the upper heart chambers beat faster than normal). Review of Resident 10's care plan revealed a focus of Psychotropic drug use, Resident receives antipsychotic medication and focus of Cardiovascular Anticoagulant therapy, with start dates of July 29, 2025. Review of Resident 10's clinical record revealed that her antipsychotic medication was discontinued on January 8, 2026, and her anticoagulant medication was discontinued on December 31, 2025. During a staff interview with the Director of Nursing (DON) and Employee 5 (Regional Director of Clinical Services) on March 12, 2026, at 10:31 AM, the DON confirmed that Resident 10's care plan should have been revised when her medication changes occurred and further indicated she revised the care plan that morning. Review of Resident 99's clinical record revealed diagnoses that included repeated falls and muscle weakness (weakness in the muscles not explained by any medical diagnosis). Observation of Resident 99 on March 9, 2026, at 10:25 AM, revealed Resident 99 lying in bed and there were fall mats on the floor on both sides of their bed. Review of Resident 99's care plan revealed a care plan of: Resident has a history of falling related to admission to facility, history of falls, with a start date of January 18, 2024. Further review failed to reveal any indication to use fall mats on the floor on both sides of Resident 99's bed. An interview with the DON on March 12, 2026, at 11:15 AM, revealed that Resident 99's care plan should have included the use of bilateral fall mats while in bed. Review of Resident 149's clinical record revealed diagnoses that included peripheral vascular disease (common condition characterized by narrowed arteries that reduce blood flow to the limbs) and spinal stenosis (narrowing of one or more spaces within the spinal canal). Observation of Resident 149 on March 9, 2025, at 12:18 PM, revealed the Resident lying in bed. During an interview with Resident 149 at that time, she stated five times that she was just there waiting for a family member to pick her up and take her home. Review of Resident 149's care plan failed to reveal any indication of whether Resident 149's goal was to receive care at the facility long term or be discharged to another level of care. Review of Resident 149's care conference notes dated December 11, 2025, revealed that Resident 149 would like to go home by herself, she has been educated that her physician feels that is not safe for her. Discussed potential for assisted living, resident declined. An interview with the DON on March 12, 2026, at 11:15 AM, revealed that Resident 149's care plan should have included her choice for discharge or long-term care at the facility. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility contract, review of select facility documentation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision or hearing abilities for one of three resident's reviewed for vision and hearing (Resident 8). Findings include: Review of agreement between the facility and contracted vision services company with an effective date of December 14, 2018, read, in part, During the term of this agreement the company agrees to arrange the following services to the residents of the facility.optometry services, which may include vision examinations, medical eye evaluations, fitting and ordering of eye glasses, and adjustment of eye glasses. Facility shall assist in coordinating receipt of any proper documentation or orders from a resident's attending physician that may be required prior to rendering services. Review of Resident 8's clinical record revealed diagnoses that included Nonexudative age-related macular degeneration (a common eye condition that leads to gradual vision loss, primarily affecting central vision due to the deterioration of the macula), dysphagia (difficulty chewing and/or swallowing), and delusional disorders (a serious mental health condition characterized by persistent, false beliefs that are not based in reality, often leading to significant distress and impairment in functioning). During an interview with Resident 8 in his room on March 9, 2026, at 1:56 PM, he revealed his glasses were three years old and he was unable to see out of them. Review of Resident 8's comprehensive care plan revealed a focus area Resident has impaired vision with an intervention for ophthalmologist/optometrist consult, as per orders. Review of Resident 8's vision consult from November 26, 2024, read, in part, Nonexudative age-related macular degeneration, bilateral. Please schedule consult with a retinal specialist for evaluation and treatment options. New spectacles recommended to maximize visual function. Review of Resident 8's vision consult from February 5, 2025, read, in part, Patient reports that he did not get glasses from November order, did not see a retinal specialist, and is not receiving any [drops]. Nonexudative age-related macular degeneration, bilateral. Please schedule consult as recommended on November 26, 2024, for additional testing, evaluation, and treatment options. Review of Resident 8's vision consult from June 17, 2025, read, in part, Patient reports not receiving new glasses. Patient also states he did not see a retinal specialist as recommended last visit. Please schedule consult with retinal specialist for evaluation and treatment of possible CNM (Choroidal Neovascular Membranes- abnormal blood vessels that grow beneath the retina, often leading to vision loss and are commonly associated with age-related macular degeneration). During an interview with the Director of Nursing (DON) on March 12, 2026, at 10:17 AM, she revealed the initial consult and February consult recommendations that were missed were prior to current facility ownership and she cannot speak to why they were missed, but the recommendations have also been missed in the follow up visit in June 2025 during current facility ownership. She revealed Resident 8 has since been admitted to hospice services in July 2025, so they will follow up with the physician to determine if the recommendations are still indicated. The DON revealed it is her expectation that contracted service recommendations are implemented or responded to by the physician if in disagreement. 28 Pa. Code 201.18(b)(1) Management28 Pa Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for one of one resident reviewed for tube feeding (Resident 115). Findings include: Review of facility policy, titled Enteral Feeding Tube Policy last revised April 1, 2016, read, in part, Licensed clinicians with demonstrated competence may administer enteral feedings and provide tube/site care. Review of Resident 115's clinical record revealed diagnoses that included gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), and dysphagia (difficulty chewing and/or swallowing). Review of Resident 115's physician orders revealed an order for Enteral: Pump Feeding up at 6:00 PM Special Instructions: At 6:00 PM hang (Isosource 1.5- tube feeding formula). Confirm rate programmed at (85 ml/hr), confirm total volume programmed in at 1360ml. Further review of Resident 115's physician orders revealed an order to take down the tube feeding at 10:00 AM daily. Review of Resident 115's comprehensive care plan revealed a focus area Nutritional status: dysphagia, calorie protein malnutrition, need for feeding tube, with an intervention for provide tube feeding supplement with water flushes as ordered, with a start date of February 22, 2026. Observation in Resident 115's room on March 10, 2026, at 9:23 AM, revealed his enteral feeding bag was hanging up and being infused and the bag was not labeled with a hang time or date. Further observation of the bag revealed a use by date of March 4, 2026. The bag read, Use for a maximum of 48 hours after connection when proper technique is followed. Observation in Resident 115's room on March 10, 2026, at 10:26 AM, revealed his enteral feeding bag was hanging up, almost empty, but not currently infusing. The aforementioned bag was not labeled with a hang time or date. Further observation of the bag revealed a use by date of March 4, 2026. The bag read, Use for a maximum of 48 hours after connection when proper technique is followed. During an interview with Employee 3 (Registered Nurse) on March 10, 2026, at 10:37 AM, revealed the aforementioned bag was the same bag she disconnected from Resident 115's tube feeding pump, but she was not the one that hung the bag up the day before. During the interview, Employee 3 was made aware of the expired tube feeding formula. She found two other bags of formula in a box in his room that were also expired and revealed she would look into finding new formula. Interview with the Director of Nursing on March 11, 2026, at 11:31 AM, revealed she would expect utilized tube feeding formulas to be labeled with a hang time and date and not to be expired. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's comprehensive care plan was implemented for one of 31 residents reviewed (Resident 10).Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, reviewed February 24, 2026, revealed, in part, All staff caring for the resident will be familiar with the resident's plan of care. Review of Resident 10's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and lack of coordination. Review of Resident 10's care plan revealed a focus of Behavioral Symptoms Resident experiences wandering activity throughout hallways and occasionally into resident rooms, with a start date of January 27, 2026. Interventions included, but were not limited to, Provide visual deterrents such as stop signs, warning signs, arrows, or do not enter signs on appropriate locations; Remove Resident from other resident's rooms and unsafe situations; and when Resident begins to wander, assess for comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.), all dated January 27, 2026. Observation of Resident 10 on March 9, 2026, at 10:49 AM, revealed she was wandering room to room in the hall where she resided. She was noted to enter Resident 64's room. Resident 64 was sitting in her wheelchair. Resident 10 picked up Resident 64's Styrofoam water cup and Resident 64 called out at her Hey. Resident 10 then dropped the cup on the floor. At the time of observation of Resident 10's wandering, three staff members (nurse aides) were present in the hallway, one of which was seated in chair outside of Resident 78's room. When the surveyor approached this staff member to share the observation of water being spilled, she indicated I saw it. During a staff interview with Employee 7 (Nurse Aide) on March 9, 2026, at 10:55 AM, Employee 7 indicated that Resident 10 always wanders room to room and stated, it is just what she does, and made no attempt to redirect her. Observation of Resident 10 on March 10, 2026, at 10:03 AM, revealed there was an activity noted to be occurring in the central area by the nurse's station. Resident 10 was wandering the hall in which she resided, closing all open resident room doors. There were two staff noted in the hall (a nurse and a nurse aide) and neither staff were attempting to redirect her. In addition, observations on March 9-12, 2026, failed to reveal any visual deterrents such as stop signs, warning signs, arrows, or do not enter signs on appropriate locations on the hallway where Resident 10 resided. During a staff interview with the Director of Nursing and Employee 5 (Regional Director of Clinical Services) on March 12, 2026, at 10:37 AM, Employee 5 confirmed that the facility had not placed any stop signs and that the facility had just ordered them. She further indicated that facility staff should have been following Resident 10's care plan. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, medication administration observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (4 errors in 25 observations, 15.38%).Findings include: Review of facility policy, titled General Dose Preparation and Medication Administration, revised November 15, 2024, revealed that prior to administering medication the nurse should verify that the medication to be administered is the correct medication, at the correct dose, for the correct resident. Review of Resident 66 current physician orders revealed medication orders for Cyanocobalamin (Vitamin B-12) 1000 mcg daily, starting on March 6, 2026. Observation on March 10, 2026, at 9:41 AM, revealed Employee 1 (Licensed Practical Nurse- LPN) was observed administering Cyanocobalamin 500 mcg to Resident 66. Review of Resident 93's current physician orders revealed medication orders for Cyanocobalamin (Vitamin B-12) 4000 mcg daily, starting October 1, 2025; Aspirin 81 mg chewable tablet, starting October 1, 2025; and Senna 8.6 mg twice daily, starting November 26, 2025. Observation on March 10, 2026, at 9:41 AM, revealed Employee 2 (Registered Nurse- RN) was observed administering the following medications to Resident 93: Senna Plus 8.6 mg-50 mg (Senna 8.6 mg and docusate 50 mg); Aspirin 81 mg enteric coated; and Cyanocobalamin 500 mcg. During an interview with the Director of Nursing on March 10, 2026, at 12:15 PM, she revealed that she would have expected the medications ordered to be given in the form and dosages ordered. Based on 4 medication errors observed out of a possible 26 opportunities, the facility medication error rate was a calculated 15.83 percent. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 32 residents reviewed (Resident 149). Findings include: Review of the facility policy, titled Resident Rights and Facility Responsibilities, revised September 3, 2020, revealed it is the facility's policy to comply with all Residents Rights, and to communicate these rights to residents and their designated representatives in a language that they understand. Review of Resident 149's clinical record revealed diagnoses that included peripheral vascular disease (common condition characterized by narrowed arteries that reduce blood flow to the limbs) and spinal stenosis (narrowing of one or more spaces within the spinal canal). Observation of Resident 149's room on March 9, 2026, at 12:17 PM, revealed a dry-erase board hanging on her wall marked that it was February 2026. Further observation revealed a calendar hanging on the wall that was open to the month of July 2025. Review of Resident 149's care plan revealed a problem area of, Psychosocial Well-Being, at risk for social isolation related to admission to the facility with a start date of January 27, 2025, and an approach of, provide activity calendar, with a start date of July 31, 2025. Review of Resident 149's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated February 2, 2026, revealed a BIMS (Brief Interview for Mental Status - Summary Score ranges from 0 to 15 and reflects a resident's cognitive function, including memory and orientation, with higher scores indicating better cognitive performance) summary score of 12. Interview with the Nursing Home Administrator on March 11, 2026, at 12:35 PM, revealed that she would expect the nursing or activities staff to update the dry-erase board and have the calendar on the correct month. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, Resident Council Meeting minutes, and resident and staff interviews it was determined the facility failed to consider the views of residents and act promptly on concerns regarding quality of life and issues with wandering residents entering other resident's rooms for three of three months (December 2025, January 2026, and February 2026). Findings include:Review of the facility policy, titled Resident Council Policy with a last revised and review date of March 31, 2025, revealed B. 2. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council, and E. Resident issues or concerns will be documented on the Resident/Family Concern form and forwarded to the facility Administrator for the appropriate follow-up.Review of facility provided Resident Council Meeting minutes dated December 9, 2025, documented an issue/concern regarding confused residents going into other resident rooms late at night; no resolution documented. The meeting held on January 13, 2026, documented the concern with confused residents wandering and removing items from other residents' rooms. The documented resolution was to provide education reminders to staff to complete purposeful rounds, checking the location of the confused residents and redirecting them out of other resident rooms. Review of the February 2026 Resident Council Meeting Minutes failed to document review of the concern regarding wandering residents from the January meeting to ensure the concern was resolved.Interview with Resident 59 on March 9, 2026, at 11:42 AM revealed concern with residents being moved from the Dementia unit to E- hall. She stated that those residents are confused, roam the hallways and come into her room. She noted that the confused residents are becoming more agitated and hostile when she tells the resident to leave her room or items they are attempting to take are not theirs. She was ambulating in her wheelchair in the hallway and one of the confused residents grabbed her chair from behind and started to push her and a staff member had to intervene.Interview with Resident 98 on March 9, 2026, at 11:09 AM revealed concern with the dementia unit being closed and the residents being moved E- hall. She stated that the confused residents roam into other resident rooms and attempt to take items that don't belong to them and have taken food off her meal tray. Interview with Resident 101 on March 9, 2026, at 11:05 AM revealed concern with the dementia unit being closed and the residents being moved E- hall. She stated that one confused resident wander into her room frequently and she stated, I think, she thinks I'm her mother and she takes her cheese curls. It was revealed she hasn't completed a concern/grievance form. It was also revealed that she doesn't get out of her bed, by her choice.Interview with the Nursing Home Administrator (NHA) on March 10, 2026, at 2:14 PM revealed that an additional activities staff member has been hired and the hours have been extended to include later on the evening shift. There also are additional activity programs held on second floor.During group interview conducted on March 10, 2026, at 11:00 AM, the following residents: 4, 41, 59, 108, and 157 revealed concerns that residents will wander in their rooms all the time, every day, and will hit and steal from residents, with minimal staff intervention. Resident reported that staff will just tell those residents to move on. The residents revealed that they suggested during the February 2026 Resident Council Meeting about getting signs to put across resident rooms that say stop to mitigate residents from wandering into their rooms and disrupting them, however have not yet received the signs or heard a response from the facility for that request.Interview with residents 59 and 98 on March 11, 2026, at 11:24 AM it was revealed that the concern regarding residents wandering into resident rooms was discussed at resident council meeting monthly since December 2025 and were told Administration would look into it. They recalled the discussion of the use of stop signs, however, couldn't recall when that discussion took place, and it was confirmed that a stop sign has not been offered to them.Interview with the NHA on March 11, 2026, at 10:45 AM it was revealed that the facility purchased stop signs to be hung across resident doorways to minimize wandering residents from entering other resident rooms. It was revealed the order was placed March 11, 2026. Review of the order summary documented the order was placed March 11, 2026, for door guard stop banner stop sign strip do not enter sign.28 Pa. Code 201.18(e)(4) Management28Pa. Code 201.29(i) Resident Rights

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in two of eight hallways observed. Findings include: Review of facility policy, titled General Routine Environmental Cleaning and Disinfection Policy last reviewed July 2, 2026, read, in part, Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc). Observation in Resident 8's room on March 9, 2026, at 12:53 PM; March 10, 2026, at 12:56 PM, and March 11, 2026, at 10:18 AM; revealed his tray table was dirty and had spilled liquid, and his floor was dirty and had a discarded plastic cup, consistent as the day before. Observation in Resident 51's room on March 9, 2026, at 10:43 AM; March 10, 2026, at 9:29 AM, and March 11, 2026, at 10:20 AM; revealed the floor appeared heavily soiled, and had a straw wrapper and a pepper packet on the floor, consistent as the day before. Observation in Resident 115's room on March 10, 2026, at 9:23 AM, revealed his tray table was heavily soiled with debris and spilled liquid stains. Observation in Resident 115's room on March 11, 2026, at 10:25 AM, revealed his tray table was heavily soiled with debris and spilled liquid stains, consistent as the day before.During an interview with the Nursing Home Administrator on March 11, 2026, at 1:33 PM, she revealed the concerns were addressed in the resident rooms and that they have been having issued with oversight in the housekeeping department. She further revealed she would expect the facility to provide housekeeping services necessary to maintain a safe, clean, comfortable and home-like environment. 28 Pa. Code 201.18(e)(2.1) Management

Based on facility policy review, clinical record review, review of facility provided documentation, and staff interviews, it was determined that the facility failed to provide written notice of a resident's transfer to the resident and the resident's representative for two of six residents reviewed for hospital transfer (Residents 10 and 56); failed to send notice of a residents transfer to a representative of the Office of the State Long-Term Care Ombudsman for two of six residents reviewed for hospital transfers (Residents 10 and 56); and failed to provide a written copy of the facility's bed-hold policy for three of six residents reviewed (Residents 8, 10, and 56).Findings include: Review of facility policy, titled Discharge Planning Policy, last reviewed February 3, 2026, revealed, in part, Transfers and discharges will meet regulatory requirements. Further review of the policy failed to reveal the requirement that a resident and their representative, as well as a representative of the Office of the State Long-Term Care Ombudsman, were to be provided with written notice of the transfer. Review of facility policy, titled Bed Hold Letter Policy, dated March 24, 2025, revealed, in part, It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. The Business Office Manager will compare bed hold tracking log to monthly census report to verify accuracy of bed holds recorded and letters sent. Business Office manager or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. Medicaid copy will be retained in resident's financial file. Review of Resident 8's clinical record revealed diagnoses that included muscle weakness, dysphagia (difficulty chewing and/or swallowing), and delusional disorders (a serious mental health condition characterized by persistent, false beliefs that are not based in reality, often leading to significant distress and impairment in functioning). Review of Resident 8's clinical record revealed that he was transferred to the hospital on July 7, 2025. Review of Resident 8's clinical record failed to reveal that a written notice of the facility's bed-hold policy was provided to Resident 8 or his representative. During a staff interview with the Director of Nursing (DON) and Employee 5 (Regional Director of Clinical Services) on March 12, 2026, at 10:23 AM, Employee 5 indicated that she had no additional information to provide for Resident 8's bed-hold notice. The DON revealed she would expect bed hold notices to be available and sent to a resident or their representative in the event of a hospitalization. Review of Resident 10's clinical revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and atrial flutter (abnormal heart rhythm that occurs when the upper heart chambers beat faster than normal). Review of Resident 10's clinical record revealed that she was transferred to the hospital on December 21, 2025. Review of Resident 10's clinical record failed to reveal that a written notice of her transfer or a written notice of the facility's bed-hold policy was provided to Resident 10 or her representative. Review of facility provided documentation of Ombudsman reporting for the month of December 2025, failed to include Resident 10. During a staff interview with the DON and Employee 5 on March 11, 2026, at 11:31 AM, Employee 5 indicated that she had no additional information to provide for Resident 10's written notice of transfer and the facility bed-hold policy. As of the time of exit, interview with the DON and Employee 5 on March 12, 2025, at 2:00 PM, no additional information was provided by the facility regarding the Ombudsman reporting for Resident 10's hospital transfer. Review of Resident 56's clinical record documented diagnoses that included fractured pelvis, spinal stenosis (narrowing of the spaces within the spine, causing pain, numbness or weakness), and chronic obstructive pulmonary disease (inflammatory disease obstructing airflow making it difficult to breathe). Further review of Resident 56's clinical record documented he was transferred to the hospital on January 23, 2026, and returned to the facility on January 28, 2026. At the time of transfer, the Resident's payor source was Medicaid. Resident 56's clinical record failed to reveal that a written notice of his transfer or a written notice of the facility's bed-hold policy was provided to Resident 56 or his representative. Interview with the Nursing Home Administrator on March 11, 2026, at 11:33 AM, revealed the facility didn't have proof of a written notice of transfer and the bed hold policy was provided to the Resident or responsible party, or that the Ombudsman was notified. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy reviews, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 66).Findings include: Review of facility policy, titled Administration of an Intermittent Infusion, with a last revised date of June 1, 2021, revealed, in part, Flush vascular access device with prescribed flushing/locking agent(s) to maintain patency between intermittent infusions. Review of facility policy, titled Short Peripheral Intravenous Catheter (PIVC) Dressing Change, with a last revised date of June 2024, revealed, in part, Transparent dressings are changed with each site rotation every seven days, or sooner if the integrity of the dressing is compromised (wet, loose or soiled). Assessment of peripheral catheter site is performed: 5.3 Before and after administration of intermittent infusions 5.4 At least once every shift when not in use 5.5 Routinely for signs and symptoms of infiltration and extravasation at a frequency based on patient condition, age, type of medication, and rate of flow. Label dressing with: 21.1 Date and time of dressing change 21.2 Nurse's initials. Review of Resident 66's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and urinary tract infection. Review of Resident 66's clinical record revealed that he was readmitted to the facility on [DATE], after a hospital stay. Review of Resident 66's physician orders revealed an order for meropenem 1 gram in 100 milliliters of 0.9% normal saline intravenously twice a day over 3 hours, dated March 6, 2026. Further review of orders failed to reveal any orders for a flushing/locking agent(s), peripheral access site changes, or intravenous access site dressing changes. Observations of Resident 66 on March 9, 2026, at 1:15 PM, and March 10, 2026, at 1:25 PM, revealed an intravenous access line in the antecubital area of his left forearm. The dressing was intact, but no date was present. Resident 66 indicated that he had that from the hospital. Review of Resident 66's hospital records failed to reveal any documentation regarding when the intravenous access site was started or when the dressing was changed. Review of Resident 66's Admission/readmission Observation dated March 6, 2026, at 5:06 PM, revealed in the Infectious Disease section that Resident 66 had a urinary tract infection and that orders were reviewed with Resident 66's physician. The assessment failed to include any documentation of the presence of an intravenous access site. In addition, the baseline care plan section failed to include Resident 66 had a current infection requiring enhanced barrier precautions or his intravenous access site and care. During a staff interview with the Nursing Home Administrator, Director of Nursing (DON), and Employee 5 (Regional Director of Clinical Services) on March 11, 2026, at 11:14 AM, the DON and Employee 5 confirmed that orders should have been in place for a flushing agent, intravenous access site changes and dressing changes when Resident 66 was readmitted to the facility on [DATE]. In addition, both confirmed that Resident 66's baseline care plan should have included his infection, isolation precautions, and his intravenous access site. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of seven residents reviewed for ADLs (Resident 51). Findings Include:Review of the facility policy, titled AM Care Policy last reviewed September 16, 2025, read, in part, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Showers and baths are scheduled two times weekly or more or less according to resident preference. Provide shaving as desired by resident.Review of Resident 51's clinical record revealed diagnoses that included age-related osteoporosis (a bone disease characterized by weak and fragile bones, increasing the risk of fractures), hypertension (high blood pressure), and abnormalities of gait and mobility (unusual patterns of walking or movement caused by injuries, neurological, musculoskeletal, or environmental factors, affecting balance, coordination, and overall mobility).Observation of Resident 51 in her room on March 9, 2026, at 10:43 AM; March 10, 2026, at 9:29 AM, and March 11, 2026, at 10:20 AM; revealed she had a quarter inch presence of facial hair on her chin.Review of Resident 51's physician orders revealed she had a preferred bathing schedule of Tuesdays and Fridays on day shift. Review of Resident 51's comprehensive care plan revealed a focus area ADL/self care/mobility deficits, with an intervention for personal hygiene/grooming assist of 1.Review of Resident 51's point of care documentation revealed she was documented as receiving a bed bath on Tuesday March 10, 2026, and required a level of assistance of total dependence. Interview with Resident 51 on March 11, 2026, at 10:20 AM, she revealed she prefers to have bed baths in her room, and the staff does not always offer to shave her. Interview with the Director of Nursing on March 12, 2026, at 10:20 AM, revealed Resident 51 has been shaved, and she would expect ADL care to be provided to dependent residents and shaving to be offered on bathing days and as needed. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found by EMS staff laying on the ground near the public road, which runs in front of the facility, with abrasions to his hand and foot. This failure placed an additional three residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 3, and 4). Findings include: Review of facility policy, titled Elopement/Unauthorized Absence Policy, revised August 2, 2024, read, in part; The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Review of Resident 1's clinical record revealed diagnoses that included alcohol abuse, encephalopathy (a group of disorders that affect the brain and cause altered mental state), congestive heart failure (chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts), lack of coordination, and muscle weakness. Further review of Resident 1's clinical record revealed that he was admitted to the facility from the hospital on June 3, 2025. Review of Resident 1's elopement evaluation completed on June 6, 2025, revealed a score of 16 (high risk) with interventions to closely monitor doors and elevators. Review of Resident 1's census information revealed he had been residing in his current room on the second floor at the facility since June 6, 2025. Observation of Resident 1's room on July 8, 2025, at 11:30 AM, revealed it is located next to the second floor ambulance entrance door. Review of Resident 1's nursing progress notes revealed the following: June 3, 2025 - Resident alert to self with some confusion .Tried getting up several times unassisted and stated that he was leaving. Unsteady gait noted. June 6, 2025 - He is oriented to self only .Doesn't always have complete thoughts. He is exit seeking and states he wants to go home. He attempted to bang on the back door to get it open .Resident constantly has to be redirected from doors or going into other residents rooms. His gait is very unsteady. June 7, 2025 - Resident alert with confusion attempting to ambulate independently, gait unsteady agitated and difficult to redirect. Multiple times walking towards ambulance entrance door was redirected but increasing agitation. June 9, 2025 - IDT [Interdisciplinary Team] review completed to discuss behaviors, risks, interventions, and care plan updates for resident. Resident is reviewed as risk of elopement due to diagnoses, history of TBI [Traumatic Brain Injury], and exit seeking/wandering - has Elopement risk observation from admission. Presents with active aggression, exit seeking behaviors, and wandering. June 9, 2025 - Writer was in the room with [a] resident when alarm rang. Upon exiting the room, a staff member informed the writer that [Resident 1] was outside the door open the door himself. Writer placed him on 15 minute checks and notified the RN [Registered Nurse]. June 10, 2025 - Resident frequently hits exit door, then is quickly redirected back into the unit. Recommendation done to move resident from the exit area to another room. June 10, 2025 - IDT review post increased wandering episode completed. Last evening resident was observed to be increasingly confused and exit seeking attempting to go and 'find his car in the parking lot'. Resident is alert and oriented to self only and has poor safety awareness. He is often combative. He was seen pushing on the exit door, successfully opening the door, and staff intervened .New intervention to place resident on 1:1 monitoring on the evening shift. June 19, 2025 - Resident at 7pm was exit seeking redirected by staff to around unit. June 21, 2025 - Non-compliant with transfer and ambulation, exit seeking. June 21, 2025 - noted resident exit seeking, close supervision provided. June 24, 2025 - Resident is up the whole night, refused to go to bed, stating he wants to go home. June 27, 2025 - Resident was found missing from his room. At 0706am, he was found at the ED [Emergency Department] after being transferred by EMS [Emergency Medical Services] who saw him on the road .Today the resident was last seen at 0645am when incontinence care was provided. The exit door alarmed at 0650am with a timely response noted. Head count was performed and resident was identified to be missing. At 0706am, Facility received a call from [the neighboring hospital] about resident. He was found about 500 ft from the facility by an ambulance. Resident verbalized that he was drunk at the time and he was taken to the ED. He was properly dressed for the weather, he was in a tee shirt and a basketball short, but no footwear was noted. Review of facility incident report revealed that on June 27, 2025, Resident 1 was found missing from his room. At 7:06 AM, he was found at the emergency room after being transferred by EMS who saw him on the road. Resident 1 was assessed in the emergency room where he was determined to be medically stable and ready to return to the facility. Resident 1 returned to the facility at noon. A Registered Nurse assessment was completed upon his return and he was found to have minor scrapes on his bilateral hands, knees and feet. Review of Employee 1's (Licensed Practical Nurse) witness statement dated June 27, 2025, revealed, I assisted the CNA [Certified Nurse Aide] to change a resident and at 5:30 to 5:35 after we changed him he was left in his room. About 10 or 15 minutes later I heard an alarm ring out. I went to the nearest exit and saw resident leaving, myself and CNA was at the door. We brought him back from the door. I left the resident with the CNA so I could call the supervisor for her help with the alarm that was ringing out. She came to the floor, turned off the alarm, educated us on how to fix door if this happened again and she left. I left the resident with the CNA. Review of Employee 2's (Nurse Aide) witness statement dated June 27, 2025, revealed about 7 AM I was making my rounds. I went into resident room he wasn't in there. I looked in bathroom. I came out and let the nurse know that he wasn't in the room and started looking on the unit and outside. Review of Employee 3's (Licensed Practical Nurse) witness statement dated June 27, 2025, revealed, [Employee 2] notified me that she had done rounds and could not find [Resident 1]. I checked the dining room & H hall rooms while making my way to the desk to call the RN. I received a call from [the hospital] @ 0730. I didn't catch the name, but the nurse asked if [Resident 1] was a pt [patient] here & if we were aware that he was in the ER. I confirmed yes he was a pt & asked her to hold for RN. Review of emergency department treatment notes dated June 27, 2025, revealed Resident 1 presented after being found outside that morning. Resident 1 reported having drinks with his friends that morning. EMS reported to the emergency department that Resident 1 was laying on the ground. Resident 1 was noted with abrasions to the left fingers, thumb and pointer finger, right foot, multiple abrasions. During an interview with the Director of Nursing (DON) on July 8, 2025, at approximately 11:30 AM, he revealed that on June 27, 2025, when the door alarmed for the second time around 6:50 AM, Employee 1 turned off the alarm again, but did not do a head count or attempt to visualize Resident 1, assuming he was with the nurse aide. The DON revealed that as a result, Employee 1 was disciplined following the incident and chose to resign. The DON confirmed that Employee 1 should have put Resident 1 on 1:1 monitoring after his first attempt to leave on June 27, 2025, and that the 15 second emergency egress function has since been disabled on the ambulance entrance door. The DON also confirmed that Resident 1 was found to have no evidence of alcohol or drugs in his system despite his claims of being intoxicated. During an interview with the Nursing Home Administrator (NHA) on July 8, 2025, at 12:30 PM, she confirmed that Employee 1 did not follow facility policy and procedure, was suspended, and ultimately decided to resign. The facility is located near a main road. There are parking lots in front of the facility, as well as housing complexes on each side of drive to the main road. Clinical record review for Residents 2, 3, and 4 revealed that they resided on the second floor unit and were determined to be at risk for elopement based on their elopement risk evaluations. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement. The NHA was provided the immediate jeopardy template on July 8, 2025, at 12:30 PM, and an immediate action plan was requested. On July 8, 2025, at 2:25 PM, the facility's immediate action plan was reviewed and accepted, which included: 1) A headcount was performed on all units. 2) A code was paged. 3) All door alarms were checked for proper function and windows were secured. Ambulance entrance/lock mechanism was found to be functioning properly. 4) A head to toe assessment was completed on Resident 1 in the emergency room by the DON. Current diagnostic studies and treatment plan were discussed. 5) The doctor and resident representative were made aware of the occurrence. 6) A timeline of investigation into the event was completed and witness statements were obtained from staff. 7) The facility was informed that Resident 1's diagnostic studies were complete and negative for any injuries and that Resident 1 would return to the facility that day. 8) Upon Resident 1's return to the facility, a head to toe assessment was completed, elopement assessment and BIMS (Brief Interview for Mental Status) were updated. 9) The doctor and resident representative were notified of Resident 1's return to the facility. 10) Resident 1 was placed on 1:1 observation for elopement risk at all times, and his care plan was updated to reflect this. 11) The Social Service Director completed a psychosocial visit to assess impact and provide support following elopement. 12) The psychiatric Nurse Practitioner completed a consult, evaluated Resident 1's medication regimen, and new orders were provided. 13) To identify others with the likelihood to be affected, the DON/designee completed new elopement assessments on all residents to ensure all residents that are at risk for elopement are identified, care plans with personalized interventions were implemented, and that the elopement binder was updated. 14) To prevent a future occurrence, all facility staff were educated on the elopement policy and how to respond to door alarms appropriately. 15) All licensed staff were educated that upon completion of Admission/Readmission/Quarterly assessments, residents identified at risk for elopement will have care plans with personalized interventions implemented and elopement binders updated. 16) The Maintenance Director/designee completed elopement drills across all three shifts. 17) The DON/designee educated all staff that the 15 second egress on the ambulance entrance will be replaced with a keypad for entrance/exit to the facility. 18) To monitor and maintain ongoing compliance, the DON/designee will complete elopement drills across all three shifts to ensure accurate response by staff to an elopement situation. Any inaccurate response will be immediately corrected/remediated weekly x 4 and then monthly x 2. 19) To monitor and maintain ongoing compliance, the DON/designee will audit elopement assessment scores on 5 random Admission/Readmission/Quarterly assessments to ensure those identified at risk for elopement have a care plan with personalized interventions implemented and elopement binder updated; any missing area identified will be corrected weekly x 4, then monthly x 2. 20) An Ad Hoc QAPI (Quality Assessment and Performance Improvement) meeting was held on June 27, 2025 with the interdisciplinary team. 21) The results of the audits will be forwarded to the QAPI committee for further review and recommendations. The Immediate Jeopardy was lifted on July 8, 2025, at 2:25 PM, after ensuring that the immediate action plan had been implemented. The facility demonstrated past non-compliance by initiating immediate interventions starting June 27, 2025, following the incident. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed on July 8, 2025, during the onsite survey and included: - An in-house resident head count was completed on June 27, 2025. - The Housekeeping/Laundry director tested the lock and alarm on the ambulance entrance door. He confirmed the door and alarm were in proper working order at 8:15 AM on June 27, 2025. He also checked all the doors and confirmed all were working as they should. - Review of service report dated June 27, 2025, revealed that the egress delay was disabled on the second floor ambulance entrance, labels were applied to the keypads stating to ensure door is closed when walking through, and signs were removed stating that pushing on the door for 15 seconds would open the door. - A new elopement assessment was completed for Resident 1 on June 27, 2025. Resident 1 was again identified as at risk for elopement and immediate interventions were added for 1:1 at all times, psychiatric referral, social services follow-up, redirection, and to encourage 1:1 activities. - A Brief Interview for Mental Status assessment was completed for Resident 1 on June 27, 2025, indicating severe cognitive impairment. - Resident 1's care plan was updated on June 27, 2025, to reflect 1:1 at all times due to elopement risk. - The Social Service Director followed up with Resident 1 on June 27, 2025, and no distress was noted at that time. - An order was initiated for 1:1 monitoring at all times for Resident 1 effective June 27, 2025. - Elopement drills were conducted on June 27, 2025, on the evening and overnight shifts. - Resident 1 was evaluated by the psychiatric nurse practitioner on June 27, 2025. - Resident 1 was evaluated by his attending practitioner on June 28, 2025. - Elopement assessments were updated for all residents on June 27, 2025. Care plans and the elopement binder were updated for each resident identified at risk for elopement. - Education was provided to all staff on June 27, 2025, regarding the elopement policy and the ambulance door egress. - Education was provided to nursing staff on June 27, 2025, regarding elopement care plan and binder updates. - The first ongoing elopement risk audit of care plans and the elopement binder was completed for the week of June 29, 2025. - The first ongoing audit of the ambulance entrance keypad function was conducted for the week of June 29, 2025. During the onsite survey on July 8, 2025, no additional concerns related to elopement were identified based on observations, clinical record review, interviews with staff, review of audits, and review of education provided to staff. 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)(3)(5) Nursing services

Based on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, and failed to assess residents to identify pressure ulcers for one of four residents reviewed (Resident 3), resulting in the development of pressure ulcers. Findings include: Review of facility policy, titled Skin and Wound Care Best Practices, with a last revised date of June 10, 2022, revealed, in part, the following: CNA's (Certified Nurse Aide) fill in shower sheet with each bath/shower and review with licensed nurse . On admission the nurse will complete a full body assessment. A second full body assessment will be scheduled in the first 24 hours of admission . The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistant's shower sheet skin reviews . Any resident leaving the facility for an appointment, LOA [leave of absence], dialysis, etc., will have a Departure/Return assessment before the resident leaves the facility and upon return to the facility. The licensed nurse will complete the assessment(s) in the health record. The policy continued, Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. Use of a consulting wound care provider for management of wounds is recommended is recommended for the following: a stage 3 or greater pressure area; complicated vascular wounds; complicated diabetic wounds; wounds which are worsening; wounds which are not healing even with treatment changes; infected wounds; when assistance with correctly staging or categorizing a wound is needed. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults); and bullous pemphigoid (a rare skin condition causing large fluid filled blisters that usually appears on the belly, chest, arms, legs, groin, or armpits). Review of Resident 3's clinical record revealed physician orders for: Cleanse open area to right lateral knee with normal saline, apply xeroform gauze, and cover with foam every shift dated August 21, 2023; Check placement of dressing to right lateral knee and reapply utilizing as needed treatment order if soiled or dislodged, dated June 29, 2023; Cleanse open area to left lateral upper arm with normal saline, apply triple antibiotic ointment, cover with non-adherent pad, and wrap with kling daily and as needed, dated June 29, 2023; Cleanse two small open areas to lower abdomen with normal saline, allow to dry, apply xerform gauze, and cover with foam daily and as needed, dated June 29, 2023; Cleanse open area to the Left Lateral Ankle with normal saline or wound cleanser and pat dry; apply a piece of Collagen AG to the wound bed, cut to fit, and cover with border foam dressing every evening shift, dated November 21, 2023; and consult dermatology for bullae (fluid filled sacs) and multiple open areas, dated July 17, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment (measurements, description, characteristics, or status [healing, worsening, infected]) of the identified open areas on the right lateral knee, the left lateral upper arm, the lower abdomen, or the left lateral ankle. Review of Resident 3's care plan revealed a care plan problem for skin integrity related to diagnosis of bullous pemphigoid, with a start date of September 28, 2023, and a last edited date of December 7, 2023. Interventions included: conduct a systematic skin inspection weekly with tub bath/shower, dated September 28, 2023; and Treat skin condition per MD order, Dermatology Consult as needed, and follow by wound team, dated September 28, 2023. The care plan failed to include actual skin impairment as identified by the multiple wounds. Further review of Resident 3's clinical record failed to reveal any documentation that a systematic skin inspection was completed weekly with tub bath/shower to determine if there were any pressure ulcers, nor was there any documentation that Resident 3's known areas of skin breakdown being evaluated on a weekly basis. Review of Resident 3's nurse aide point of care documentation revealed that on December 6, 2023, at 2:23 AM, that Employee 2 (Nurse Aide) noted redness and bruising to Resident 3's back, buttock, and leg (no specification as to which leg was given). There was no documentation noted that this identified concern was reported to the licensed nurse. Review of Resident 3's clinical record progress notes failed to reveal any documentation that the aforementioned redness and bruising to their back, buttock, and leg was assessed by a licensed nurse on December 6, 2023. Email communication received from NHA on December 28, 2023, at 4:00 PM, revealed that they were not aware of the bruising and redness being reported to a licensed nurse to assess when identified by Employee 2 on December 6, 2023. Review of Resident 3's clinical record revealed that he had been seen by Employee 3 (Primary Care Physician) on November 10, 15, 29, 2023, and December 6, 13, and 18, 2023. Review of these physician progress notes from the aforementioned visits failed to reveal an assessment of Resident 3's identified skin issues. Review of Resident 3's clinical record revealed that for November 2023 and December 2023, they had been seen by Employee 4 (Certified Registered Nurse Practitioner) on November 2, 3, 6, 7, 10, 13, 14, 16, 17, 24, 28, 2023, and December 1, 5, and 12, 2023. Review of these physician services progress notes revealed new lesions were indicated in the progress notes on November 6, 2023, which was noted as seen by dermatology November 7, 2023. On November 13, 2023, multiple lesions and open areas were reported by nursing and follow-up with dermatology was recommended. On November 14, 2023, in section titled Issues reported by nursing indicated skin lesions. On November 16, 2023, in section titled Issues reported by nursing indicated increased lesions all over, and the assessment/plan indicated bullous pemphigoid with more new lesions. The note also indicated that the charge nurse was asked to contact dermatology regarding the new lesions; On November 17, 2023, stated lesions remain the same. The note also indicated that Resident 3's Prednisone (a steroid medication) dose was increased. Review of Resident 3's progress notes revealed no physical assessment of Resident 3's skin was documented. Notes identified the bullous pemphigoid lesions but failed to complete an assessment documenting the characteristics of the wounds. Review of Resident 3's clinical record revealed a note dated December 18, 2023, at 9:45 AM, completed by Employee 5 (Registered Nurse) that indicated This writer asked MD to see resident r/t (related to) his Bullous Pemphigoid and ulcers that resident has been having treated on his lateral left lower leg. MD felt that resident should be sent out to the hospital. Review of Resident 3's clinical record revealed a physician progress note completed by Employee 6 (Physician) dated December 18, 2023, prior to sending Resident 3 to the hospital, indicated the following: Patient with bullous pemphigoid has unstageable lesion over L[eft] malleolus [ankle] ulceration. Ext[ensive] multiple wounds on LLE [left lower extremity]. Unstageable L[eft] ankle ulcer with necrotic [dead] tissue 1) Unstageable left ankle ulceration with necrosis probable OM [osteomyelitis-infection in the bone] elevated white blood cell count, needs debridement [medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue] and IV [intravenous] antibiotics; 2) bullous pemphigoid. Review of Resident 3's clinical record revealed a note dated December 19, 2023, at 8:46 AM, that indicated he was admitted to the hospital with a diagnosis of sepsis, wound infection, and critical limb ischemia (severe blockage in the arteries of the lower extremities which markedly reduces blood flow). Review of Resident 3's hospital admission history and physical dated December 18, 2023, at 4:17 PM, indicated, in part, Per nursing at Colonial Park Care Center (River's Bend), the wounds have been present for several months with worsening over the last several weeks. MRI was concerning for osteomyelitis of the fibula. Podiatry recommended vascular surgery consult. Vascular surgery recommended AKA (above knee amputation) as patient has multiple wounds, decreased blood supply. General surgery is following patient and planning for left AKA. Facility provided a copy of Resident 3's wound assessment from the hospital that was completed by a Wound Ostomy Continence Nurse on December 19, 2023, at 10:10 AM. Review of this report indicated that, upon admission, the presence of the following pressure areas were identified: 1) right hip presents with a stage 3 pressure injury with wound bed yellow/pink and moist. Several circular superficial pink open wounds noted of peri-wound skin (skin surrounding the wound bed); 2) sacrum presents with an unstageable pressure injury with center brown/black, edges red/yellow; 3) left lateral knee presents with a stage 3 pressure injury with wound bed pale yellow/pink and moist; 4) unstageable pressure injury noted on left lateral lower leg extending to the lateral ankle with wound bed brown with tan and red, bone exposed over the ankle; 5) left medial ankle presents with a deep tissue injury with area maroon and intact. There is an unstageable pressure injury over left posterior heel with bed dry and black. Further review of Resident 3's hospital record revealed a note dated December 21, 2023, at 1:34 PM, that indicated Given patient's comorbidities and severe dementia I do not think he is a good candidate for surgical intervention with AKA. Resident 3's family opted for comfort care with hospice and was transferred back to the facility on [DATE]. Review of Resident 3's clinical record revealed a progress note dated December 22, 2023, at 12:49 AM, that indicated, in part, Resident admitted .diagnosis is left leg osteomyelitis .As per hospital report family decided on comfort measures .has several bruises all over his body with multiple wounds on sacral, lower extremity, and back . Hospice was called. Email was sent to the Nursing Home Administrator (NHA) on December 26, 2023, at 1:35 PM, requesting information regarding a weekly assessment with measurements of Resident 3's identified skin areas. Email response received from NHA on December 26, 2023, at 1:37 PM, indicated that there were no weekly assessments of Resident 3's skin issues with measurements because Resident 3 was being seen by dermatology. Review of facility provided dermatology visit note from November 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Review of facility provided dermatology visit note from December 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Email communication received from NHA on December 26, 2023, at 1:42 PM, the NHA confirmed that there were no assessments of any of Resident 3's skin conditions that the facility could locate. Email communication received from NHA on December 27, 2023, at 1:03 PM, the NHA indicated that staff are to document weekly skin checks on a form called Weekly Observation. She further indicated that she noted that Resident 3 did not have an order for this weekly observation to be completed and that an order had now been placed in system. The NHA confirmed that she would expect staff to have complete weekly assessments of Resident 3's known skin conditions and document the findings. During further correspondence with the NHA, she stated that, upon readmission to the facility, Resident 3 had a pressure area noted to the sacrum extending to buttock measuring 5.2 centimeters (cm - unit of measure) x 7 cm with the depth unstageable. She indicated that a wound sheet for this wound was not completed on admission and that the agency nurse left measurements on paper. She further indicated that the measurements will be placed in the computer that day, on December 27, 2023. In response to the concern about care plan interventions of follow by wound team dated September 28, 2023, not being implemented, the NHA indicated wound nurse starts Tuesday (January 2, 2024). Follow-up review of Resident 3's clinical record on December 28, 2023, at 3:41 PM, revealed that a Wound Management Detail Report was completed by the DON on December 27, 2023, at 2:35 PM; a total of five days after Resident 3's readmission to the facility. This report indicated the presence of a pressure ulcer to their sacrum and was described as: Length - head to toe direction: 5.2 cm Width - side to side direction: 7 cm Can depth be measured?: No Exudate Amount: Moderate Exudate color and consistency: Serosanguineous (pale red to pink, thin and watery) Stage: Unstageable - Slough and/or Eschar Tissue Type: Necrotic Tissue Comments: Upon readmission resident noted with unstageable pressure ulcer to sacrum/extending into bilateral buttocks. Resident now comfort care and awaiting hospice consult. 90% thick adherent yellow slough noted to wound bed with 10% dry black eschar tissue. Moderate serosanguineous draining with slight odor noted. No s/sx (signs or symptoms) of pain when wound is assessed. Peri-wound WNL [within normal limits]. Wound cleansed with NSS [normal saline solution], calcium alginate with Ag [silver] placed to wound bed and covered with foam. Review of a progress note dated December 28, 2023, at 2:59 PM, (six days after Resident 3's readmission to the facility) by the DON, indicated Full body assessment completed on resident: Following are his current wounds/measurements. Right hip lesion: measures 0.4 cm x 0.2 cm, no depth, with light serous drainage; Right lateral back lesion: 1.5 cm x 2.7 cm, no depth, with light serous drainage; Right lower back lesion: 0.8 cm x 1.2 cm, no depth, with light serous drainage; Right upper lateral shin lesion: 1 cm x 1 cm, no depth, with light serous drainage; and Right lower lateral shin lesion: 1 cm x 1.4 cm, no depth, with light serous drainage Right shin: four intact scabs Right thigh: Intact fluid filled blister 1 cm x 0.7 cm, with surrounding skin intact and no discoloration. Continued review of the DON's progress note revealed multiple areas of deep discoloration, intact eschar tissue, etc., to the left lower extremity, related to critical limb ischemia and severe PVD. The progress note revealed the following area assessments were noted related to the Resident's left lower extremity: Heel: 7.5 cm x 6 cm, noted with a mixture of black eschar tissue and deep purple areas with no drainage; Medial ankle: 1 cm x 1.5 cm, intact deep purple area with surrounding skin reddened; Medial foot: 1.4 cm x 1.5 cm, intact deep purple area with surrounding skin reddened; Distal medial foot: 1.5 cm x 1.3 cm, intact deep purple area with surrounding skin reddened, Reddened area noted to medial aspect of left great toe; Medial skin: 1.6 cm x 1 cm, with light serous drainage; Medial upper knee: 2.5 cm x 1.8 cm, with light serous drainage; Medial lower knee: 3.5 cm x 2.5 cm, with light serous drainage; Distal lateral foot: 1.8 cm x 2.3 cm, intact deep purple tissue; Lateral foot: 1.2 cm x 1.3 cm, intact eschar with no drainage; Lateral foot: 6.2 cm x 5.5 cm, intact eschar tissue with no drainage; Lateral lower knee: 3 cm x 1 cm, with light serous drainage; Lateral knee: 1.9 cm x 4.3 cm, with light serous drainage; Lower back: 8 cm x 1 cm, with light serous drainage; Lateral ankle: 8 cm x 5.2 cm, unable to measure depth, wound with 80% thick yellow slough and 20% dry eschar, foul smelling with moderate serosanguineous drainage; Lateral shin: 6.4 cm x 2.5 cm, with 100% dry eschar. The progress note revealed that there was no pedal pulse to the left foot and that the left lower extremity, including the foot, was cool to the touch. Further, it stated that the Resident was currently on comfort care with a Hospice evaluation pending. A follow-up review of Resident 3's clinical record on December 29, 2023, at 9:30 AM, revealed that there were no other Wound Management Detail Reports completed for the other hospital identified wounds. During an interview with the NHA and Director of Nursing (DON) on December 29, 2023, at 10:24 AM, the NHA confirmed that the dermatologist had only assessed Resident 3's right arm and forehead, and had not assessed Resident 3's lower extremity open areas. The DON indicated that the facility process was that an order would be entered upon admission for all residents to have a weekly skin assessment, and that this assessment would be completed by the charge nurse on that assignment on the scheduled day. She indicated that this would either be a Registered Nurse or a Licensed Practical Nurse and that wound characteristics and measurements would be documented on a form called Weekly Observation. She confirmed that Resident 3 had no order for a weekly skin check. When asked if Resident 3 had been seen by the facility wound team as indicated on their care plan, the DON indicated that the wound team only assesses pressure area wounds and confirmed that Resident 3's skin conditions (open areas, rashes, blisters) had not been assessed by the facility wound team. When asked how a nurse would know when to report a concern with the skin condition, the DON indicated the nurse doing the treatment should notice the changes in the wound/ skin condition and should notify their superior. When specifically asked if, to her knowledge, Resident 3 was receiving a weekly skin assessment by a nurse, the DON replied, Not that's documented. When asked about all the areas that the hospital's Wound Ostomy Continence Nurse identified as pressure area, the DON indicated that the facility only identified the sacral wound as a pressure area, She said that the areas identified on Resident 3's legs and heels were considered vascular wounds since the Resident was diagnosed with PVD and chronic limb ischemia at the hospital. She said that, as for the others identified at the hospital, they are considered blisters that have opened and that they are flat to the skin. She also indicated that some of them were scars from previous bullous pemphigoid areas. When asked about Employee 2's documentation of the redness and bruising to Resident 3's back, buttock, and leg, the DON confirmed that there was no evidence that this was reported to a licensed nurse. When asked if this documented concern by Employee 2 could have been the start of the development of the pressure ulcer, the DON indicated No. When asked specifically if the sacral pressure ulcer should have been identified prior to Resident 3's admission to the hospital, the DON replied, Maybe, we don't know. When asked if a skin assessment was completed prior to Resident 3's transfer out of the facility as indicated in the facility policy, the DON indicated it was not done as this was an emergent transfer. When asked if the facility has a specialized wound care consultant that visits the facility on a routine basis to assess residents with noted skin conditions such as open areas, the DON indicated that they do not have an in-house provider, and that they send residents to a wound care provider on an as needed basis. She confirmed that Resident 3 had not been seen by a specialized wound care provider for his ongoing skin conditions (open areas, rashes, blisters). When asked if Resident 3's physician was aware of the extent of Resident 3's skin conditions and if the physician had actually assessed the areas prior to December 18, 2023, she indicated, not that I am aware. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d)Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure care and services were provided including skin and wound assessments in accordance with professional standards of practice, resulting in development and deterioration of wounds and subsequent transfer to the hospital with a diagnosis of wound infection and sepsis, requiring an above the knee amputation for one of three residents reviewed (Resident 3). Findings include: Review of facility policy, titled Skin and Wound Care Best Practices, with a last revised date of June 10, 2022, revealed, in part, the following: CNA's (Certified Nurse Aide) fill in shower sheet with each bath/shower and review with licensed nurse . The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistant's shower sheet skin reviews. The policy continued, Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. Use of a consulting wound care provider for management of wounds is recommended for the following: a stage 3 or greater pressure area; complicated vascular wounds; complicated diabetic wounds; wounds which are worsening; wounds which are not healing even with treatment changes; infected wounds; when assistance with correctly staging or categorizing a wound is needed. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults); and bullous pemphigoid (a rare skin condition causing large fluid filled blisters that usually appears on the belly, chest, arms, legs, groin, or armpits). Further record review revealed wound areas to the Resident's right lateral knee, left lateral ankle, left lateral upper arm, and abdomen. Review of Resident 3's clinical record revealed physician orders for: clobetasol ointment 0.05 % apply small amount topically to rash on right wrist twice daily, dated December 10, 2023; fluocinonide cream 0.05 % apply small amount topically to right wrist every day for bullous pemphigoid, dated December 16, 2023; fluocinonide cream 0.05 % apply small amount topically to blistered area(s)/rashes topically on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen every day as needed related to bullous pemphigoid, dated August 23, 2023; triamcinolone acetonide cream; 0.1 % apply a small amount topically twice a day to rashes on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen related to bullous pemphigoid, dated August 1, 2023; and tacrolimus ointment 0.1 % apply a small amount topically every shift to blistered area(s)/rashes on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen related to bullous pemphigoid, dated August 9, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment of their skin for the extent, number, or description of these blistered areas and/or rashes. Further review of Resident 3's clinical record revealed physician orders for: Cleanse open area to right lateral knee with normal saline, apply xeroform gauze, and cover with foam every shift, dated August 21, 2023; Check placement of dressing to right lateral knee and reapply utilizing as needed treatment order if soiled or dislodged, dated June 29, 2023; Cleanse open area to left lateral upper arm with normal saline, apply triple antibiotic ointment, cover with non-adherent pad, and wrap with kling daily and as needed, dated June 29, 2023; Cleanse two small open areas to lower abdomen with normal saline, allow to dry, apply xerform gauze, and cover with foam daily and as needed, dated June 29, 2023; Cleanse open area to Left Lateral Ankle with normal saline or wound cleanser and pat dry; apply a piece of Collagen AG to the wound bed, cut to fit, and cover with border foam dressing every evening shift, dated November 21, 2023; and consult dermatology for bullae (fluid filled sacs) and multiple open areas, dated July 17, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment (measurements, description, characteristics, or status [healing, worsening, infected]) of the identified open areas on the right lateral knee, the left lateral upper arm, the lower abdomen, or the left lateral ankle. Review of Resident 3's care plan revealed a care plan problem for skin integrity related to diagnosis of bullous pemphigoid, with a start date of September 28, 2023, and a last edited date of December 7, 2023. Interventions included: conduct a systematic skin inspection weekly with tub bath/shower, dated September 28, 2023; and treat skin condition per MD order, Dermatology Consult as needed, and follow by wound team, dated September 28, 2023. Further review of Resident 3's clinical record failed to reveal any documentation that a systematic skin inspection was completed weekly with tub bath/shower, nor was there any documentation that Resident 3's known areas of skin breakdown were being evaluated on a weekly basis. Review of Resident 3's clinical record revealed a note dated December 18, 2023, at 9:45 AM, that indicated This writer asked MD to see resident r/t (related to) his Bullous Pemphigoid and ulcers that resident has been having treated on his lateral left lower leg. MD felt that resident should be sent out to the hospital. Review of Resident 3's clinical record revealed a note dated December 19, 2023, at 8:46 AM, that indicated the Resident was admitted to the hospital with a diagnosis of sepsis, wound infection, and critical limb ischemia (severe blockage in the arteries of the lower extremities which markedly reduces blood flow). Review of Resident 3's hospital admission history and physical dated December 18, 2023, at 4:17 PM, indicated, in part, Per nursing at Colonial Park Care Center (River's Bend), the wounds have been present for several months with worsening over the last several weeks; . MRI was concerning for osteomyelitis of the fibula. Podiatry recommended vascular surgery consult. Vascular surgery recommended AKA (above knee amputation) as patient has multiple wounds, decreased blood supply. General surgery is following patient and planning for left AKA. Facility provided a copy of Resident 3's wound assessment from hospital that was completed by a Wound Ostomy Continence Nurse on December 19, 2023, at 10:10 AM. This report indicated the presence of the following skin areas: 1) several superficial circular wounds noted on right forearm with beds red/yellow; 2) right hip presents with a stage 3 pressure injury with wound bed yellow/pink and moist. Several circular superficial pink open wounds noted of peri-wound skin (skin surrounding the wound bed); 3) sacrum presents with an unstageable pressure injury with center brown/black, edges red/yellow; 4) left lateral knee presents with a stage 3 pressure injury with wound bed pale yellow/pink and moist; and 5) unstageable pressure injury noted on left lateral lower leg extending to the lateral ankle with wound bed brown with tan and red, bone exposed over the ankle. Further review of Resident 3's hospital notes revealed a physician progress note dated December 21, 2023, at 12:46 PM, that indicated Patient was found to have osteomyelitis of the left fibula. General surgery is following and planning for left AKA on Friday. Cardiology is consulted for preop clearance. Further review of Resident 3's hospital record revealed a note dated December 21, 2023, at 1:34 PM, that indicated Given patient's comorbidities and severe dementia I do not think he is a good candidate for surgical intervention with AKA. Resident 3's family opted for comfort care with hospice and was transferred back to the facility on [DATE]. Email was sent to the Nursing Home Administrator (NHA) on December 26, 2023, at 1:35 PM, requesting information regarding a weekly assessment with measurements of Resident 3's identified skin areas. Email response received from NHA on December 26, 2023, at 1:37 PM, indicated that there were no weekly assessments with measurements because Resident 3 was being seen by dermatology. Review of facility provided dermatology visit note from November 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Review of facility provided dermatology visit note from December 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Email communication received from NHA on December 26, 2023, at 1:42 PM, the NHA confirmed that there were no assessments of Resident 3's skin conditions that the facility could locate. Email communication received form NHA on December 27, 2023, at 1:03 PM, the NHA indicated that staff are to document weekly skin checks on a form called Weekly Observation. She further indicated that she noted that Resident 3 did not have an order for this weekly observation to be completed and that an order had now been placed in system. The NHA confirmed that she would expect staff to have complete weekly assessments of Resident 3's known skin conditions and document the findings. During an interview with the NHA and Director of Nursing (DON) on December 29, 2023, at 10:24 AM, the NHA confirmed that the dermatologist had only assessed Resident 3's right arm and forehead and had not assessed Resident 3's lower extremity open areas. The DON indicated that the facility process was that an order would be entered upon admission for all residents to have a weekly skin assessment, and that this assessment would be completed by the charge nurse on that assignment on the scheduled day. She indicated that this would either be a Registered Nurse or a Licensed Practical Nurse and that wound characteristics and measurements would be documented on a form called Weekly Observation. She confirmed that Resident 3 had no order for a weekly skin check. When asked if Resident 3 had been seen by the facility wound team as indicated on their care plan, the DON indicated that the wound team only assesses pressure area wounds and confirmed that Resident 3's skin conditions (open areas, rashes, blisters) had not been assessed by the facility wound team. When asked how a nurse would know when to report a concern with the skin condition, the DON indicated the nurse doing the treatment should notice the changes in the wound/ skin condition and should notify their superior. When specifically asked if, to her knowledge, Resident 3 was receiving a weekly skin assessment by a nurse, the DON replied, Not that's documented. When asked if the facility has a specialized wound care consultant that visits the facility on a routine basis to assess residents with noted skin conditions such as open areas, the DON indicated that they do not have an in-house provider and that they send residents to a wound care provider on an as needed basis. She confirmed that Resident 3 had not been seen by a specialized wound care provider for his ongoing skin conditions (open areas, rashes, blisters). When asked if Resident 3's physician was aware of the extent of Resident 3's skin conditions and had assessed the areas prior to December 18, 2023, she indicated, not that I am aware. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice is cited as Past Non-Compliance. Findings Include: Review of the clinical record for Resident 1 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of meal intakes from February 8 through February 15, revealed one meal that Resident 1 consumed 0-25% of the meal. Resident 1 ate 26-50% seven times. The resident ate 51-75% of her meal 13 times and 75-100% of her meals three times. Review of Resident 1's clinical record revealed that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing (DON) on March 4, 2021, at 9:35 AM, she explained that when a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were unaware of the new order for blood sugar checks; therefore, they were not being done. On February 22, 2021, at 5:48 AM, routine labs were drawn. Results revealed that Resident 1's glucose (blood sugar level) was 455. Normal glucose level is 70-99. The labs were signed as reviewed by Certified Registered Nurse Practitioner (CRNP) 1, but no new orders were initiated for the resident's elevated glucose. Review of previous lab results revealed that on February 11, 2021, Resident 1's glucose level was 30, on February 4 it was 66, on January 29 it was 83, on January 28 it was 107 and on January 21 it was 176. During an interview with CRNP 1 on March 4, 2021, at 11:48 AM she stated that she reviewed the labs for Resident 1 and contributed the elevated glucose to a sugary drink she may have had. She confirmed that she did not check to see what the results of the blood sugar checks were that were supposed to be performed at the facility according to the physician order. On February 27, 2021, a nursing note states that Resident 1 had been lethargic (sleepy or fatigued and sluggish that can be related to an underlying physical or mental condition). The nurse also wrote that the resident had minimal intake and output. The nursing note also stated that Resident 1 slept most of the day and the nurse was not able to give morning medications. On February 28, 2021, at 4:52 AM, a nursing note revealed that Resident 1 was very lethargic. Non verbal (not talking) but does moan with repositioning in bed. Not alert enough to swallow meds safely. Vital signs were: Temperature 96.8, Pulse 76, respirations 30 (Normal is 12-16) and O2 sat 90% on room air (normal is 95-100%). On February 28, 2021, at 9:35 AM, a nursing note revealed that Resident 1 continued to be lethargic, unable to take medications, not eating. Blood sugar check read HI on the glucometer (device to check blood sugar). HI indicates that the blood sugar is above the readable level of the glucometer. The physician was notified, and a new order was obtained for labs, Intravenous (IV) fluids, [MEDICATION(S)] 5 units and to check blood sugar every four hours. On February 28, 2021, at 11:30 AM, Resident 1 remained lethargic. Blood sugar level remained HI when staff re-checked it. Labs from that day were reviewed and revealed glucose was >960. Blood urea nitrogen (BUN) (measures kidney and liver function) was 103 (normal 6-20) creatinine (kidney function) was 4.25 (normal 0.60-1.20). The physician was notified and an order was given to send Resident 1 to the emergency room (ER). Labs were obtained from Resident 1 in the ER. Review of results revealed a blood glucose of 1,329. An insulin drip was ordered and transfer to the ICU discussed. Further review of hospital notes revealed Resident 1 was found to be in multi-organ failure with Diabetic Ketoacidosis (DKA), NSTEMI ([CONDITION(S)]), respiratory failure, and acute renal (kidney) failure. Resident 1's family opted for comfort measures and the resident was admitted to the hospital and started on comfort measures only. Hospice was consulted who recommended general inpatient hospice and a [MEDICATION(S)] drip (constant medication for pain or shortness of breath). On March 1, 2021, at 1:15 AM, less than 24 hours after admission, Resident 1 was pronounced dead. During an interview with the Director of Nursing on March 4, 2021, at 9:35 AM she explained that the order for blood sugar checks was not entered into the electronic medical record correctly and did not transfer over for the nurses to complete. She confirmed that the blood sugar checks were not done per physician order. The facility failed to monitor Resident 1's blood sugars after discontinuing the order for insulin. The facility also failed to act upon an abnormal lab value of elevated glucose level. This failure resulted in Resident 1 developing DKA which resulted in multiple organ failures and death. Immediate corrective actions implemented by the facility included: Orders entered by involved staff have been reviewed for accuracy and addressed as needed. Baseline review of diabetic residents revealed no additional documentation errors in blood glucose order entries. Current policy and procedure was reviewed regarding the 24 hour review of new orders to assure compliance and assurance orders entered accurately. Policy updated for changes in electronic medical records. Director of Nursing/Designee completed immediate in-servicing with facility nursing staff regarding diabetic education/recognition, accurate order entry, and 24 hour chart review. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 10/4/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/12/19, 8/7/19, 4/4/19, 10/4/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 9/12/19, 8/7/19, 4/4/19, 10/4/18. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/12/19, 10/4/18. 28 Pa. 211.12(d)(1)(5) Nursing services. Previously cited 9/30/20, 8/28/20, 12/12/19, 9/12/19, 8/7/19, 4/4/19, 10/4/18. 28 Pa. 211.12(d)(3) Nursing services. Previously cited 9/12/19, 8/7/19, 4/4/19, 10/4/18. 28 Pa. 211.2(a) Physician services.

Based on observations, interviews, and review of an incident/accident report it was determined that the facility failed to provide the highest practicable care regarding transfers for one resident of three reviewed (Resident 2). Resident 2 required the use of a mechanical lift for transfers, the action by staff resulted in harm when the mechanical lift sling came unhooked and Resident 2 fell to the floor and developed a deep tissue injury, which became an open wound and required a wound vac (a device that uses negative pressure to remove fluid from the wound reducing swelling, clean the wound, and remove bacteria) for healing. (Resident 2) Findings include: Review of the facility procedure in the employee handbook, last reviewed (MONTH) 21, (YEAR), titled: Full-Body Mechanical Lift Hoyer Presence, revealed steps which included, Plan the transfer in advance, making sure you have a clear path from point A to point B. Transfer resident to destination-Ensure that resident is no longer touching and is in correct position to clear surface that they are being transferred from and to. Review of an incident/accident investigation report provided by the facility dated (MONTH) 12, 2019, revealed that on (MONTH) 12, 2019, at approximately 5:00 PM Resident 2 was being transferred from a Geri chair (a large padded, comfortable reclining chair with casters designed to allow patients recovering from illness, surgery, or the elderly to get out of bed and sit comfortably while being fully supported and transported to other areas) to bed. Nurse Aide (NA) 1 and NA 2 had clipped the lift sling (nylon seat like device designed to go under a resident and attach to the bottom of the lift to support the resident during a full body mechanical lift transfer), when the resident was at the maximum height of the lift. Resident 2 was not high enough to clear the Geri chair in which she was sitting. NA 1 and NA 2 then put their hands under Resident 2 and lifted the bottom of the sling to raise the resident up high enough to clear the Geri chair. NA 1 and NA 2 lifting on the bottom of the sling then caused the tension to be released on the sling and one of the hooks became dislodged. This resulted in the resident falling to the floor and struck her buttocks and the back of her head. Review of a witness statement from Resident 2 revealed the statement, My left leg was hanging from the Hoyer lift, I asked if they could take my leg out of the lift. They lowered my leg to the floor and put a pillow under my head. During an interview with Resident 2 on (MONTH) 14, 2019, beginning approximately 1:58 PM it was revealed that Resident 2 was still upset related to the fall from the lift. She revealed that she was in her chair and the aides were trying to lift her to the bed. The resident stated, when they lifted me up, I was still too far down in the chair to make it over the arms. The aides lifted up on the sling, and I told them I was falling, and that NA 1 said, 'No you're not falling' and the next thing I know, I was on the floor. Resident 2 continued that a part of either the lift or the sling hit me in the left thigh, and now I have an open wound there. It started a couple days later, I don't think it was a whole week but a couple days, and now I have a wound vac because they dropped me. Review of a witness statement from NA 1 signed on (MONTH) 12, 2019, revealed While transferring Patient to bed from lift we had the lift half way up, so we had to push a little under her from chair. Once we got the chair from under her we proceeded to transfer her. During transferring the latch on the left side of lift became detached. Resident fell to floor. Review of a witness statement from NA 2, undated but signed by the staff member, revealed we transferring resident from chair to the bed. When I went their (SIC) resident was all hooked to lift all four side. (NA 1) run the machine and her bottom was not out and we manually push little and get chair out of her. After move chair away resident fall on floor. When we check all hook the left side of bottom was unhook. Assessments at the time of the fall revealed that Resident 2 had no apparent injuries, though back of head on the right-side tender to touch but no redness or swelling noted. Review of Resident 2's clinical record revealed the following progress notes: On (MONTH) 14, 2019, two days after Resident 2 was dropped from a full body lift, Resident had no bruises/injury on 6/13 (June 13) when I checked her body prior to going to [MEDICAL TREATMENT]. However, she did have (sic) a bruise on the left thigh on the 14th of (MONTH) when I went to do an assessment on her roommates' bed. When ask resident stated that it came from falling. Skin was warm to touch, intact with purplish color skin the size of a dollar. Resident c/o (complained of) being in pain of 2/10 (2 out of 10 maximum). Resident was laying down on her bed wearing a gown with legs elevated. Charge nurse informed of pain. Resident is own RP (responsible party). (MD) made aware. June 14, 2019, Resident has a purple mark on left thigh about the size of dollar. Not warm to touch. Resident had c/o but refused anything for pain. Resident believes came from lift pad hitting her the other day. June 17, 2019, Noted small quarter size bruise. Denied any tenderness. No redness noted. Resident stated, I know this is from my fall, I felt something hit my leg but did not know what it was. June 18, 2019, Resident called me over to look at the bruise to her left thigh. Resident reported increase in pain to area. Area looked red and slightly warm to touch. June 19, 2019, Went to resident's room to look at bruise to left inner thigh this AM. Noted to have increased redden (sic) area, fire engine red, and warm to touch and tender to touch while assessing. Also noted a small open area. MD aware and in to see resident. New order for [MEDICATION NAME] (antibiotic), 100 mg BID (twice a day) x 10 days for [MEDICAL CONDITION] of inner thigh. Wound nurse aware of area and recommended cleanse with NSS (normal saline solution), apply xeroform (a gauze dressing treated with additional medications to enhance healing), and cover with a foam border. June 20, 2019, Labs drawn this AM, CBC (a blood test) reviewed with CRNP (certified registered nurse practitioner-a high schooled nurse that assist physicians with patient care). Resident noted with increased WBC (white blood cell count-an indication of an infection). June 20, 2019, Conclusion of investigation of bruise on left thigh shows that staff are referring to a bruise that had developed 2 days after resident had a fall (was dropped by staff). Resident also stated that she is aware why and how the bruise occurred, and staff continues to monitor area frequently. CRNP into and new orders received and noted. Staff education continues, to help prevent future occurrence and all lift competencies were completed for the fall that led to the bruise. June 21, 2019, at 3:37 PM Staff reported at 1500 (3:00 PM) hours that resident's left posterior thigh [MEDICAL CONDITION] area bleeding. June 21, 2019, at 8:41 PM Resident requested to change dressing at this time, noted small amount of bleeding on the dressing when removed, oozing blood from the left posterior [MEDICAL CONDITION] area at 6 o'clock skin slit and oozing zero-sanguineous (blood tinged) color, no foul odor, skin flat and black in color, surrounding area red and warm to touch. C/O pain when attempt to re-dress the area. June 21, 2019, at 11:23 PM Found a small hole that was oozing with serongerrous (sic) blood. June 24, 2019, Resident's wound on the thigh had some yellow odorless discharge, cleansed with NSS and pat dry, covered with xeroform and ABD (abdominal dressings typically used for large wounds), had a lot of discharge. June 26, 2019, Upon removal of the dressing the wound bed is covered with blackened tissue from the middle to proximal end of the wound and from middle to distal end is mixed with yellow slough (dead tissue separated from the living structure) and moist pink tissue. There is a small shallow opening at 9 o'clock with small depth. The site was used to obtain the wound culture. There is undermining noted around the entire edges of the wound and small amounts of odorless yellow drainage is noted. MD spoke at length in regard to need to be evaluated in the ER (emergency room ) with possible debridement to remove dead tissues and aid with healing. Review of physician order [REDACTED].) The facility failed to ensure the highest practicable care for one resident that required the use of mechanical lift, which resulted in actual harm to Resident 2, when the staff lifted on the sling, which then disconnected one of four hooks; therefore, causing Resident 2 to fall to the floor and develop a deep tissue injury, which became an open wound and required a wound vac (a device that uses negative pressure to remove fluid from the wound reducing swelling, clean the wound, and remove bacteria) for healing. 42 CFR 483.25 Quality of Care. Previously cited 10/4/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/4/19, 10/4/18. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Previously cited 4/4/19, 10/4/18. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 4/4/19. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 4/4/19. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/4/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/4/19, 10/4/18, 9/14/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/4/19, 10/4/18.

Based on clinical record review, review of select facility documentation, as well as staff and resident interviews, it was determined that the facility failed to implement interventions in place to assure resident safety during a transfer, resulting in a broken clavicle (long bone between the shoulder blade and breastbone) for one of six residents reviewed (Resident 3). Findings include: Review of Lift Policy last revised (MONTH) 10, (YEAR), revealed All residents will be evaluated for the safest transfer based on resident cognition and orthopedic diagnosis. If the evaluation reveals the safest transfer is a passive (full body) or active lift (sit-to-stand - tool used to transfer a person by lifting them to a partial or full standing position), 2 staff members are required for transfer. Review of Resident 3's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 3's orders dated (MONTH) 11, 2019, revealed an order to transfer with minimum assistance of two persons. Review of mobility evaluation completed (MONTH) 7, 2019, revealed a recommendation to transfer using stand-assist lift with a minimal assist of two persons due to [MEDICAL CONDITION]. Review of Resident 3's care plan interventions that were in place on (MONTH) 13, 2019, for inability to independently complete activities of daily living as well as to prevent falls, included the use of two staff for transfers. Review of facility incident report revealed that on (MONTH) 13, 2019, at 6:30 p.m. Resident 3 complained of left shoulder pain after being transferred using the standing lift. Review of nurse's progress note dated (MONTH) 13, 2019, revealed, At 1830 hours resident c/o (complained of) shoulder pain and said, STANDING LIFT CAUSING THIS Resident does not use left arm, it is always closes(sic) to the chest due to previous stroke .C/O pain 6 out of 10 .received order for X-ray. Review of mobile X-ray report dated (MONTH) 13, 2019, revealed a bony irregularity of the clavicle (collarbone). Review of nurse's progress note dated (MONTH) 13, 2019, at 11:00 p.m. revealed that when the X-ray results were communicated to the physician, an order was given to transfer the resident to emergency department. Review of emergency department consult notes revealed a midshaft clavicle fracture with a recommendation to obtain a CT scan (combines a series of X-ray images taken from different angles, which provides more information than plain X-rays). Review of CT scan results dated (MONTH) 14, 2019, revealed acute comminuted displaced fracture (break or splinter of the bone into more than two fragments that do not line up) of the left clavicle midshaft. During an interview with Nurse Aide (NA) 1 on (MONTH) 1, 2019, at 2:45 p.m. she revealed that on the date in question, she put the resident on the stand lift properly, but that the resident had a habit of hanging in the lift. NA 1 stated that when she asked the resident to not hang and support herself with her legs, the resident stated, honey, I can't. NA 1 then revealed she put the lift as high as she could to get the resident safely into her wheelchair, which she described as bulky. She then called for assistance with getting the resident positioned properly in her chair. NA 1 also revealed that she was aware that she was not to transfer the resident by herself, but no one was available to assist her due to break time. NA 1 revealed she decided to complete the transfer by herself since the resident was insistent she needed to use the restroom and she was fearful she would be reported for neglect if she did not respond. During an interview with Registered Nurse (RN) 1 on (MONTH) 1, 2019, at 3:20 p.m. she revealed that she was on duty during the incident and assessed the resident for injury. RN 1 revealed NA 1 reported to her that she was transferring Resident 3 by herself. During an interview with NA 2 on (MONTH) 1, 2019, at 3:25 p.m. NA 2 revealed that he was not in the room at the time NA 1 was transferring Resident 3 but did assist her when summoned with positioning Resident 3 in her chair. During an interview with the Director of Nursing on (MONTH) 1, 2019, at 3:45 p.m. she revealed the expectation that NA 1 should have followed the policy of using two persons with transfers for safety. The facility failed to implement interventions in place to assure resident safety during a transfer, resulting in a broken clavicle for one of six residents reviewed (Resident 3). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Previously cited 10/4/18. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/4/18, 9/14/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/4/18.

Based on staff witness statements and staff interview, it was determined that the facility failed to ensure that care and services were provided in an environment that enhanced each resident's dignity regarding restraining a resident to the side rail of the bed for one of 3 residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. An incident occurred on August 19, 2016, at 6:15 p.m. where Resident 1 was found by Licensed Practical Nurse (LPN) 1 tied to the side rail of his bed by the waist ties from his gown. Review of LPN 1's witness statement revealed that Resident 1 was having behaviors and refused to stay in bed or in a chair. She stated that Nurse Aide (NA) 1 assisted Resident 1 to his room to be toileted, provided evening care and assisted him to bed with the bed alarm (a device that can detect movements and sound an alarm if the resident tries to get up on their own) in place. She then saw NA 1 leave Resident 1's room and walk to the dining room to collect dinner trays. She noted that Resident 1's bed alarm was not sounding and his tone (quality of a person's voice) of his calling out had increased in pitch (highness or lowness of a tone) and volume. She went to check and found Resident 1 laying on his left side in his bed with the waist ties of his gown tied to the side rail of his bed. LPN 1 immediately called the Registered Nurse Supervisor (RN) 1 and NA 1 into the room. RN 1 instructed NA 1 to untie the resident immediately. At that time Resident 1 was untied from the side rail. Further review of the incident revealed that after the abuse incident was identified RN 1 did not call the Director of Nursing (DON), but instead she emailed her. RN 1 also did not suspend NA 1 and instruct him to go home per the facility abuse policy. NA 1 continued to work on the same unit that Resident 1 resided on for the remainder of his shift until 11:00 p.m. Review of the witness statement from NA 1 revealed that he confirmed tying Resident 1 to the side rail. The facility failed to provide care in a manner that maintained Resident 1's dignity as evidenced by Resident 1 being tied to the side rail of his bed. During an interview with the DON on August 29, 2016, at 1:35 p.m. she confirmed that the act was substantiated as abuse (mistreatment of [REDACTED]. She also gave disciplinary action to RN 1 for not calling the DON and not suspending (NA 1). 28 Pa. Code 201.29(a) Resident rights. Previously Cited 9/17/15. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 201.29(j) Resident rights. Previously cited 9/17/15, 10/9/14. 28 Pa. Code 201.18(b)(1) Management. Previously Cited 7/22/16, 9/17/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously Cited 9/17/15, 10/9/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/22/16, 9/17/15, 10/9/14.

Based on review of the facility's abuse policy, witness statements and staff interviews, it was determined that the facility failed to implement its' established abuse procedures for the protection of residents during an abuse investigation for one out of 3 residents reviewed (Resident 1). Findings include: Review of the current facility policy titled, Abuse (mistreatment to another person) stated, The facility will take all reasonable measures to ensure protection of the residents during the abuse investigation. It also stated, in the event that the alleged perpetrator is an employee, that employee will be suspended pending the investigation. Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. An incident occurred on August 19, 2016, at 6:15 p.m. where Resident 1 was found by Licensed Practical Nurse (LPN) 1 tied to the side rail of his bed by the waist ties from his gown. Review of LPN 1's witness statement revealed that Resident 1 was having behaviors and refused to stay in bed or in a chair. She stated that Nurse Aide (NA) 1 assisted Resident 1 to his room to be toileted, provided evening care and assisted him to bed with the bed alarm (a device that can detect movements and sound an alarm if the resident tries to get up on their own) in place. She then saw NA 1 leave Resident 1's room and walk to the dining room to collect dinner trays. She noted that Resident 1's bed alarm was not sounding and his tone (quality of a person's voice) of his calling out had increased in pitch (highness or lowness of a tone) and volume. She went to check and found Resident 1 laying on his left side in his bed with the waist ties of his gown tied to the side rail of his bed. LPN 1 immediately called the Registered Nurse Supervisor (RN) 1 and NA 1 into the room. RN 1 instructed NA 1 to untie the resident immediately. At that time Resident 1 was untied from the side rail. Further review of the incident revealed that after the abuse incident was identified, RN 1 did not call the Director of Nursing (DON), but instead she emailed her. RN 1 also did not suspend NA 1 and instruct him to go home per the facility abuse policy. NA 1 continued to work on the same unit that Resident 1 resided on for the remainder of his shift until 11:00 p.m. Review of the witness statement from NA 1 revealed that he confirmed tying Resident 1 to the side rail. During an interview with the DON on August 29, 2016, at 1:35 p.m. she confirmed that the act was substantiated as abuse and NA 1 was terminated. She also gave disciplinary action to RN 1 for not calling the DON and not suspending the (NA 1). The facility failed to implement its established abuse procedures for the protection of Resident 1 during the course of an abuse investigation by allowing NA 1 to remain in the facility and working on the same unit that Resident 1 resided on. 28 Pa. Code 201.29(a) Resident rights. Previously Cited 9/17/15. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 201.29(j) Resident rights. Previously cited 9/17/15, 10/9/14. 28 Pa. Code 201.18(b)(1) Management. Previously Cited 7/22/16, 9/17/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously Cited 9/17/15, 10/9/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/22/16, 9/17/15, 10/9/14.

Based on facility policy, review of clinical records, staff witness statements and staff interviews, it was determined that the facility failed to ensure that residents were free from physical restraints for one out of 3 residents reviewed (Resident 1). Findings include: Review of the facility policy titled, Restraint Use reviewed July 2016, stated, It is the policy of this facility to use restraints only as required by medical need. The facility will use the least restrictive device only after proper assessment and use of alternative interventions. The facility philosophy on restraint use stated, Our goal is to keep residents in a safe and homelike environment without the restrictions and potential harm caused by restraints, whenever possible. Restraints will only be used as appropriate for an individualized therapeutic approach to treat a medical symptom. Review of the current facility policy titled, Abuse (mistreatment to another person) stated, The facility will take all reasonable measures to ensure protection of the residents during the abuse investigation. It also stated, in the event that the alleged perpetrator is an employee, that employee will be suspended pending the investigation. Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. An incident occurred on August 19, 2016, at 6:15 p.m. where Resident 1 was found by Licensed Practical Nurse (LPN) 1 tied to the side rail of his bed by the waist ties from his gown. Review of LPN 1's witness statement revealed that Resident 1 was having behaviors and refused to stay in bed or in a chair. She stated that Nurse Aide (NA) 1 assisted Resident 1 to his room to be toileted, provided evening care and assisted him to bed with the bed alarm (a device that can detect movements and sound an alarm if the resident tries to get up on their own) in place. She then saw NA 1 leave Resident 1's room and walk to the dining room to collect dinner trays. She noted that Resident 1's bed alarm was not sounding and his tone (quality of a person's voice) of his calling out had increased in pitch (highness or lowness of a tone) and volume. She went to check and found Resident 1 laying on his left side in his bed with the waist ties of his gown tied to the side rail of his bed. LPN 1 immediately called the Registered Nurse Supervisor (RN) 1 and NA 1 into the room. RN 1 instructed NA 1 to untie the resident immediately. At that time Resident 1 was untied from the side rail. Further review of the incident revealed that after the abuse incident was identified, RN 1 did not call the Director of Nursing (DON), but instead she emailed her. RN 1 also did not suspend NA 1 and instruct him to go home per the facility abuse policy. NA 1 continued to work on the same unit that Resident 1 resided on for the remainder of his shift until 11:00 p.m. Review of the witness statement from NA 1 revealed that he confirmed tying Resident 1 to the side rail. During an interview with the DON on August 29, 2016, at 1:35 p.m. she confirmed that the act was substantiated as abuse and NA 1 was terminated. She also gave disciplinary action to RN 1 for not calling the DON and not suspending NA 1. The facility failed to ensure that Resident 1 was free from physical restraints resulting in the resident being tied to the side rail of the bed and causing him to call out until found by a Licensed Practical Nurse. 28 Pa. Code 201.29(a) Resident rights. Previously Cited 9/17/15. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 201.29(j) Resident rights. Previously cited 9/17/15, 10/9/14. 28 Pa. Code 201.18(b)(1) Management. Previously Cited 7/22/16, 9/17/15. 28 Pa. Code 211.8(a) Use of restraints. 28 Pa. Code 211.12(d)(1) Nursing services. Previously Cited 9/17/15, 10/9/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/22/16, 9/17/15, 10/9/14.

Based on clinical record review and interviews with staff it was determined that the facility failed to provide the appropriate care and services to prevent a urinary tract infection for one of 25 residents reviewed (Resident 12). Findings include: Review of the clinical record for Resident 12 revealed Physician order [REDACTED]. Review of the physician notes dated December 23, 2012 revealed that Resident 12 was experiencing bleeding from a recent catheter change, and instructions for the catheter to be under tension to resolve bleeding to the urethra and penis. Review of nursing notes dated January 17, 2013 revealed physician was in to change the catheter. There were no nursing notes or physician notes indicating the catheter was changed in February 2013 or March 2013. Review of Hospital admission records dated February 23, 2013 revealed Resident 12 was admitted to the hospital with [REDACTED]. During an interview on October 31, 2013 at 2:35 p.m., the DON stated there was no documentation indicating the catheter was changed as ordered every 3-4 weeks. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and facility policy and interviews with staff, it was determined that the facility failed to ensure that one of eight residents (Resident R1) reviewed received sufficient fluid intake to maintain proper hydration. Findings include: Review of Intake and Output policy revised on April 7, 2010, revealed that the licensed nurse will review the 24 hour totals in CareTracker (computerized system to log care of daily living of residents by nursing staff). Any negative findings will be reported to the charge nurse for additional interventions and any signs and symptoms of decreased intake will be reported to the physician. Review of Resident R1's Minimum Data Set quarterly assessment dated [DATE], identified that she required extensive assistance with feeding. Her current care plan for risk of dehydration secondary to poor intake by mouth was in initiated on May 4, 2009. Interventions included to follow dietary recommendations for estimated daily fluid needs, encourage fluids, monitor fluid intake and notify the physician of any negative changes. Her Medical Nutritional Therapy Assessment form dated July 1, 2010, identified that her estimated fluid needs were 1500 cubic centimeters (cc) of fluids orally per day (minimum). A Hydration Risk Assessment completed July 4, 2010, identified a continuing need for the hydration program as her fluid intake fluctuated. Resident R1's October 2010 Intake and Output by Day Chart indicated that she consumed an average of 1104.8 cc of fluid daily for 23 days. Her daily intake from October 13-18, 2010, was as follows: October 13=1060 cc; October 14=1320 cc; October 15= 840 cc; October 16=1320 cc; October 17= 1260 cc and October 18, 2010=1200 cc for a daily average of 1166 cc. (334 cc. less than the required daily amount). Additionally, her average meal intake over the same period of time ranged from 30-36%. Interdisciplinary progress notes from October 13-19, 2010, reported that 'will continue to monitor' but documentation of the resident's status was inconsistent. A note on October 19, 2010, reported that an order was obtained from Physician 1 to send Resident R1 to the emergency room after he had spoken to the resident's daughter. Resident R1's Transfer and Referral Record for the hospital included that the resident was being transferred due to a 'change in condition' Documentation also included that she responds via head nods and that she had not been eating and taking very little fluids over the past 48-72 hours and voiding small amounts of yellow urine and that her skin was very warm and diaphoretic. Resident R1 was emergently transferred to the hospital at 8:15 p.m. Resident R1's emergency room report dated October 19, 2010, identified that she had altered mental status, profound weakness and poor skin turgor. Her blood level results were abnormal: Blood Urea Nitrogen level was 50 ( normal 8-23) and her Sodium level was 154 ( normal 137-147). She was diagnosed to have severe dehydration and was treated with intravenous fluids and admitted for further rehydration. Interview on October 26, 2010, at 2:00 p.m., with the Dietitian revealed that Resident R1 needed 1500 cubic centimeters (cc) of fluids orally to meet her daily fluid needs and she did not meet her needs for October 2010. She said that she was aware that the resident was not eating but not aware of that she was not meeting her fluid needs. She reported that she would have ordered blood work and assessed her skin turgor if she was aware of her poor fluid intake. Interview on October 26, 2010, at 3:15 p.m., with Physician 1 revealed that he was not aware that from October 13-19, 2010, Resident R1's fluid intake had decreased or he would have ordered intravenous (IV) fluids for hydration if he had been made aware of her hydration status. Interview on October 27, 2010, at 9:10 a.m., with the Director of Nursing confirmed that any staff that notices a resident is not drinking should report the information to the registered nurse supervisor and appropriate measures should be put in place. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 8/24/10, 10/7/10 28 Pa. Code: 211.5 (f)(g)(h) Clinical Records. Previously cited 10/7/10 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 8/24/10, 10/7/10