Every finding on record at Rochester Residence and Care Center

Based on review of facility policy, reports submitted to the State, and staff interview it was determined that the facility failed to report allegations of abuse for two of two residents (Resident R2, and R3). Findings include: Review of the facility policy Abuse, Neglect, &; Exploitation dated 7/6/26, indicated the facility will protect the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Reporting of all alleged violations will occur immediately, but no later than two hours after the allegation is made, if involves abuse or serious bodily injury. On 7/29/26, at 11:15 a.m. State Agency (SA) conducted an interview together with Resident R2 and R3 per their request. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - periodic assessment of care needs) dated 7/15/26, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and wound infection. Section GG-Functional Abilities-Admission, Toileting hygiene is marked as a 2, indicating resident is substantial/maximal assistance. Helper does more than half the effort. During an interview on 7/29/26, at 11:33 a.m. Resident R2 stated, I struggle to get out of bed quick enough, and I've wet myself a couple times. They get mad. I keep clicking the call bell, they don't come in. I don't care; I just keep clicking. I was soaked because no one would come. One smacked me on the wrist. It was about three or four days ago. It was nightshift. Then they tried hiding my call bell. If they don't come, I just keep ringing the bell. Sometimes we have to sit in urine for hours. There were two staff in the room. The one who hit me and one was just in the room. There is no excuse to slap or put hands on anyone. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], included diagnoses of psychotic disorder (mental health disorder), muscle weakness, and sepsis (an infection in the body). During an interview on 7/29/26, at 11:47 a.m. Resident R3 stated, People yell at you. I was itching to high hell and I was itchy. I called for help with the call bell because my cream was against the wall over there. One person stated to the other, he's itchy. All he wants is his itch cream. They talk right in front of you. It happened three or four nights ago. It was nightshift. This is nursing home abuse. This is neglect. Its works on your mind when they keep bitching to each other in front of you or when I can hear them and you know it's about you, they are talking about. On 7/29/26, at 12:32 p.m. SA requested to meet with Nursing Home Administrator and Director of Nursing and reported Resident R2 and R3's allegations. On 7/30/26, at 3:35 p.m. reports submitted to the State were reviewed and failed to include alleged Abuse allegations that were reported to administration on 7/29/26, as required. During an interview on 7/30/26, at 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to report allegations of abuse for two of two residents (Resident R2, and R3) 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility documents and staff interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for one of three quarters reviewed (Quarter 2).Findings include: Review of the PBJ staffing data reports revealed that the facility did not submit data for Quarter 2 (January 1, 2026 - March 31, 2026). During an interview on 7/10/2026, at 11:26 a.m. the Nursing Home Administrator was informed that the facility failed to submit direct care staffing information in the Payroll-Based Jornal system as required. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the main kitchen which created the potential for cross contamination. Findings include: During an observation 3/2/26 at 9:20 a.m. of the main kitchen the following was observed:Kitchen drain by three compartment sink was blocked, causing water backupWalk in freezer-several areas of ice build up(5) kitchen carts - residue covering all areas During an interview on 7/6/26 at 11:30 a.m., Dietary Manager Employee E10 confirmed that the facility failed to maintain sanitary conditions which created the potential for cross contamination in the main kitchen. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication pharmacy medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R8, R9, R14, and R27). Findings include: Review of facility policy Medication Regimen Review dated 3/2/26, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels), paranoid schizophrenia (subtype of schizophrenia characterized primarily by paranoia and delusions), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R8 for May 2026. Review of Resident R8's MRR Note to Attending Physician/Prescriber on 4/7/26, revealed that Certified Registered Nurse Practioner (CRNP) Employee E9 signed this form indicating See above, however when reviewed above, there was no documented evidence what See above refers too, failing to address recommendations from pharmacy's MRR. Further review of Resident R8's MRR's Note to Attending Physician/Prescriber on the following dates, were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required on: 4/7/26, and 6/26/26. During an interview on 7/9/26, at 10:18 a.m., the Director of Nursing (DON) confirmed that Resident R8's 4/7/26, MRR Note to Attending Physician/Prescriber was not addressed properly; confirmed that a CRNP signed pharmacy MRR documents requiring the attending physician to complete, and that the facility failed to provide monthly MRR for May 2026. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls. Review of Resident R9's MRR dated 3/30/26, indicated the following recommendation from pharmacist to physician: The resident has been receiving Depakote (an anticonvulsant medication used to decrease manic episodes, affecting neurotransmitters in the Central Nervous System) 250 mg (milligrams) by mouth every morning and by mouth every evening since 9/2025. Please review current medication regimen and doses to ensure resident is using the lowest possible effective dose with minimal side effects. Please review for a Gradual Dose Reduction (GDR) and document if any change in therapy is contraindicated for that resident. Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/30/26. On 4/7/26, facility CRNP Employee E9 addressed the MRR, stating, Patient has good response to current treatment which maintains baseline function. Dose reduction is not indicated due to benefits outweigh risks, likely to impair the resident's function or cause psychiatric instability. Continue monitoring. Review of Resident R9's MRR dated 3/30/26, indicated the following recommendation from pharmacist to physician: The resident has been receiving Seroquel 25 (an antipsychotic medication used to stabilize mood) mg by mouth every evening since 9/2025 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/30/26. On 4/7/26, facility CRNP Employee E9 addressed the MRR, stating, The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to with no further documentation available. Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R9 for May 2026. Review of Resident R9's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician: The resident has been receiving Depakote 250 mg in morning and 500 mg at bedtime, Zoloft (a medication used to treat depression) 50 mg daily, and Seroquel 50 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regiment. Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 6/15/26. On 6/26/26, facility CRNP Employee E9 addressed the MRR, stating, Decrease Depakote to 250 mg BID (twice a day) for GDR trial. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R14 for May 2026. Review of Resident R14's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician: The resident has been receiving Melatonin (a medication given to treat sleep disorders) 3 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regimen. Review of Resident R14's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 6/15/26. On 6/24/26, facility CRNP Employee E9 addressed the MRR, stating, Disagree - has failed GDR in past. Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of Resident R27's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R27 for May 2026. During an interview on 7/9/26, at 10:21 a.m. the DON confirmed the facility failed to complete MRRs for May 2026 for Residents R9, R14, and R27 and failed to ensure the attending physician addressed monthly MRRs for Residents R9, R14, and R27. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for two of four residents (Residents R6 and R27) with an indwelling urinary catheter (a tube inserted in the bladder to drain urine).Findings include: Review of facility policy Catheter Care dated 3/2/26, indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of high blood pressure, neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and anxiety. Review of a physician order dated 1/9/26, indicated catheter/suprapubic foley (a catheter inserted into the bladder via a small incision in the lower abdomen) order: change every month: balloon; 5 cc (cubic centimeter), 16 French change monthly in the evening every 20 months starting on the 28th for 28 days. Review of treatment documentation revealed the order was transcribed to be administered every 20 months instead of every one month per physician order. Review of Resident R6's comprehensive care plan dated 7/15/24, indicated the resident demonstrates an alteration in urinary elimination related to: suprapubic catheter due to neurogenic bladder. Interventions include cath size: 18 French with 5 cc balloon. Change every month. During an interview on 7/10/26, at 11:34 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E8 confirmed Resident R6's catheter order was entered incorrectly and the facility failed to update the resident's care plan to accurately reflect the resident's current status. Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of Resident R27's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of a physician order dated 4/21/26, indicated suprapubic catheter French 16, 10 cc balloon every shift related to retention of urine. During an observation on 7/6/26, at 10:12 a.m. Resident R27 was observed lying in bed. The resident's catheter drainage bag was observed attached to the right side of the bed with no privacy cover. During an interview on 7/6/26, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed Resident R27's catheter drainage bag did not have a privacy cover. Review of Resident R27's comprehensive care plan dated 4/22/26, indicated suprapubic catheter, I will be free from adverse effects related to suprapubic catheter. Interventions included Catheter - type: supra French 16F 10CC. The care plan failed to include any additional interventions related to Resident R27's indwelling urinary catheter care and usage. During an interview on 7/10/26, at 11:34 a.m. RNAC Employee E8 confirmed the facility failed to develop an individualized care plan for Resident R27's indwelling urinary catheter care and usage. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to timely assess the nutritional status of two of five residents (Residents R9 and R14).Findings include: Review of facility policy Nutritional Management dated 3/2/26, indicated a comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls. Section A0310: Type of Assessment, A. Federal OBRA Reason for Assessment, was coded 02 Quarterly Assessment. Review of Resident R9's clinical record failed to reveal documentation of nutritional status monitoring associated with MDS dated [DATE]. Further review of Resident R9's clinical record failed to reveal any Medical Nutritional Therapy documentation since 3/9/26. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Section A0310: Type of Assessment, A. Federal OBRA Reason for Assessment, was coded 02 Quarterly Assessment. Review of Resident R14's clinical record failed to reveal documentation of nutritional status monitoring associated with MDS dated [DATE]. Further review of Resident R14's clinical record failed to reveal any Medical Nutritional Therapy documentation since 3/9/26. During a telephonic interview on 7/9/26, at 1:35 p.m. Registered Dietitian Employee E11 confirmed the facility failed to timely assess the nutritional status of Residents R9 and R14. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of four residents (Resident R6).Findings include: Review of facility policy Restorative Nursing Programs dated 3/2/26, indicated the facility is to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: maintaining proper positioning and body alignment and assisting residents in adjustment to their disabilities and use of any assistive devices. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of high blood pressure, arthritis (inflammation of one or more joints, causing pain and stiffness), and hemiplegia (paralysis on one side of the body). Review of a physician order dated 5/15/26, indicated RUE (right upper extremity) rolled wash cloth in R (right) hand at all times as tolerated except for hand hygiene and skin checks. Review of Resident R6's comprehensive care plan dated 5/15/26, indicated the resident has ADLS (Activities of Daily Living)/deficit for self-care related to: weakness/debility, suprapubic catheter, allergic rhinitis, cardiac history, CVA (a stroke) with right side hemiplegia, depression/anxiety, DJD (Degenerative Joint Disease). Interventions include RUE rolled wash cloth in R hand at all times except for hand hygiene and skin checks. During an observation on 7/9/26, at 10:53 a.m. Resident R6 was observed lying in bed without a rolled wash cloth in their right hand. Review of Resident R6's clinical record failed to include documentation that the resident refused or did not tolerate the rolled wash cloth to their right hand. During an interview on 7/9/26, at 11:24 a.m. Licensed Practical Nurse Employee E5 confirmed the above observation and that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of four residents (Resident R6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of four residents (Resident R3).Findings include: Review of facility policy Documentation of Wound Treatments, dated 3/2/26, indicated that the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/26, indicated diagnoses of dementia (syndrome characterized by a decline in cognitive function), and pulmonary hypertension (type of high blood pressure that affects the arteries of the lungs and the right side of the heart). Review of facility provided document Pressure Sore List, dated 7/6/26, revealed the Resident R3 has an unstageable (full thickness wound in which the base is completely obscured by slough or eschar, preventing accurate staging until debridement reveals the true depth) pressure sore on his sacrum, with date of onset 6/4/26. Review of Resident R3's care plan dated 6/20/26, revealed a sacral wound, with an intervention to administer treatments as ordered and monitor for effectiveness. Review of physician order dated 6/5/26, discontinued 6/18/26, indicated to cleanse sacrum wound with NSS (normal saline solution - sterile isotonic solution)/wound cleanser. Pat dry. Apply layer of silver gel (topical antimicrobial treatment that helps prevent infection and maintains a moist healing environment) to wound bed and cover with bordered dressing. Change every day shift for wound care. Review of Resident R3's Treatment Administration Record (TAR) for June 2026, revealed the above treatment was not signed off as completed or refused on the following day shifts: 6/5/26, 6/7/26, 6/9/36, and 6/12/26. During an interview on 7/9/26, at 9:51 a.m., the Wound Care Nurse (WCN) Employee E7 confirmed that the facility failed to make certain that residents received proper treatment for pressure ulcers for Resident R3. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to follow physician orders for two of six residents (Resident R19 and Resident R40) reviewed. Findings include: Clinical record review revealed Resident R19 was admitted to the facility on [DATE], with diagnosis to include, Diabetes Mellitus (condition that happens when blood sugar is to high), and hemiplegia (paralysis that affects one side of your body). Review of physician orders dated 6/10/26, included Trulicity Subcutaneous Solution Auto-injector 0.75 MG/0.5ML Inject 0.75mg subcutaneously one time a day every Mon for DM. A review of Resident R19's Medication Administration Record (MAR) for June 2026, revealed medication was not administered the following days: 6/15, 6/22, 6/29. A review of Resident R19's MAR for July 2026, revealed medication was not administered the following days: 7/6. A review of clinical record progress notes indicated medication not received from the pharmacy. Clinical record review revealed Resident R40 was admitted to the facility on [DATE], with diagnosis to include, hypertension (force of blood against artery walls is consistently too high), Alzheimer's (progressive mental deterioration, due to degeneration of the brain) and chronic kidney disease. Review of physician orders dated 6/16/26, included the following: Terazosin HCl Oral Capsule 5 MG, Give 1 capsule by mouth A review of Resident R40's Medication Administration Record (MAR) for June 2026, revealed medication was not administered the following days:6/16/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/24/26, 6/29/26 A review of clinical record progress notes indicated the medication was unavailable from pharmacy, unavailable in pyxis. During an interview with Director of Nursing (DON) on 7/10/26, at 11:30 a.m. confirmed physician orders were not followed for Resident R40 as required. 28 Pa. Code 211.10(a)(c) Resident policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a residents medication regimen was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of five residents (Resident R9).Findings include: Review of facility policy Medication Regimen Review dated 3/2/26, indicated Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. Facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Review of facility policy Use of Psychotropic Medications dated 3/2/26, indicated residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any dug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. When a medication(s) is used that can affect brain activity (e.g., antihistamines, anti-cholinergic medications, and central nervous system agents for use in conditions such as seizures, mood disorders, pseudobulbar affect (PBA), and muscle spasms or stiffness) and the documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication, then the medication(s) is subject to the requirements pertaining to psychotropic medications. Residents who use psychotropic drugs shall receive gradual dose reduction (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls. Review of a physician order dated 4/3/26, indicated Depakote (an anticonvulsant medication used to decrease manic episodes, affecting neurotransmitters in the Central Nervous System) Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (milligrams) give 2 capsules (250 mg) by mouth one time a day related to major depressive disorder. Review of a physician order dated 4/3/26, indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg give 4 capsules (500 mg) by mouth at bedtime related to major depressive disorder. Review of Resident R9's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician:The resident has been receiving Depakote 250 mg in morning and 500 mg at bedtime, Zoloft (a medication used to treat depression) 50 mg daily, and Seroquel (an antipsychotic medication used to stabilize mood) 50 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regiment. Review of a response completed by the facility Certified Registered Nurse Practitioner (CRNP) Employee E9 dated 6/26/26, indicated decrease Depakote to 250 mg BID (twice a day) for GDR trial. Review of Resident R9's clinical record revealed the GDR for Depakote ordered 6/26/26, was not implemented until 7/8/26. During an interview on 7/9/26, at 10:21 a.m. the Director of Nursing confirmed that the facility failed to ensure Resident R9's medication regimen was free from unnecessary psychotropic medication. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on one of two nursing units (3rd floor nursing unit).Findings include: During observations on 7/6/26, at 11:56 a.m., the following was identified:Missing ceiling tiles by the nurse's station and further down the hallway were observed with a container on the floor underneath the missing tile indicating caution wet floor, a drip was noted and there were ceiling tiles that were stained brown. During an interview on 7/6/26, at 12:06 p.m. NHA (Nursing Home Administrator) confirmed that there was a leak from the ceiling and there were multiple missing ceiling tiles. During the interview the NHA confirmed that the leak started approximately three weeks ago. During an interview on 7/6/26, at 12:09 p.m. NHA confirmed that there was a leak from the ceiling and there were missing ceiling tiles and ceiling tiles were stained brown and that the facility failed to provide a safe, clean comfortable and homelike environment for 3rd floor nursing unit. 28 Pa. Code 201.14(a)Responsibility of Licensee28 Pa. Code 201.18(b)Management

Based on document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for coverage under Medicare Part-A for two of three sampled resident records (Residents R5 and R100). Findings include: Review of facility policy Advance Beneficiary Notices, dated 3/2/26, indicated the facility is to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides:An item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary, orCustodial care. Review of Resident R5's admission record indicated he was originally admitted on [DATE], recently readmitted [DATE]. Review of Resident R5's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/30/26, indicated diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels), respiratory failure, and anemia (condition characterized by a deficiency of healthy red blood cells or hemoglobin, leading to insufficient oxygen delivery to the body's tissues). Review of facility provided SNF Beneficiary Notification Review for Resident R5 indicated she was issued a NOMNC (Notice of Medicare Non-Coverage: a form provided to residents to inform them of the facilities determination to end a Medicare based services) with last covered day of 6/4/26. Resident R5 continued to remain in the facility long-term care. Review of Resident R100's admission record indicated he was originally admitted on [DATE], recently readmitted [DATE]. Review of Resident R5's MDS assessment dated [DATE], indicated diagnoses of aphasia (language disorder that affects and individuals ability to communicate), necrotizing fasciitis (bacterial infection), and dementia (syndrome characterized by a decline in cognitive function). Review of facility provided SNF Beneficiary Notification Review for Resident R100 indicated she was issued a NOMNC with last covered day of 4/30/26. Resident R100 continued to remain in the facility long-term care. Review of facility documentation did not include evidence that Skilled Nursing ABN forms (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage: SNF-ABN, a form providing information that at a specific date Medicare coverage ends and the specific amount of financial liability will be passed onto the residents) were provided to Resident R5 and Resident R100. During an interview on 7/9/26, at 10:28 a.m., the Business Office Manager (BOM) Employee E6 confirmed that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for Residents R4 and R57 as required. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R27).Findings include: Review of facility policy Oxygen Administration dated 3/2/26, indicated staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy as needed if they become soiled or contaminated. Keep delivery devices covered in plastic bag when not in use. Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of Resident R27's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of high blood pressure, anxiety, and depression. Review of a physician order dated 1/6/26, indicated oxygen maintenance per orders. Change tubing and filter weekly every night shift every Tuesday. Review of a physician order dated 1/21/26, indicated nebulizer (a machine used to deliver aerosolized medications) maintenance, change tubing and filter weekly. Review of a physician order dated 4/7/26, indicated to administer oxygen at 3 LPM (liters per minute) via n/c (nasal cannula - a lightweight tube that delivers oxygen through the nostrils) for O2 sat (blood oxygen saturation) greater than 90% as needed. Review of a physician order dated 6/11/26, indicated to administer Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML (milligrams per milliliter) 3 ml inhaled orally via nebulizer three times a day for wheezing and every 4 hours as needed for shortness of breath/wheezing. During an observation on 7/6/26, at 10:12 a.m. Resident R27 was observed receiving oxygen at 3 LPM via nasal cannula. No date was observed on the nasal cannula tubing. The humidifier bottle attached to the oxygen concentrator was empty and did not have a date. An empty plastic belongings bag was observed hanging from the oxygen concentrator with the date 5/27/26. During this observation, Resident R27's nebulizer machine was observed on an overbed table out of the resident's reach. No date was observed on the nebulizer tubing, and the mouthpiece was placed inside of the carboard tubing of an upright paper towel roll that was placed next to the nebulizer machine.During an interview on 7/6/26, at 10:12 a.m. Resident R27 stated, That is my nebulizer machine. I get breathing treatments twice a day. During an interview on 7/6/26, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observations and that the facility failed to provide appropriate respiratory care for Resident R27. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of six sampled residents (Resident R71). Findings include: Review of the admission record indicated agitated Resident R71 admitted to the facility on [DATE]. Review of Resident R71s Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/26, indicated the diagnoses anxiety disorder, major depressive disorder and hyperlipidemia (abnormally high levels of lipids). Review of Resident R71's clinical record revealed the following: 2/8/26 client has been caught multiple times this shift with her fingers down her throat trying to make herself vomit, attempted to redirect client and she has had an emesis from sticking her fingers down her throat. 2/8/26 Rt midline covered in emesis. Patient stated she is not happy to be in this facility. 3/4/26 Nurse walked into this resident's room and observed resident having her index and middle finger down her throat and gagging. 3/21/26 resident is yelling out this shift for no apparent reason. During an interview 7/9/26 at 10:30 a.m. Social Worker E12 indicated the facility was without psychiatric services for about a month. Nursing will usually refer a resident to social services and then they will refer to behavioral health. During an interview 7/9/26 at 10:45 a.m. Social Worker E12 confirmed Resident R71 was not referred to behavioral health maintain the highest practicable well-being as required. 28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medications carts (Rosewood Medication Cart) and one of two medication rooms (Third Floor Medication Room).Findings include: Review of facility policy Medication Storage dated 3/2/26, indicated it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. Review of United States Food and Drug Administration (FDA) approved manufacturer prescribing information for Latanoprost (an eye drop medication used to reduce elevated pressure inside the eye) dated 7/2017, indicated to store unopened bottle under refrigeration 2 to 8 degrees Celsius (36 degrees to 46 degrees Fahrenheit). Protect from light. During shipment, the bottle may be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks. During an observation on 7/6/26, at 9:40 a.m. the following was observed in the Rosewood Medication Cart:Resident R25's unopened box of Latanoprost eye drops. The box was sealed and the label contained a large pink sticker that read REFRIGERATE. During an interview on 7/6/26, at 9:43 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation and stated, I noticed that this morning, I'm going to call the pharmacy later to ask for another to be sent. It's not open, I don't know why it isn't in the refrigerator. During this interview, LPN Employee E1 confirmed that the facility failed to properly store medications in the Rosewood Medication Cart. During an observation on 7/6/26, at 12:03 p.m. of the Third Floor Medication Room, an opened bottle of tuberculin solution (a medication used to test for tuberculosis) was observed in the medication room refrigerator with no open date. During an interview on 7/6/26, at 12:04 p.m. LPN Employee E1 confirmed the above observation and that the facility failed to properly store medications in the Third Floor Medication Room. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R45).Findings include: Review of facility policy Enhanced Barrier Precautions dated 3/2/26, indicated it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs target gown and gloves during high contact resident care activities. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care: any skin opening requiring a dressing. Review of facility policy Hand Hygiene dated 3/2/26, indicated hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of facility policy Clean Dressing Change dated 3/2/26, indicated set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Losen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves. Cleans the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Secure dressing. [NAME] with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/29/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and depression. Review of a physician order dated 7/6/26, indicated Enhanced Barrier Precautions related to sacral (sacrum - triangular bone in the lower back formed from fused vertebrae and situated between the type hipbones of the pelvis) wound. Review of a physician order dated 6/18/26, indicated to apply Santyl (an ointment used to help remove dead skin tissue and aid in wound healing) External Ointment 250 unit/gram, apply to sacral wound topically every day shift for sacral wound, cleanse wound with NSS (normal sterile saline)/wound cleanser, pat dry and apply Santyl and bordered foam (an absorbent adhesive dressing) to sacrum. During an observation on 7/8/26, at 1:45 p.m. a sign posted outside of Resident R45's room indicated the resident is ordered Enhanced Barrier Precautions. A plastic box full of personal protective equipment (PPE - gloves, gowns, etc.) was observed outside of the resident's room. During a dressing change observation on 7/8/26, from 1:49 p.m. to 2:10 p.m. Licensed Practical Nurse (LPN) Employee E3 and LPN Employee E4 did not don gowns prior to entering Resident R45's room and performing the wound care treatment as ordered. LPN Employee E3 did not establish a clean field using the overbed table. LPN Employee E3 placed a paper field on the resident's nightstand and placed the dressing supplies on the paper field. LPN Employee E3 did not cleanse the nightstand prior to placing the paper field and supplies on the nightstand. After cleansing the sacral wound, LPN Employee E3 removed their gloves and did not perform hand hygiene prior to donning a new pair of gloves and applying Santyl to the wound bed. After the treatment was complete, LPN Employee E3 did not cleanse the resident's nightstand after discarding the dressing supplies. During an interview on 7/8/26, at 2:12 p.m. LPN Employee E3 confirmed the above observations and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for Resident R45. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of regulations, documents submitted to the State Agency and staff interviews it was determined that the facility failed to notify the State Agency of a change in the facility's Nursing Home Administrator (NHA) at the time of the change, and ensure that a qualified NHA was assigned to the facility for two of 31 days (3/28/26, and 3/29/26).Findings include: Review of written communication dated 3/29/26, revealed that Nursing Home Administrator (NHA) Employee E3 informed State Agency (SA) that his last day as NHA at the facility was 3/27/26. Review of written communication dated 3/30/26, from SA to [NAME] President of Operations (VPO) Employee E4, requested clarification as to who is the acting NHA at the facility as SA has been made aware of NHA Employee E3's departure from the facility. VPO Employee E4 stated It's me for now, I have been out with an illness so I will get everything to you asap. Review of the above information revealed that the facility failed to have an assigned NHA to the facility from 3/28/26 through 3/29/26. During an interview on 4/1/26, at 9:00 a.m. the Director of Nursing confirmed that the facility failed to notify SA of a change in the facility's NHA at the time of the change, and have an NHA assigned to the facility from 3/28/26 through 3/29/26. PA Code: 201.14(a) Responsibility of licensee.

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure a safe, and functional environment for one of two Entry Doors (Employee Entrance).Findings include: Review of the facility policy Preventative Maintenance Program last reviewed 12/11/25, indicated a program shall be developed and implemented to ensure the provision of a safe, functional, sanitary environment for residents, staff, and the public. Review of a resident representative concern dated 2/27/26, stated The employee entrance for staff is supposed to be locked and a code entered at all times, the door for the employee entrance does not safely close and or locked. It is accessible to anyone in the public if they feel the need. During an observation and interview on 4/1/26, at 9:35 a.m. State Agency (SA) went to the Employee Entrance (which is secured from resident access,) with Maintenance Director (MD) Employee E1, who explained that the door has a motion sensor, and does not require a code to exit the building, but that a code is required to punch into a keypad outside to gain entrance to the facility. During an observation on 4/1/26, at 9:36 a.m. SA went outside the Employee Entrance door, and was able to open the door to get into the facility without punching in a code, as the door did not appear to fully close and latch properly. During an interview on 4/1/26, at 9:37 a.m. MD Employee E1 and Maintenance Employee E5, confirmed that the door was not latching properly, and would attempt to have it fixed immediately. MD Employee E1 stated that the door was Broken a couple of weeks ago, and we fixed it. Didn't know that it was broken again. During an interview on 4/1/26, at 12:24 p.m. MD Employee E1 confirmed that the door remained broken, and that they had to call a vendor to replace the lock as it is broken and cannot be replaced by staff. During an interview on 4/1/26, at 1:20 p.m. the Director of Nursing confirmed that the facility failed to ensure a safe, and functional environment for one of two Entry Doors (Employee Entrance). 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.

Based on review of facility documents, vendor interview, and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units (Third Floor).Findings include: The facility Pest Control Program dated 12/11/25, indicated that the facility will maintain an effective pest control program that eradicates and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Review of a resident representative concern dated 2/25/26, stated Rodents are running around the building. Rat traps are placed in patients rooms. Over a dozen of rodents were spotted running through the building. Administration and Director of Nursing were asked to get Pest Control in the building immediately. I as a family member fear my loved one getting sick or attacked by a rat completely unsanitary and unsafe. Review of an additional resident representative concern dated 2/27/26, stated Director of Nursing and Administrator continuously deny the fact of rodents being present even with proof of dead rodents, their droplets and rat traps in patients rooms. Rats are seen both by patients, staff and family members. During an interview on 4/1/26, at 9:20 a.m. the Director of Nursing (DON) confirmed that there has been sightings of rodents in the building, and that Pest Control has been called. DON also stated that the facility has a chicken [NAME] with chickens residing in it in the front of the property, and that it was discussed today that it needs to be removed to prevent it from drawing rodents, and it was also discussed that facility may need to call a different Pest Control company to ensure mitigation of the rodents. State agency requested copies of any Pest Control Services rendered for this issue. During an interview on 4/1/26, at 9:24 a.m. Maintenance Director (MD) Employee E1 also confirmed that there has been reports of rats in the building, and that he has been making daily rounds, but has not seen the rodents. MD Employee E1 stated that employees have been reporting that they are seen at night, especially on the Third Floor, and that traps were placed in some resident rooms. Some traps were in residents' reach, but I moved them out of the way. Review of facility provided documents from Pest Control Vendor 1 did not list any services for rodents. Services provided in February 2026, were as follows: 2/26/26 Standard Monthly, and Fly Light Service, and 2/27/26: Bed Bug monthly, Standard. During an interview on 4/1/26, at 10:29 a.m. Registered Nurse (RN) Employee E2 stated that he/she has seen rats during the day, and will often hear them running around in the ceiling. I saw one for the first time about four or five weeks ago. I see one that I think is pregnant because it keeps getting bigger and bigger. I took a picture of a pile of rat shit that was in a corner of one of the bathrooms. They called housekeeping to and clean it up but I haven't seen any exterminators and I still see rats. During an interview on 4/1/26, at approximately 10:35 the DON stated that a new Pest Control Company was on-site to investigate the rats. State Agency requested to speak with Pest Control Vendor to confirm any findings. During an interview at 4/1/26, at 10:49 a.m. Pest Control Vendor 2 (PCV2) stated that the company just received a call this morning (4/1/26) to come to the facility for a rat issue. PCV2 stated that he had just completed a tour of the outside perimeter of the building , and found several bait traps by the dumpster area. When I picked them (traps) up a bunch rats ran out of them. If the traps had been maintained the rats would be dead. Instead they were using them as shelter. During an additional interview on 4/1/26, at 11:33 a.m. PCV2 stated that a tour of the inside of the facility had just been completed, and that fecal evidence of rats were found on the Third Floor. PCV2 placed some traps on the Third Floor, but would write up a proposal for a plan going forward and would recommend about 20 traps be placed on the outside of the building. I found a trap that looked newer on the Third Floor, but it was too small for a rat. During an interview on 4/1/26, at approximately 1:20 p.m. the DON confirmed that the facility failed to maintain an effective pest control program for one of two nursing units. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seventeen residents (Resident R77) identified as having a high risk for wandering.Findings include: Review of the facility policy Elopements and Wandering Residents last reviewed 12/11/25, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-entered plan of care addressing the unique factors contributing to wandering or elopement risk. Adequate supervision will be provided to help prevent accidents or elopements. Post-elopement: A nurse will perform a physical assessment, document and report findings to physician.Any new physician orders will be implemented and communicated to the family/authorized representative.A social service designee will reassess the resident and make referrals for counseling or psychological/psychiatric consults.The resident and family/authorize representatives will be included in the plan of care.Staff may be educated on the reason for elopement and possible strategies for avoiding behavior.When repeated elopements attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternates placement in an appropriate facility.Document in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. Review of the facilities Elopement Log Events Quick Reference Guide worksheet indicated: To be completed at time of occurrence: Time of first reported missing.Time of notify executive director, director of nursing, and other staff in building.Time of overhead paging Mr., Mrs., Ms., residents name, please return to your room repeated three times.Time of all rooms checked (including bathrooms, closets, offices etc.).Time of the outside perimeter check of the building and property.Time of coordination of emergency team for vehicle and foot search. Go out in pairs and set specific check in times utilizing cell phones if available.Time of Contacting the police. Give them elopement risk identification form, with current photo, time and location when last seen, and an accurate description of what resident was wearing.Time of notification residents responsible party, Question for possible locations resident may have gone, friends, other family members.Time of physician notification.Time of staff members knocking on door (neighborhood homes and businesses) within a 2-3 block radius.Time of assisting police department.Time of two staff searches of the resident's room, looking for wallet, shoes, and coat.Time of searching any place that the resident has a history of frequenting.Time of checking previous living arrangements.Time of calling motels, restaurants, and shopping malls within search area.Time of extending perimeter search.Time of notification to the nursing facility licensing unit per state guidelines.Time of search continued until resolution or until police/fire rescue instruct to cease. To be completed at time of return: Time returned to facility and obtained witness statements.Time completed head to toe exam and document results. Notify physicians of any identified issues.Time of notification of all previous contacts.Time of documenting the factual account of the occurrence and complete an incident report.Time of updating the elopement risk evaluation form.Time placed on wander guard following the elopement/wandering policy.Time of review and update to care plan and Kardex -update interventions. Review of the facility policy Comprehensive Care Plans last reviewed 12/11/25, indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a residents medical, nursing, mental and psychosocial need. Review of the admission record indicated Resident R77 was admitted to the facility on [DATE]. Review completed of Resident R77's physician orders dated 7/20/25, indicated wander guard system for safety elopement and exit seeking. Review Resident R77's care plan dated 7/20/25, indicated resident is at risk for elopement, but failed to identify any triggers that may cause the resident to be exit seeking. Review of clinical record revealed an Elopement evaluation dated 9/14/25, which revealed that Resident R77 had score of 25, indicating that resident was at risk for elopement. The clinical record failed to reveal any further elopement risk. Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/5/25, indicated the diagnoses of hypertension (high blood pressure), depression, and hyperlipidemia. Section C0500 the Brief Interview for Mental Status indicated a score of five - severe impairment. Review of a written statement dated 1/31/26, Licensed Practical Nurse (LPN) Employee E2 indicated I was going to get on the elevator to leave, as the elevator door opened, the girl from personal care unit was standing there. She asked me if we were missing someone. I said not that I know of. She told me about Resident R77. I then told the other two nurses LPN Employee E34 and LPN Employee E35 and they went down to get him. The last time we visualized him me and LPN Employee E35 were at the lilac medication cart about to count narcotics. Resident R77 came to the side of the cart and then he was redirected. I never heard any alarm. That doesn't necessarily mean it didn't go off. There were a couple of instances during the shift that he was exit seeking a little that day. I did put a progress note. We re-directed him because of this. He is usually with me. I wouldn't of thought to check the stairwells if the alarm did sound but I personally did not hear one. Review of a written statement provided by the Personal Care Employee (PCU) Employee E33 dated 2/1/26, scratched off and re-dated 1/31/26, indicated I just got done giving a shower, I was putting linens in a bin, and I heard a bell go off, I saw on the wall where it said back door. I walked back and PCU Employee E32 followed. We are walking back and I saw a gentleman, and I said hey buddy are you ok? He said no, I asked if he wanted a cup of tea, so I gave him some. Then I went up to the girls on the third floor. It was between 6:30 p.m. to 7:00 p.m. I think he came through the stairwell, but we can't confirm. When I went upstairs, the ladies' upstairs were complaining about the alarms going off. I said I don't know about that I am just returning him back. The resident was very pleasant and fine. Pleasantly confused. Review of a written statement provided by the PCU Employee E32 dated 1/31/26, indicated I heard the back door alarm inside of the personal care facility and went to go look. Me and another personal care employee saw a manor resident who was in the back hall asked if he was ok. We redirected him to the dining room then brought him back up to the third floor. He was not injured and was pleasantly confused. I don't know if he came from the stairwell or the main door. We don't know which way he came from. I could have missed him, I can't say for sure. Review of a written facility provided statement dated 1/31/26, Licensed Practical Nurse (LPN) Employee E34 indicated I responded to the alarm to the back of the 370 hall. Then the stair alarm went off on the other side of the hall and I responded to them. This was around 7:00 p.m. I turned the alarm off, and I didn't see anyone around and then started answering call lights because those were also going off. The lady from the second floor told us Resident R77 was down there. Me and LPN Employee E35 went and got him. When we got him, he was fine. Review of Resident R77's nursing progress note dated 2/1/26, at 6:51 p.m. indicated resident has been exit seeking this shift. Redirection ineffective. Review of facility provided documentation of Resident R77's incident dated 2/1/26, at 7:00 p.m. indicated resident exhibiting more exit seeking behavior than normal in the evening of 2/1/26. Residents wander guard was evaluated and ensured it was intact. Resident is able to be redirected back to common areas on the unit. Alarms on doors deemed to be audible when resident ambulated near them, Personal care staff came off the elevator with Resident R77 around 6:30 p.m. - 7:00 p.m. after finding him on the personal care unit. Resident had tried to open the back door of the personal care unit to exit the facility and set the alarm off alerting the personal care staff to evaluate the alarm. Resident R77 was found pleasantly confused and able to tell the personal care staff that he lived on the third floor. Resident had no injuries. Resident R77 was offered tea by the personal care staff and returned to the third floor. Resident reports going downstairs in his house, resident also reports nice people offering me tea, Resident denies any injuries, no pain, remains at baseline which is cognitively confused. Review of Resident R77's nursing progress note dated 2/1/26, at 9:30 p.m. indicated resident noted to have increased exit seeking behavior this day. New elopement risk evaluation completed. Wander guard evaluated for functionality and is working appropriately. Review of Resident R77's progress note date 2/2/26, at 11:27 a.m. indicated residents wander guard is intact. Resident was walked throughout unit (by staff) to ensure all doors/exits are alarming as they should if resident should try and exit unit. All alarms are audible and functioning. Resident is able to be redirected and is currently not exhibiting exit seeking behavior. Staff ensuring resident is visualized at all times on the unit. Will continue to monitor and ensure resident safety. Review of Resident R77's nursing progress note dated 2/2/26, at 3:33 p.m. indicated son of this resident called at this time and was inquiring about a missed call he received from facility. This nurse explained the elopement last night and son was understanding. Son asked many questions about his father's clinical condition and this nurse provided answers to the best of ability. Son was satisfied and thankful for the information. Further review of Resident R77's progress notes did not include any documentation about the resident leaving the floor. Review of Resident R77's progress notes dated 2/4/26, at 10:37 RN Employee E36 indicated episode clarified that this was a wandering incident. Resident never eloped from facility. Resident remained safe and unharmed throughout incident, and all follow up. During an observation completed on 2/9/26, at 11:48 a.m. Resident R77 was in the common area across from the third-floor nursing station. A nurse aid was next to him. Upon asking Licensed Practical Nurse (LPN) Employee E2 concerning the resident's behaviors stated Resident R77 is one on one supervision. The nurse aid just got here at 11:00 a.m. They called her in when they found out that the State Agency (SA) was here. He has a wander guard on. Last week the resident went out the back stairway down two flights of stairs into the personal care facility. Further interview with LPN employee E2 on 2/9/26, at 12:38 p.m. stated I came in at 7:00 a.m. I worked a 12-hour shift, about 10 min after 7:00 p.m. Resident R77 came to the cart I asked him to give me a minute we were doing the narcotic count. I did not see him after as my shift was over. I did not hear an alarm while I was here. When I went to get on the elevator to leave the girl from the personal care facility was in the elevator and asked if we were missing anyone, the girl stated Resident R77's first name. I gave the nurses the information. The girl from the villa said he was down having a cup of tea. LPN Employee E35 went down to get him. It must have been a very short time that he left the cart and went down the steps. I would 100 percent consider it an elopement. The Director of Nursing called me on the way home and asked me to tell her if it was an elopement, I told her yes 100 percent it was an elopement. There was no staff members with him just the girl from downstairs who redirected. During a telephonic interview completed on 2/9/26, at 2:45 p.m. Upon asking Registered Nurse (RN) Employee E36 concerning the discrepancies in the documentation and the date of event replied The incident report is dated 2/1/26, I was asked to put the report in and back date it to the first. I was not there when it happened. LPN Employee E2 was leaving at the end of her shift she would know the exact date. It was later in the evening around shift change; I was directed to complete the incident report by the Former Nursing Home Administrator Employee E31 and the [NAME] President of Clinical Operations Employee E7. Interview completed on 2/9/26, at 2:55 p.m. upon asking LPN Employee E2 concerning the date and time of the event she clarified it did happen on 2/1/26. Interview on 2/10/26, at 12:37 p.m. the [NAME] President of Operations Employee E7 confirmed the facility failed to provide adequate supervision for one of seventeen residents (Resident R77) resulting in elopement and were notified that Immediate Jeopardy was called due to the elopement of Resident R77 on 2/1/26. An Immediate Jeopardy template was issued to Nursing Home Administrated (NHA) and [NAME] President of Operations (VPO) Employee E7 and a corrective action plan was requested. On 2/10/26, at 4:21 p.m. an immediate action plan was received and accepted which included the following interventions: Immediate action: Resident was returned to his room by staff and assessed by RN. No injuries observed.Staff evaluated wander guard on residents and door alarm checks were conducted with no issues.provided resident redirection based on his likes and needs, provided beverages, placed on 15 min checks.2/4 he was placed on 1:1.Resident was assessed by NP for change in medical condition and any labs needed and he is at baseline.Medication review conducted 2/9/26, with no orders.Elopement risk evaluation will be updated, and care plan updated to include resident preferences and any triggers for exit seeking behaviors.All residents will have updated elopement risk evaluations completed by DON or designee by 2/10/26.Care plan interventions for residents identified for elopement risk will be updated with specific person-centered triggers and interventions to ensure residents identified as elopement risk are not permitted to leave supervised areas unattended. This will be completed by DON or designee by 2/11/26.All residents who have been identified as an exit seeking risk will have wander guard care plans and orders to check function.Elopement Risk Binders were updated to ensure accuracy on 2/10/26. System Correction: All staff will be educated on recognizing exit seeking behaviors, door alarm response, supervision, elopement binder process and policies, and reporting exit seeking behavior.Licensed nurses will be educated on elopement risks and assessments, and care planning, exit seeking. This education includes agency staff, and staff will be educated prior to their next scheduled shift. This will be completed by the NHA or designee.Review and update the elopement policy as needed to ensure it includes. identification of residents who are at risk for eloping. Maintenance did conduct a door alarm check. Door alarm company will also be onsite to ensure all doors have appropriate sensitivity rand for the wander guard to trigger the alarm, and that all alarms are functioning appropriately on 2/10/26. Monitoring: Audits of exit seeking behaviors and implementation of care plan interventions as needed, and door alarms/wander guard system will be conducted by DON or designee daily x 2 weeks, weekly x 4 weeks, then monthly x 3 months to ensure evaluations and care plans are up to date.Audits of assignment sheets to confirm R77's 1:1 supervision will be conducted by DON or designee daily x 2 weeks, weekly x 4 weeks, then monthly x 3 months.Elopement binders will be audited by NHA or designee daily x 2 weeks, weekly x 4 weeks, then monthly x 3 months.Findings of audits will include updated elopement evaluations and care plan goals/interventions.QAPI Ongoing results will be submitted to QA for further evaluation. Verification of the facility's Corrective Action Plan revealed all elements of plan were met on 2/11/26, as follows: Care plans were updated for triggers for exit seeking behaviors. 17/17 care plans updated to include triggers. All residents with updated elopement risk completed. Orders reviewed, new elopement risk, care plans were updated to include triggers for elopement.All residents identified have orders in place.Elopement binders on units and at front desk with 17 residents at risk for elopement all with identifies/descriptions.98/108 in-house staff were educated on recognition of exit seeking behaviors, door and wander guard response, supervision of elopement risk residents, care plans and elopement binders, reporting requirements and is ongoing.23 employee interviews confirmed the education. Review of audits completed on 2/10/26, at 4:00 p.m. fourth floor visitor elevator, service elevator, door one by activities, door two by room [ROOM NUMBER], door three by room [ROOM NUMBER]. No corrective action needed all functioning appropriately.Review of audits completed on 2/10/26, at 4:00 p.m. third floor visitor elevator, service elevator, door one by therapy, door two by room [ROOM NUMBER], door three by room [ROOM NUMBER]. No corrective action needed all functioning appropriately.Facility tour completed on 2/11/26, all doors are functioning appropriately.Audits of assignments sheets indicate 1:1 scheduled.Audits created for the elopement binders and completed on 2/10/26.The policies around elopement risk and wander guard use have been reviewed by Nursing Home Administrator and [NAME] President of Clinical Operations Employee E7 and Director of Nursing on 2/10/26.QAPI Ongoing results will be submitted to QA for further evaluation. During an interview completed on 2/11/26, at 1:00 p.m. Upon asking Nurse Aid (NA) Employee E38 concerning any education recently received replied yesterday they told us about elopements, a care plan and a binder at the desk, I was not aware of the binder at the desk. During an interview completed on 2/11/26, at 1:04 p.m. Upon asking NA Employee E39 concerning any education recently received replied I had some this morning about elopements, I was not aware of the elopement binders. During an observation and additional interview on 2/11/26, at 3:50 p.m. NA Employee E38 was in Resident R77's room as she had been assigned to provide one on one observation of Resident R77 beginning at 3:00 p.m. Resident was seen walking around his room with his wheeled walker. NA Employee E38 stated that resident likes to walk around a lot and that she was going to take him for a walk on the nursing unit to wear him out. I'm supposed to keep him busy, so he doesn't elope again. I'm going to try to play cards with him later. When SA asked if she had ever conducted these activities with Resident R77 before, she stated No. The Nursing Home Administrator and [NAME] President of Operations Employee E7 were made aware the Immediate Jeopardy was lifted on 2/11/26, at 5:30 p.m. 28 Pa. Code 201.14 (a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, facility policy, resident interviews, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents. Findings Include:Review of the facility policy Safe and Homelike Environment dated 12/11/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. This includes ensuring that the residents can receive care and services safely. Comfortable and safe temperature levels mean that temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia and is comfortable for the residents.Review of the facility policy Loss of Heating or Cooling dated 12/11/25, indicated the facility will take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71 -81 degrees Fahrenheit. The facilities include the following:Monitor temperatures in the facility.Increase frequent rounding to assess residents for changes in condition related to heat/cold.Layer clothing.Provide extra blankets.Serve warm foods and liquids.Monitor residents for signs of hypothermia. Notify physician as needed.During an interview on 1/28/26, at 3:30 p.m. Nursing Home Administrator (NHA) stated that she was made aware that the heat wasn't working last week. Then on Saturday 1/24/26, a heating company came in to fix a problem and after that fix facility was made aware that another part is needed. NHA presented audits of 5-6 random rooms on each floor but did not check all resident rooms nor did NHA have staff assess or interview residents to ensure their needs were being met.During an interview on 1/28/26, 5:30 p.m. Maintenance Employee E5 indicated that the heating system is not working at its full capability and that the heating company is returning to make the repairs needed. During observations on 1/28/26, 5:35 p.m. through 6:10 p.m. with Maintenance Employee E5 for rooms on the 3rd and 4th floor nursing units revealed that some residents say they were cold and some stating they were comfortable. Temperatures ranged from 68 degrees to 81 degrees. Observed resident windows were not fully closed and some residents stated that they opened the window. Residents did have extra blankets and clothing. All residents interviewed did state that no staff member offered any extra blankets or warm fluids to drink. During an interview on 1/28/26, at 6:08 p.m. Nursing Home Administrator confirmed that the heat is not working as it should and heating company will be returning to make repairs. NHA was made aware of the environmental concerns with the windows not being fully closed, the need to assess and ensure residents' needs are being met. Also, the need to conduct temperatures audits of the entire facility.During an interview on 1/29/26, at 9:05 a.m. NHA stated, The heaters are working but not 100%. That's why we are trying to get it fixed. We noticed it in the middle of last week. We called a company and they came on 1/24/26 and installed a control board. He then realized that the gas valve needed replaced. I approved the quote on 1/27/26, and he is here today fixing it. We are doing whole house temperature checks every shift, and started to audit blankets, offering hot chocolate, and to check windows to ensure they are closed.During a review of facility provided documentation, labeled Room Temp Audits, on 1/29/26, at 9:30 a.m. revealed that temperatures were obtained and recorded as the follow:At 2:00 a.m. the Third-Floor temperatures included 29 of 31 resident rooms were below 71 degrees Fahrenheit. The lowest temperature recorded was 63 degrees Fahrenheit.At 2:45 a.m. the Fourth-Floor temperatures included 30 of 31 resident rooms were below 71 degrees Fahrenheit. The lowest temperature recorded was 58.6 degrees Fahrenheit.During a tour of the facility on 1/29/26, from 10:30 a.m. - 11:15 a.m. the facility temperature felt cold throughout the Third, and Fourth floors.Observations conducted on 1/29/26, from 10:15 a.m. to 10:55 a.m. with Maintenance Employee E5 revealed the following air temperatures:Third floor Nursing Floor-room [ROOM NUMBER] -69.8 degrees Fahrenheit-room [ROOM NUMBER] -69.6 degrees Fahrenheit-room [ROOM NUMBER] -70.2 degrees Fahrenheit-room [ROOM NUMBER] -69.2 degrees Fahrenheit-room [ROOM NUMBER] -69.0 degrees Fahrenheit-room [ROOM NUMBER]- 67.8 degrees Fahrenheit-room [ROOM NUMBER]- 70.8 degrees Fahrenheit-room [ROOM NUMBER]- 68.4 degrees Fahrenheit-room [ROOM NUMBER]- 68.2 degrees Fahrenheit-room [ROOM NUMBER]- 68.2 degrees Fahrenheit-room [ROOM NUMBER]- 67.2 degrees Fahrenheit-room [ROOM NUMBER]- 68.6 degrees Fahrenheit-room [ROOM NUMBER]- 70.2 degrees FahrenheitDuring an observation on 1/29/26, at 10:18 a.m. Resident R2 was lying in bed with four blankets on covering her body.During an interview on 1/29/26, at 10:20 a.m. Resident R2 stated, My legs are cold, they gave me extra blankets. My window was cracked open last night.Observations conducted on 1/29/26, from 11:00 a.m. to 11:15 a.m. with Maintenance Employee E5 revealed the following air temperatures:Fourth floor Nursing Floor-room [ROOM NUMBER]-67.4 degrees Fahrenheit-room [ROOM NUMBER]-69.0 degrees Fahrenheit-room [ROOM NUMBER]-68.0 degrees Fahrenheit-room [ROOM NUMBER]- 66.2 degrees Fahrenheit-room [ROOM NUMBER]- 67.0 degrees FahrenheitDuring an interview on 1/29/26, at 11:24 a.m. Licensed Practical Nurse E6 stated, Residents complain that they are cold. I have brought in two bags full of blankets to pass out to keep them warm.During an observation on 1/29/26, at 11:29 a.m. Resident R1 was lying in bed, wearing a housecoat and had four blankets on covering his body.During an interview on 1/29/26, at 11:30 a.m. Resident R1 stated, I've been cold. I have all these blankets on. It gets real cold at night.During an observation on 1/29/26, at 11:32 a.m. Resident R8 was lying in bed, wearing a tassel cap and had three blankets covering her body.During an interview on 1/29/26, at 11:34 a.m. Resident R8 stated, This room is cold. When I get up, I get real cold.During an observation on 1/29/26, at 11:36 a.m. Resident R4 was lying in bed resting his eyes with four blankets on and personal winter coat laying over his legs.During an observation on 1/29/26, at 11:37 a.m. Resident R5 was lying in bed with four blankets covering her body.During an interview on 1/29/26, at 11:38 a.m. Resident R5 stated, I have been cold. I have all these blankets so I'm warm now.During an observation on 1/29/26, at 11:39 a.m. Resident R6 was lying in bed with blankets covering her body.During an interview on 1/29/26, at 11:40 a.m. Resident R6 stated, It is cold. I went to a meeting yesterday and it was really cold.During a tour and observation of the Third and Fourth Nursing Floors revealed only a few residents in the hallway or sitting at the nurse's station, with blankets covering them.During an interview on 1/29/26, at 12:21 p.m. the Heating Repairman stated, They called us last week and we came Saturday to look at it. There is two stages of heating. The first stage is working; the second stage is not working. We got the control board and installed it but then noticed the gas valve was needed. I just installed it and it is working now.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).During a review of Resident R1's clinical record on 1/29/26, at 12:47 p.m. failed to reveal any physician orders to monitor for hypothermia and to monitor resident temperatures. Last documented temperature was dated 1/6/26.Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's MDS dated [DATE], indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), high blood pressure, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).During a review of Resident R7's clinical record on 1/29/26, at 12:48 p.m. failed to reveal any physician orders to monitor for hypothermia and to monitor resident temperatures. Last documented temperature was dated 1/25/26.Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].Review of Resident R8's MDS dated [DATE], indicated diagnosis of dementia, depression, and high blood pressure.During a review of Resident R8's clinical record on 1/29/26, at 12:450 p.m. failed to reveal any physician orders to monitor for hypothermia and to monitor resident temperatures. Last documented temperature was dated 12/2/25.On 1/29/26, at 2:30 p.m. the NHA was notified that Immediate Jeopardy was called due the facility failed to maintain a temperature range between 71-81 degrees Fahrenheit and failed to monitor and assess all residents for hypothermia. The NHA was provided with the Immediate Jeopardy template, and a corrective action plan was requested.On 1/29/26, at 6:15 p.m.an immediate action plan was received and accepted which included the following interventions:Environmental Stabilization and Monitoring - The heating system repair has been completed as of approximately 12:15 p.m. on 1/29/26. Maintenance continues ongoing monitoring of system performance. Room temperature audits will be conducted in every resident room, every two hours until all resident rooms are at 71 degrees Fahrenheit or higher, then once every four hours by the Director of Nursing (DON) or designee daily for seven days, weekly for three weeks, then monthly for three months to ensure sustained compliance. Audits will include ensuring windows are closed and residents are offered plastic covering for windows, which will be completed by 7:00 p.m. on 1/29/26.Resident Monitoring and Hypothermia Evaluation, Resident Evaluation - All residents have been evaluated for signs and symptoms of hypothermia, including residents unable to independently express needs and residents who had a temperature taken over the last three days, and/or during whole house audit, of 97.6 degrees Fahrenheit or lower with no issues noted. This was completed by DON or designee by 4:00 p.m. on 1/29/26, with no issues noted. Any identified concerns in ongoing audits will be addressed immediately with individualized interventions, and orders are being placed for ongoing monitoring. Temperatures will be documented in weights/vitals section of electronic medical record and evaluation will be documented in progress notes.Resident Monitoring - Nursing staff or designee has conducted an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature by 5:00 p.m. on 1/29/26. Interviewable residents are asked about comfort level and offered interventions as needed. Non-Interviewable residents are evaluated for observable signs of discomfort related to temperature. Resident monitoring audits will be conducted in every resident room, every shift by DON or designee daily for seven days, weekly for three weeks, then monthly for three months.Staff Education. Hypothermia Education - Nursing staff, including agency staff, will be educated on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures to provide to residents, and appropriate response when signs or symptoms are identified. Nursing Assistants were educated on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed. Education will be completed by the DON or designee and will be reinforced as needed. Education will be completed by 1/30/26, at 8:00 a.m. Staff educated by phone or email will sign the education prior to next working shift.Mitigation and Contingency Planning - Additional blankets, layering, and environmental adjustments are provided as needed. Residents offered room relocation as appropriate to maintain comfort. The facility has a plan to utilize outside resources, if necessary, to maintain safe air temperatures during future weather events or mechanical issues with updated rental company in place by 11:30 a.m. on 1/29/26.Policy and Procedure Review - Facility leadership has reviewed relevant policies and procedures related to environmental safety, resident monitoring, and emergency response. This was completed by 4:30 p.m. on 1/29/26. Policies will be updated as indicated based on audit findings and Quality Assurance Performance Improvement (QAPI) review.QAPI Oversight - Audit findings, trends, and corrective actions are reported to the QAPI committee. The QAPI committee will evaluate effectiveness and recommend changes as needed.On 1/30/26, an Addendum was added, by the NHA, to the approved plan of correction to include the following:During review of audits and QAPI process, the facility leadership determined additional steps would be taken to continue to improve the facility temperature.After window audit, it was determined that every resident room and hallway windows in resident care areas would all receive plastic coverings to prevent drafts.After identifying that some knobs on registers were turned off, instead of on, leadership determined that clarification was needed to prevent others from inadvertently turning the heat off. This was completed by 11:00 p.m. on 1/29/26.Heating vendor who completed work on 1/29/26, is sending a tech back in to ensure correct functionality and to further explore the system to ensure no further corrections are needed. If any are needed, vendor will fix as soon as possible pending any parts or additional resources necessary.Six rental One ton heating units were installed by 2:00 a.m. on 1/30/26. These are being rented for the week at a minimum. On 1/31/26, a second Addendum was added, by the NHA, to the approved plan of correction to include the following:During review of audits and QAPI process, the facility leadership determined additional steps would be taken to continue to improve the facility temperature.On 1/30/26, the facility ordered two additional rental heating units and they were installed by 3:45 p.m.On 1/31/26, for facility resident rooms at 11:30 a.m. room temperature audits included five resident rooms that were showing under 71 degrees Fahrenheit with the laser thermometer gun. For those rooms, we re-temped using a room air thermometer, and all showed above 71 degrees Fahrenheit.Facility ordered air thermometers for each room which are due to be delivered on 1/31/26.During an interview on 1/30/26, at 9:00 a.m. NHA stated, We decided to put plastic on all the windows. We are still doing every two-hour room temperature check. At night we're having trouble keeping up the temperatures, but they are getting better. We got six portable heaters late last night. There are three on each floor.On 1/30/26, all resident orders were reviewed and verified to include monitoring for signs and symptoms of hypothermia and resident temperature checks.On 1/30/26, all residents progress notes were reviewed and verified to include a current temperature and an assessment for hypothermia.On 1/30/26, all residents were assessed and skin evaluations were completed and documented in residents' medical records. No negative outcomes were identified.On 1/30/26, temperature audits were reviewed. The facility is completing every two hours of temperature audits until all rooms are within normal range.On 1/30/26, QAPI meeting was held and signatures provided that attended meeting.On 1/31/26, current nursing staff, including agency, educated on signs and symptoms of hypothermia, identifying and reporting concerns to the physician, interventions used to prevent hypothermia, and how to prevent hypothermia. Staff will sign the education prior to their next working shift if education isn't completed in person.Staff education was verified with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated.During in-person verification completed on 1/31/26, from 10:00 a.m. until 12:00 p.m. 13 nursing staff confirmed that they were educated in person. Staff were educated on the definition of hypothermia, signs and symptoms to look for, when to report to physician, applying extra blankets, room changes, providing hot food and drinks, and to monitor residents more frequently.All staff educated in person signed the education sheet. All nursing staff members were educated. All other staff will be educated prior to their next shift and sign the education sheet.During an interview on 1/31/26, at 10:42p.m. Registered Nurse (RN) Employee E3 stated, I was educated on hypothermia. Monitor for signs and symptoms. Interventions like hot beverages and warm clothes. Watch for shivering, swelling, decrease responsiveness, decrease temperatures. Try to warm up but not too quickly.During an interview on 1/31/26, at 10:53 a.m. Nurse Aide (NA) Employee E8 stated, Residents are now requesting to take blankets off. If they were cold, I would offer them blankets. They may be confused. Give them warm drinks. Report low temperatures of residents to the nurse. I thought the education was helpful. It's a nice reminder.During an interview on 1/31/26, at 11:20 a.m. Nurse Aide (NA) Employee E7 stated, I was educated on hypothermia and temps of rooms. I would check temperatures, bundle residents up with blankets, and wear extra clothing. Keep them hydrated. I think the education was good. Helpful.During an interview on 1/31/26, at 11:32 a.m. Nurse Aide (NA) Employee E9 stated, They went over signs and symptoms of hypothermia. Watch for them complaining of cold, puffy faces, loss of consciousness, low temperatures. I learned to observe signs and symptoms of hypothermia. I thought the education was good and informative.During an interview on 1/31/26, Resident R2 stated, I feel a difference in the temperatures. It's warmer. They put plastic on the windows.During an interview on 1/31/26, Resident R9 stated, I'm warm. A few days ago, it was cooler but its warmer now.During an interview on 1/31/26, Resident R1 stated, Its warmer now. They put plastic up at the windows. I only need one blanket now.During an interview on 1/31/26, Resident R10 stated, Its much nicer than the other day. I don't need to use the blankets as much.Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 1/31/26, at 1:15 p.m. NHA was made aware.During an interview on 1/29/26, at 2:30 p.m. the NHA confirmed that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents. This failure created an immediate jeopardy situation by potentially putting residents at risk of harm or injury.28 Pa. Code: 201.18(b)(3) Management

Based on facility policy, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with an insulin pump (wearable device that delivers insulin continuously to people with diabetes), and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted. Findings include: Interview on 4/29/25, at 9:35 a.m. the Director of Nursing (DON) indicated I don't think we have a policy for insulin pumps. Review of facility policy Competent Nursing Staff dated 1/7/25, indicated it is the policy of the facility to provide staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12 - moderately impaired cognition. Review of Resident R1's nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity - chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was erroneously transcribed by LPN Employee E6. Review of Resident R1's care plan on 4/29/25, failed to include a problem, goal, or interventions for care and management of an insulin pump. Interview on 4/29/25, at 9:41 a.m. Registered Nurse (RN) Employee E1 indicated No. I haven't had education on an insulin pump. Interview on 4/29/25, at 9:44 a.m. Licensed Practical Nurse (LPN) Employee E2 indicated remembering Resident R1 having an insulin pump, but admitted she only knows about the pump because a relative of hers had one. Nobody at the facility taught her about an insulin pump. She believed the pump came with insulin already inside of it. When asked how long the pump lasted before needing changed or refilled, LPN Employee E2 indicated they last a long while and that she did not know what type of insulin pump Resident R1 had or what it looked like. Interview on 4/29/25, at 9:51 a.m. RN Employee E3 indicated she had not received education regarding an insulin pump. Recalled Resident R1 had one because she found it beeping one day and notified the resident's nurse. Indicated the pump looked like a very tiny infusion machine. Interview on 4/29/25, at 9:54 a.m. LPN Employee E4 indicated she had not received education regarding an insulin pump. Interview on 4/29/25, at 9:57 a.m. LPN Employee E5 indicated not receiving training on an insulin pump, but recalls a resident downstairs had one recently. It was LPN Employee E5's first day of orientation and that's all they could recall. Telephonic interview on 4/29/25, at 10:12 a.m. LPN Employee E6 indicated she only picked up one shift at this facility. Recalled an admission that night during her shift of 7:00 p.m. - 7:00 a.m. When asked if she was familiar with insulin pumps, she indicated not having experience with one or receiving education on it. Recalled she arrived to work at 7:00 p.m. for her first shift at the facility and they told her she had a new admission. She remembered calling the On Call doctor who said someone will come in and see the new admission in the morning. She indicated she transcribed the orders from the hospital discharge transfer orders. She indicated she did not receive any training at the facility, had to pass her medications and do the admission on her own. She indicated she was not aware she entered the incorrect insulin type and that she was not aware she wrote the insulin to be injected subcutaneously in error, rather than to refill the pump. Review of Resident R1's progress note dated 3/31/25, at 12:03 p.m. indicated resident was wearing an insulin pump. Resident was ordered to be given 90 units Humulin insulin to refill insulin pump; but the nurse administered Humulin 90 units subcutaneously in error and was transferred to the hospital where he was diagnosed with hypoglycemia and accidental insulin overdose. Review of LPN Employee E6's employee file failed to include evidence of orientation to the facility, Interview on 4/29/25, at 2:00 p.m. the Director of Nursing confirmed LPN Employee E6, and the facility nursing staff were not trained on insulin pumps. Confirmed LPN Employee E6 was not trained on facility processes, admission process, transcribing physician orders from hospital discharge papers, transcribed the incorrect insulin type in the admission orders, and this resulted in a negative resident outcome. On 4/29/25, at 2:03 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, that placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. On 4/29/25, at 4:01 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident was sent out to the hospital for evaluation regarding insulin medication error and returned to the facility in stable condition. Resident R1 has been discharged from the facility with no plans to return. The root cause of the event was that the facility failed to educate licensed staff on insulin pump usage, admission process, and transcribing physician orders from hospital discharge paperwork. Residents: -Residents will be audited by the DON or designee to identify specialty equipment by 4/29/25. If specialty equipment is identified, the staff will obtain physician orders. Care plans will be updated to include specialty equipment (if applicable) by 4/29/25. -Admission assessments for residents admitted from 3/25/25, to present will be audited for special equipment specifically insulin pumps and/or continuous glucose monitors by the DON or designee by 4/29/25. -Physician orders from discharge paperwork for residents admitted from 3/25/25, to present will be audited for accuracy by DON or designee by 4/29/25. System Correction: -Pre-admission resident screening will be conducted by the Admissions Director (AD) or designee to identify any special equipment. Special equipment needs will be communicated to the nursing team prior to resident admission. AD will be educated on this process by the NHA or designee by 4/29/25. Licensed nursing staff (including agency) will be educated on the following: -Pre-admission resident screening will be conducted by the AD or designee to identify any special equipment. Special equipment needs will be communicated to the nursing team prior to resident admission. -Assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors (CGM's). -Obtaining physician orders for specialty equipment. -Accurate order transcription and admission red lining processes (a process to double check accuracy of orders). -Care plan updates on specialty equipment (insulin pumps/CGM's). -The DON or designee will educate licensed nursing staff (including agency) on updated processes by 4/30/25, or before the start of their next scheduled shift. -Facility policy on medication administration updated and reviewed to include specialty equipment, obtaining physician orders, and updating care plans. Monitoring: -Audits of new resident admission assessments will be conducted by the DON or designee weekly for four weeks, monthly for two months to ensure assessments, redlining, and orders are completed and accurate. Findings of audits will be submitted through facility Quality Assurance and Performance Improvement (QAPI) program. Next QAPI meeting scheduled for 5/1/25. Interview on 4/30/25, at 10:50 a.m. RN Employee E6 indicated she wasn't familiar with insulin pumps prior to receiving training, and that Resident R1's insulin pump was beeping and she asked him what it was. Resident R1 (with a BIMS of 12) educated RN Employee E6 on the insulin pump. RN Employee E6 drew up the insulin and Resident R1 showed RN Employee E6 how to fill the pump with the insulin. Telephonic interview on 4/30/25, at 11:29 a.m. LPN Employee E7 verified she received education on insulin pumps, facility processes, admission process and transcribing physician orders from hospital discharge papers. Telephonic interview on 4/30/25, at 11:37 a.m. LPN Employee E8 verified she received education on insulin pumps, facility processes, admission process and transcribing physician orders from hospital discharge papers. Review of the Abatement plan on 4/30/25, indicated: -Resident R1 was sent out to the hospital and later returned. Has since discharged home status post physical and occupational therapy and wound care. -The root cause of the event was listed as the facility failed to educate licensed staff on insulin pump usage, admission process, and transcribing physician orders from hospital discharge paperwork. -The DON completed a house audit on 84 of 84 residents in house for specialty equipment needs. No new residents identified. -New Admissions (20 residents) assessed for special equipment since 3/25/25, completed. -New Admissions (20 residents) physician order audit for accuracy and no discrepancies found. -AD was in-serviced on pre-admission screening for special equipment prior to acceptance to facility including, life vest, insulin pump, CGM's, pacemakers, etc. -Facility policy updated to include specialty equipment having physician orders and care plans reflective of equipment. -Facility professional nurses 27 of 27 received education. -Agency professional nurses 17 of 17 received education. Total professional staff 44. -Interviewed nine of nine professional staff in house on 4/30/25, who verified they received training. -Six professional nurses confirmed via phone on 4/30/25, 11:39 a.m. -Total of 15 verified receiving education. -Audit forms completed per plan, next QAPI, May 1, 2025. -No additional equipment needs were identified through the abatement process. The Immediate Jeopardy was lifted on 4/30/25, at 12:03 p.m. when the action plan was verified. During an interview on 4/29/25, at 2:03 p.m. the NHA and DON confirmed that the facility failed to ensure that nursing staff have the specific competencies, and skill sets necessary to provide care for a resident with an insulin pump, and placed one resident (Resident R1) in immediate jeopardy in which health and safety were impacted. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of three residents which created an actual harm of an accidental insulin overdose and acute care emergency room visit for Resident R1. Findings include: Review of the facility policy Medication Administration dated 1/7/25, indicated medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: right resident, right drug, right dose, right route, right time, and right documentation. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12, moderately impaired cognition. Review of Resident R1's Nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity - chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was transcribed by LPN Employee E6. Review of Resident R1's progress note dated 3/31/25, at 12:03 p.m. indicated resident was wearing an insulin pump. Resident was ordered to be given 90 units Humulin insulin to refill insulin pump; but Licensed Practical Nurse (LPN) Employee E10 administered Humulin 90 units subcutaneously in error and Resident R1 was transferred to the hospital where he was diagnosed with hypoglycemia and accidental insulin overdose. Review of LPN Employee E10's witness statement dated 3/31/25, indicated Statement is in regard to wrong dose medication. Resident R1 was ordered 90 units subcutaneously one time a day for diabetes insulin pump maximum dose 100 units daily. When she read the order, she thought Resident R1 was supposed to get 90 units subcutaneously daily in one dose. The insulin pump was empty, so she just administered subcutaneously from how she read the order at 8:50 a.m. Around 11:00 a.m. on 3/31/25, the wound nurse alerted LPN Employee E10 that Resident R1 was groggy. LPN Employee E10 then explained what she did, and the supervisor was made aware of the mistake. Resident was then sent to the emergency room per physician order. Interview on 4/29/25, at 9:30 a.m. the Director of Nursing, and telephonic interview on 5/15/25, at 9:19 a.m. with the Nursing Home Administrator confirmed the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of three residents which created an actual harm of an accidental insulin overdose and acute care emergency room visit for Resident R1. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on observation, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received treatment and care in accordance with professional standards of practice which resulted in actual harm to Resident R1, who received a medication that was not given according to the physician's orders, resulting in Resident R1 being overdosed on insulin (injectable diabetic medication) overdose and required treatment in an acute care emergency department. Findings include: Review of the facility policy Provision of Quality Care dated 1/7/25, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the resident's choices. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of the blood against the artery walls is too high). Section C0500 a Brief Interview for Mental Status test (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12, moderately impaired cognition. Review of Resident R1's Nursing admission evaluation dated 3/25/25, indicated Section D Skin Integrity - chronic (something that lasts a long time, often three months or more) wound left foot, and right below the knee amputation (surgical removal of a limb or part of a limb) incision with staples (used to close incisions after surgery). The skin assessment failed to indicate the presence of an insulin pump. Review of Resident R1's hospital discharge transfer orders dated 3/25/25, indicated Humalog (insulin Lispro) a rapid-acting insulin used to manage blood sugar) 100 units/milliliter injectable solution, injectable via insulin pump (wearable device that delivers insulin continuously to people with diabetes) - average daily dose is 90 units (max dose 100 units daily). Review of Resident R1's physician order dated 3/25/25, indicated Humulin R (insulin regular - a short acting insulin used to manage blood sugar) injection solution, inject 90 units subcutaneously (injecting a drug into the fatty tissue layer beneath the skin) one time a day for Diabetes Insulin Pump, max dose 100 units daily. Order was transcribed by LPN Employee E6, incorrectly from the written hospital discharge orders, was not written clearly by the admitting nurse, the physician was not questioned by the admitting nurse for clarification and the medication was not given according to the physician's written orders upon discharge from the hospital. Review of Resident R1's care plan on 4/29/25, failed to include a problem, goal, or interventions for care and management of an insulin pump. Interview on 4/29/25, at 9:30 a.m. the Director of Nursing confirmed, and telephonic interview on 5/15/25, at 9:19 a.m. with the Nursing Home Administrator confirmed the admission nursing evaluation dated 3/25/25, failed to identify the use of an insulin pump for Resident R1, confirmed that the admitting nurse transcribed the hospital discharge transfer order on 3/25/25, as Humulin R and not the correct medication ordered, which was Humalog, confirmed the order read subcutaneously rather than injectable via insulin pump, further confirmed that Resident R1 was given 90 units of subcutaneous Humulin R insulin as a result of these omissions and errors in transcription and administration that resulted in actual harm and that the resident was sent to the emergency room for monitoring from an insulin overdose and hypoglycemia. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289). This failure created an immediate jeopardy situation for two of 11 residents (Resident R79 and R289). Findings include: Review of the facility policy Elopements and Wandering Residents dated 1/7/25, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Review of the admission record indicated Resident R79 was admitted on [DATE]. Review of Resident R79's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/29/24, indicated diagnoses of Alzheimer's (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), dementia (loss of cognitive functioning-thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and non-exudative age-related macular degeneration (AMD- common eye condition that primarily affects older adults, leading to a gradual loss of central vision). The residents Brief Interview for Mental Status (BIMS) assessment was 7, severely cognitively impaired. Review of an Elopement Risk Evaluation dated 12/28/24, indicated Resident R79 was a high elopement risk. Review of Resident R79's care plan dated 12/30/24, indicated Resident R79 was care planned for elopement. The care plan failed to include supervision as an intervention. Review of progress note dated 12/18/24, indicated Resident R79 was ambulating through hallway with walker attempting to figure out codes to exits to find her way out. Wander guard applied to the left wrist after verifying function. Resident R79 was attempting to obtain the codes to the exits and wanted to go home. Review of a progress note dated 2/6/25, at 5:01 p.m. revealed staff heard alarm sounding on the 4th floor at 3:05 p.m. Resident R79 was observed in the stairwell. Staff assisted Resident R79 back to the unit. An assessment was completed with no injuries observed. The resident's responsible party and certified registered nurse practitioner (CRNP) were notified. There were no new orders. Review of information submitted to the Department of Health on 2/7/25, indicated on 2/6/25, Resident R79 eloped from the 4th floor at 3:05 p.m. It was indicated Resident R79 was in the stairwell. Staff assisted the resident back to the unit. The resident's wander guard (system designed to support the safety and independence of patients by monitoring their movements and gently preventing them from unintentionally leaving) was in place at the time of the event and was functioning appropriately. The Registered Nurse completed an assessment with no injuries observed. The resident was able to move extremities, and no pain or bruising was noted. The resident's responsible party and physician were notified. There were no new orders. It was indicated elopement assessments and care plans were updated. Review of Nurse Aide, Employee E14's witness statement dated 2/6/25, indicated at 3:05 p.m. an alarm was going off in the back stairwell. NA, Employee E14 opened the door and saw Resident R79 sitting on a step three floors down. NA, Employee E14 notified staff. Review of Nurse Aide, Employee E18's witness statement dated 2/6/25, indicated while giving report to NA, Employee E19, NA, Employee E14 came up to the nursing station and said a resident went down the stairwell. NA, Employee E18 and E19 looked at the call bell system and noticed Resident R79's call light was not on. NA, Employee E14, E18, and E19 ran down the hall to get the resident. Resident R79 made it about five flights of steps between the 3rd and 2nd floor. NA, Employee E18 took the resident back to the 4th floor using the elevator. The nurse and Director of Nursing were notified. Review of NA, Employee E19's witness statement dated 2/6/25, indicated at 3:05 p.m. NA, Employee E14 stated Resident R79 was observed past the third floor in the stairwell. NA, Employee E18 escorted Resident R79 to the third floor, and took the elevator back up to the fourth floor. During an interview on 3/18/25, at 10:15 a.m. Licensed Practical Nurse, Employee E31 was notified by staff on 2/6/25, Resident R79 was found in the stairwell. When LPN, Employee E31 went to assess Resident R79, Resident R79 was being brought back to the unit by a nurse aide. LPN, Employee E31 stated earlier that day Resident R79 was observed coming out of their room and seemed confused earlier in the day. Resident R79's room was located near the door at the end of the hallway. Resident R79 eloped during a change in shift. During an interview on 3/18/25, at 9:40 a.m. NA, Employee E18 stated Resident R79 eloped down the stairwell during shift change on 2/6/25. NA, Employee E18 indicated Resident R79 was observed down five flights of stairs. Resident R79 was throwing the walker down the steps. NA, Employee E18 indicated Resident R79 was tired after returning to the unit. NA, Employee E18 indicated the button on the stairwell was not working and maintenance was called to get it fixed. Resident R79's room was not changed. During an interview on 3/18/25, at 9:51 a.m. Director of Maintenance, Employee E32 indicated the door's egress (system used to provide a safe and accessible exit route in case of an emergency) and magnetic locks weren't working properly on 2/6/25. The facility had a company come the night Resident R79 eloped to take care of situation. The door got repaired around 1:00 a.m. on 2/7/25. During an interview on 3/18/25, at 10:39 a.m. Registered Nurse, Employee E34 stated on 2/6/25, it was reported that Resident R79 was found in the stairwell. Resident R79 had tossed the walker down the stairs. During an interview on 3/18/25, at 10:57 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to supervise Resident R79 and prevent an elopement on 2/6/25. The NHA confirmed the facility failed to update Resident R79's care plan for elopement. Resident R289 was admitted to the facility on [DATE], with the diagnoses of heart failure (heart doesn't pump blood as well as it should), UTI (urinary tract infection), non-Alzheimer's Dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), depression, and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R289's MDS dated [DATE], indicated the diagnoses remained current. Section C indicated a BIMS score of 10 (Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment). A score of 8-12 indicates moderately impaired cognition. Section GG question Q - Does the resident use a wheelchair and/or scooter - Yes. Question R - Wheel 50 feet with two turns: once seated in wheelchair/scooter the ability to wheel at least 50 feet and make two turns indicated resident can do with supervision or touching assistance. Question S - Ability to wheel 150 feet once seated in wheelchair/scooter the ability to wheel at least 150 feet in a corridor or similar place indicated resident can do with supervision or touching assistance. Review of elopement risk evaluation dated 3/2/25, indicated Resident R289 was not at risk for elopement. Review of R289's clinical documentation progress notes indicated the following: - 3/1/25, 11:04 p.m. Resident stated that she was able to walk. Per report, husband stated that she could stand but was non-ambulatory. -3/2/25, at 1:40 a.m. Resident asked earlier when her husband was coming to get her. -3/3/25, at 2:23 a.m. Resident was alert and verbal with confusion, she continued to ask when her husband was coming to get her. Required frequent reminders regarding location and situation. -3/4/25, at 8:30 a.m. Resident was unable to verbalize reason for fall. Stated that she needed to go on down there. -3/4/25, at 1:13 p.m. Resident room changed to 353 B due to resident increase in falls and baseline confusion. -3/10/25, at 5:30 p.m. this nurse was alerted by Physical Therapist (PT) Employee E4 that resident had fallen down emergency exit steps. She was assessed and assisted into her wheelchair and carried up ten stairs with maximum assistance. Orders received and implemented to send her to the emergency room (ER) for further evaluation. -3/10/25, at 9:44 p.m. spoke with ER nurse at local hospital, resident being transferred to a level one trauma center for further evaluation at that time. Review of facility provided witness statements indicated the following: PT Employee E4 indicated she was in the gym charting with the doors closed due to it being the end of the day. She heard some loud thuds and bangs nearby and went to check where the noise came from. She looked through the window to the stairwell by the gym and saw Resident R289 lying down the stairs on the landing on her right side with her wheelchair down by her feet. PT Employee E4 ran to get a nurse. Licensed Practical Nurse (LPN) Employee E5 indicated she was alerted by PT that a resident fell down the stairs in her wheelchair. Found resident lying at the bottom of stairs in stairwell. Resident was out of her wheelchair lying on her right side. A little diaphoretic (sweaty) and somewhat incoherent. EMS (emergency medical services) called. Nurse Aide (NA) Employee E6 indicated at 5:20 p.m. she was passing trays and noticed Resident R289 was not by the nurse's station where she was a few minutes prior. The alarm was going off so she and NA Employee E7 started checking doors, arrived at the Pub's door and resident was in stairwell with the nurses. NA Employee E7 indicated at the end of passing the second cart they heard an alarm go off and she and NA Employee E6 went to stair wells and didn't see anyone. A nurse was putting food in the fridge over in the cafe end of the floor and stated Resident R289 fell down the steps. During a telephonic interview on 3/17/25, at 1:51 p.m. PT Employee E4 indicated I heard a bunch of noise. I was in the therapy room with the door shut. It was around dinner time and the aides were passing trays. Something was crashing or falling nearby, I looked for where the noise was and there was a glass window I glanced down because there was nothing in hall. Resident R289 was on the landing on the floor below. She was on the landing, fell down ten steps and the wheelchair was with her. I ran to get a nurse. The first noise I heard was a banging crash, the first nurse I grabbed (LPN Employee E5) ran with me and stayed with the resident. She was not her nurse, so I ran a second time to get the patients nurse (Registered Nurse, RN Employee E8). The wheelchair was on its side on top of her legs, she was on her side on the landing and the wheelchair was on its side. I've seen Resident R289 in the lobby area, I did work with her for physical therapy. I saw her that day and she was due for a report. I reviewed her goals, resident stated I'm glad I'm making progress because I want to go. Telephonic interview attempted with LPN Employee E5 on 3/21/25, at 11:52 a.m. unsuccessfully and voice mail was full. During an interview on 3/18/25, at 9:42 a.m. NA Employee E6 indicated Resident R289 said she wanted to go home. She's been saying that ever since she got here. She did not have a wanderguard. At the time we were picking up a second food cart and Resident R289 was out front at the desk. I was taking the cart back around the corner and Resident R289 said I want to go home. I told her let's eat dinner first and then we'll talk about it. When I came back Resident R289 was gone. At that time, I didn't tell the nurse because she wasn't in the hallway then I would have to find her which would take how long. During an interview on 3/18/25, at 11:31 a.m. NA Employee E7 indicated the type of residents they've been bringing in here are more confused residents, and it was dinner time. Resident R289 was saying she wanted to go home the same week she came. Said we were keeping her hostage, and she was saying she wanted to leave. Everyone was noticing Resident R289 was saying that. She was starting to show it in the hallway roaming. Resident R289 was at the nurses desk by her room, but more by the desk. We just got the second cart, and we were passing it. We heard the alarm. I ran to one stairwell and NA Employee E6 ran to the other steps. That's when therapy found her at the other stairway down the steps. During a telephonic interview on 3/17/25, at 2:28 p.m. RN Employee E8 indicated I was passing my meds as RN Supervisor; I think therapy put her in her chair and Resident R289 was asking about dinner to some staff. I said what's wrong, Ms. Resident R289 She said I'm not talking to you. The therapist came to get me and said she fell down the steps. I went straight to the stairwell. I saw her lying down ten steps on the landing with her wheelchair. There were other nurses there when I arrived. Resident was laying on her side/belly and she was alert. I did text the Assistant Director of Nursing (ADON) Employee E9 because one of the aides expressed concern for her needing a wander guard. Before I knew it, she was at the bottom of the steps, maybe within ten minutes of me texting the ADON. During an interview on 3/17/25, at 12:22 p.m. Assistant Director of Nursing (ADON) Employee E9 indicated RN Employee E8 called me ten minutes prior to the incident asking where the wander guards were kept because Resident R289 was acting agitated and asking about the elevators which was new for her. RN Employee E8 called me back about ten minutes later and stated Resident R289 went to the Pub, opened the door in her wheelchair. The magnetic lock has a fire safety mechanism that if pushed on long enough will open up as a fire safety rule. Someone in therapy heard a noise and found Resident R289 at bottom of stairs. During an interview on 3/18/25, at 1:55 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that Resident R289 was in the hallway, pressed the doorway to release the fire alarm on the doorway, wheeled self through doorway and went down the stairs in her wheelchair and the facility failed to identify elopement risk behaviors timely. The DON and NHA were made aware that an Immediate Jeopardy situation existed for residents on 3/18/25, at 1:55 p.m. and an immediate action plan was requested. On 3/18/25, at 1:55 p.m. the Immediate Jeopardy template was provided to the facility administration. On 3/18/25, at 4:32 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R79 was returned safely to her room by staff and assessed by RN. No injuries observed and no pain voiced by resident. Elopement risk evaluation updated, and care plan updated to include resident preferences and any triggers for exit seeking behavior. Care plan also updated to include remaining safe on my unit and free of elopements through next review. Cited Resident R289 dated 3/10/25 is no longer in facility and no longer expected to return. Family collected personal belongings. Root cause analysis identified as staff did not report exit seeking behavior timely and facility failed to provide appropriate supervision. Residents: All residents will have updated elopement risk evaluations completed by DON or designee by 3/19/25. Care plan interventions for residents identified for elopement risk will be implemented by ensuring staff are provided with person centered interventions. This will be completed by DON or designee by 3/19/25. Care plan goals for residents who are identified for elopement risk updated to include remaining safe on the unit through staff supervision and free of elopements through next review. This will be completed by DON or designee by 3/19/25. System Correction: Whole house education on elopement risks and assessments, supervision, and care plans of residents. This education includes agency staff and staff will be educated prior to their next scheduled shift. This will be completed by NHA or designee by 3/20/25. Review and update the elopement policy as needed by end of day 3/19/25. Monitoring: Audits of new exit seeking behaviors will be conducted by DON or designee daily x 2 weeks, weekly x 2 weeks, then monthly x 2 months to ensure evaluations and care plans are up to date. Findings of audits will include updated elopement evaluations and care plan goals/interventions. Ongoing results will be submitted to QA. Immediate Jeopardy was lifted on 3/19/15, at 1:53 p.m. and the abatement plan was verified as follows: -88/88 Residents were assessed for risk of elopement on 3/18/25. Two residents were newly admitted after IJ was called and the facility completed an elopement assessment. The residents were not identified as a risk. Total of 90/90 residents were assessed for elopement risk. -12/12 Residents identified as an elopement risk through assessment. 12/12 Resident care plans were updated on 3/18/25, with interventions to prevent elopement, including supervision of the resident. Review of assessments identified one resident was newly identified as an elopement risk from entrance. The resident was added to elopement binders. -12/12 Resident care plan goals were updated to I will remain safe on the unit through staff supervision and free of elopements through next review. -106/138 in-house staff were educated on elopement risks and assessments, supervision, and care plans of residents. The facility utilizes two agency companies. 24/24 agency staff were educated. 36/36 in-person interviews were completed and confirmed staff were educated. 7/7 telephonic interviews conducted revealed staff received education. Staff were educated on the importance of supervision of residents, exit-seeking behaviors as well as when to reevaluate residents for an elopement risk. All staff must verify education prior to the start of their next shift. -Elopement and Wandering Residents policy was reviewed and revised on 3/18/25. It was indicated care plan goals will include remaining free of elopements by supervision. Adequate supervision will be provided to help prevent accidents or elopements. -An audit of residents with newly identified exit seeking behaviors was completed on 3/18/25, and 3/19/25. No residents were observed with exit seeking behaviors. -The facility's next scheduled QA meeting is 3/26/25. During an exit interview on 3/21/25, at 2:45 p.m. information was disseminated to the Director of Nursing (DON), Nursing Home Administrator (NHA), and the Corporate [NAME] President of Operations Employee E26 that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk, failed to re-evaluate residents for elopement risk, which resulted in an elopement for two of eleven residents (Residents R79 and R289) and transfer to a local hospital, then to a level one trauma center for one of eleven residents (Resident R289) and this failure created in an immediate jeopardy situation potentially placing residents at risk of harm or injury for two of 11 residents (Resident R79 and R289). 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to document the appropriate assistance level and failed to provide appropriate assistance for one of three residents (Resident R1), to prevent an avoidable fall for one of three residents reviewed (Resident R1) resulting in actual harm of a skin tear (a traumatic wound caused by blunt force, friction, and shear). Findings include: Review of the Certified Nursing Assistant job description indicated that responsibilities include to assist resident with or performs activities of daily living for resident in accordance with care plans and establishes policies and procedure. Assist resident with lifting, turning moving, positioning, and transporting into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 6/28/24, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), anemia (too little iron in the body causing fatigue), and muscle weakness. Review of the MDS dated [DATE], revealed that during the lookback assessment prior (6/26/24- 6/28/24) Resident R1 was documented by staff to have been Dependent on staff to roll left and right, meaning that the help does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident R1's plan of care, as of 7/22/24, indicated Resident R1 had potential for falls due to weakness/debility, and paired mobility and that Resident R1 will remain free from serious injury from falls. Interventions included to assess activity tolerance level. Allow adequate time to complete tasks. Schedule activities to allow for rest periods. Keep room well-lit and clutter free. Review of Resident R1's plan of care, as of 7/22/24, failed to indicate the assistance level required to perform bed mobility. Review of Resident R1's point of care documentation from 7/1/24 through 7/30/24, revealed Resident R1's assistance level provided while rolling back and forth was documented 50 times, revealing the following: Total Dependence: 40 of 50 times (approximately 80%). Extensive Assistance: 2 of 50 times (approximately 0.04%). Limited Assistance: 5 of 50 times (approximately 10%). Supervision: 3 of 50 (approximately 0.06%). Review of Resident R1's clinical record revealed a progress note dated 8/9/24, at 8:00 a.m. that stated, Called to unit for resident assessment and assistance. Found resident on the floor to the right of bed. Skin tear noted to lateral side of left elbow. Resident assessed and assisted by staff via Hoyer (a mechanical device used to safely lift a person with minimal physical effort) back into bed. Once resident safely situated in bed, skin tear was cleaned, skin rolled back and Steri-Strips (thin bandages to help wounds stay closed while they heal) applied by this RN (registered nurse). Resident tolerated treatment well. Complained of pain at the tear. No other complaints of pain. Vitals were taken by team nurse. Resident administered Tylenol (a mild pain reliever) by team nurse according to order and at resident's request. Resident voiced no further complaints. Staff continued to monitor. Review of Resident R1's clinical record revealed a progress note dated 8/9/24, at 6:07 p.m. that stated, IDT (interdisciplinary team) review of the incident that occurred at 5:30 a.m. on 8/9/24. Witnessed fall, RN was alerted by staff that resident had slid out of bed while providing care. Upon entering the room resident was on the floor in a supine position (lying horizontally with the face and torso facing up). A skin assessment was done and noted that the resident obtained a skin tear to the left elbow. The area was cleansed with NSS (normal saline solution- a mixture of water and salt) and the skin was rolled back intact to close the area with steri strips and dry dressing applied. Vital signs are stable and no complaints of pain or discomfort. The resident is currently in a bariatric bed (a larger bed designed for people who are a larger size) provided by Hospice. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) were aware, treatment orders were obtained, and the care plan was updated with the intervention of 2 people for all care, transfers, and bed mobility. Hospice was contacted and informed, and nursing requested a perimeter mattress for the resident, which was ordered. POA agrees with plan of care. Review of a statement written by Nurse Aide (NA) Employee E1 dated 8/9/24, stated, I was giving care to resident (Resident R1). As I rolled her on her on her right side, the sheet and pad shifted as I rolled her, and resident slid out of bed on her back and bumped her arm as she slid. Review of a statement written by Licensed Practical Nurse Employee E2 dated 8/9/24, stated, This writer was alerted by nurse aide she was freshening resident when resident slid out of the bed to the floor. Upon entering room resident was witnessed laying on her back on the floor on the right side of her bed. Resident was noted to have bleeding from left elbow. During an interview on 8/13/24, at 2:10 p.m. NA Employee E3 stated that how a resident should be transferred or rolled in bed is located, In the Kardex (a snapshot of a resident's care needs) in the computer. When NA Employee E3 was asked what dependent means, she replied. That means you need two people. During an interview on 8/13/24, at 2:22 p.m. NA Employee E4 stated that transfer information is in the Kardex and that if she saw someone was listed as dependent I would get somebody to help me. During an interview on 8/13/24, at 2:28 p.m. RN Employee E5 stated Dependent means you use two people. During an interview on 8/13/24, at 4:48 p.m. NA Employee E6 stated that transfer information Is in the Kardex, and dependent means use two people. She (Resident R1) needs two people. During an interview on 8/13/24, at 5:05 p.m. the Nursing Home Administrator confirmed that NA Employee E1 did not have the assistance of an additional employee to assist with Resident R1's care, and the facility failed to document the appropriate assistance level Resident R1 required for bed mobility in her care plan and Kardex and failed to provide appropriate assistance to prevent an avoidable fall for one of three residents as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to provide goods and services resulting in neglect for one of three residents reviewed (Resident R1), which resulted in an avoidable fall resulting in actual harm causing a skin tear (traumatic wound caused by blunt force, friction, and shear) for one of three residents (Resident R1), and failed to identify Resident R1's concerns as neglect to prevent future incidents. Findings include: The facility's policy Abuse, Neglect and Exploitation dated 5/31/24, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse, neglect and exploitation include but are not limited to, failure to provide care needs such as feeding, bathing, dressing, turning and positioning. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 6/28/24, indicated diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior), anemia (too little iron in the body causing fatigue), and muscle weakness. Review of the MDS dated [DATE], revealed that during the lookback assessment prior (6/26/24- 6/28/24) Resident R1 was documented by staff to have been Dependent on staff to roll left and right, meaning that the help does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident R1's plan of care, as of 7/22/24, indicated Resident R1 had potential for falls due to weakness/debility, and paired mobility and that Resident R1 will remain free from serious injury from falls. Interventions included to assess activity tolerance level. Allow adequate time to complete tasks. Schedule activities to allow for rest periods. Keep room well-lit and clutter free Review of Resident R1's plan of care, as of 7/22/24, failed to indicate the assistance level required to perform bed mobility. Review of Resident R1's point of care documentation from 7/1/24 through 7/30/24, revealed Resident R1's assistance level provided while rolling back and forth was documented 50 times, revealing the following: Total Dependence: 40 of 50 times (approximately 80%). Extensive Assistance: 2 of 50 times (approximately 0.04%). Limited Assistance: 5 of 50 times (approximately 10%). Supervision : 3 of 50 (approximately 0.06%). Review of Resident R1's clinical record revealed a progress note dated 8/9/24, at 8:00 a.m. that stated, Called to unit for resident assessment and assistance. Found resident on the floor to the right of bed. Skin tear noted to lateral side of left elbow .Resident assessed and assisted by staff via Hoyer (a mechanical device used to safely lift a person with minimal physical effort) back into bed. Once resident safely situated in bed, skin tear was cleaned, skin rolled back and Steri-Strips (thin bandages to help wounds stay closed while they heal) applied by this RN (registered nurse). Resident tolerated treatment well. Complained of pain at the tear. No other complaints of pain. Vitals were taken by team nurse. Resident administered Tylenol (a mild pain reliever) by team nurse according to order and at resident's request. Resident voiced no further complaints. Staff continued to monitor. Review of Resident R1's clinical record revealed a progress note dated 8/9/24, at 6:07 p.m. that stated, IDT (interdisciplinary team) review of the incident that occurred at 5:30 a.m. on 08/09/24. Witnessed fall, RN was alerted by staff that resident had slid out of bed while providing care. Upon entering the room resident was on the floor in a supine position (lying horizontally with the face and torso facing up), A skin assessment was done, and noted that the resident obtained a skin tear to the left elbow. The area was cleansed with NSS (normal saline solution- a mixture of water and salt) and the skin was rolled back intact to close the area with steri strips and dry dressing applied. Vital signs are stable and no complaints of pain or discomfort. The resident is currently in a bariatric bed (a larger bed designed for people who are a larger size) provided by hospice. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) were aware, treatment orders were obtained and the care plan was updated with the intervention of 2 people for all care, transfers, and bed mobility. Hospice was contacted and informed, and nursing requested a perimeter mattress for the resident, which was ordered. POA agrees with plan of care Review of a statement written by Nurse Aide (NA) Employee E1 dated 8/9/24, stated, I was giving care to resident (Resident R1). As I rolled her on her on her right side, the sheet and pad shifted as I rolled her and resident slid out of bed on her back and bumped her arm as she slid. Review of a statement written by Licensed Practical Nurse Employee E2 dated 8/9/24, stated, This writer was alerted by nurse aide she was freshening resident when resident slid out of the bed to the floor. Upon entering room resident was witnessed laying on her back on the floor on the right side of her bed. Resident was noted to have bleeding from left elbow. During an interview on 8/13/24, at 2:10 p.m. NA Employee E3 stated that how a resident should be transferred or rolled in bed is located In the Kardex (a snapshot of a resident's care needs) in the computer. When NA Employee E3 was asked what dependent means, she replied. That means you need two people. During an interview on 8/13/24, at 2:22 p.m. NA Employee E4 stated that transfer information is in the Kardex and that if she saw someone was listed as dependent I would get somebody to help me. During an interview on 8/13/24, at 2:28 p.m. RN Employee E5 stated Dependent means you use two people. During an interview on 8/13/24, at 4:48 PM NA Employee E6 stated that transfer information Is in the Kardex, and dependent means use two people. She (Resident R1) needs two people. During an interview on 8/13/24, at 5:05 p.m. the Nursing Home Administrator confirmed that the facility failed to provide goods and services resulting in neglect for one of three residents reviewed (Resident R1), which resulted in an avoidable fall resulting in actual harm for one of three residents (Resident R1), and failed to identify Resident R1's concerns as neglect to prevent future incidents. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.8 (b)(1) Management. 28 Pa. Code 201.29 (4) Resident rights.

Based on a review of facility policies, facility documents, observations, staff interviews, and resident interviews, it was determined that the facility failed to properly label and date food items, and utilize beard restraints in the Main Kitchen, failed to properly date food items on two of two nursing floor pantries (Third and Fourth Floor), and failed to comply with food safety regulations by serving undercooked, unpasteurized eggs creating the potential for food borne illness. This failure created an immediate jeopardy situation for four of 108 residents who consumed these eggs (Residents R40, R65, R70 and R73). Findings include: Review if facility policy Date Marking for Food Safety, dated 10/23/23, indicated that food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Review of the facility policy Use and Storage of Food Brought in by Family or Visitors, dated 10/23/23, indicated that food items brought in from family or visitors must be labeled with content and date. Review of facility policy Food Safety Requirements, dated 10/23/23, indicated that dietary staff must wear hair restraints, (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. It also indicated that foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current FDA (Food and Drug Administration) Food Code and facility policy for food temperatures as needed. Review of FDA Food Code, dated 3/7/22, indicated that establishments that serve elderly persons such as nursing homes, should take precautions due to factors such as age, medications, compromised immune systems, and various health conditions, as they are especially vulnerable to foodborne illness. In NO case should soft-cooked eggs, that are made from raw eggs or other foods containing raw or undercooked eggs be served in these facilities. Accept egg products only if pasteurized. During an observation on 12/11/23, at 10:10 a.m., in the Main Kitchen Pantry, the following items were noted to be opened and did not have a label with a date: macaroni, sandwich crackers, hot chocolate, pancake mix, and cookies. During an interview on 12/11/23, at 10:25 a.m. Acting Food Service Director Employee E22 confirmed that the facility failed to properly label and date food items to prevent foodborne illness. During an observation on 12/12/23, at 12:20 p.m., Cook Employee E23 was noted to be on the lunch tray line without a beard restraint, and had a beard that extended greater than one inch below his chin. During an interview on 12/12/23, at 12:20 p.m., Cook Employee E23 confirmed that the facility failed to utilize beard restraints to prevent hair from contacting food. During an observation on 12/13/23, at 9:30 a.m. a plate covered with plastic wrap was on the counter of the Third-floor Nurses' Station waiting to be delivered to a resident, that contained two eggs with yolk seeping out. During a tour of the kitchen on 12/13/23, at 9:35 a.m., shell eggs were noted to be sitting on the counter, not in the original box. The cook was not in the department, and dietary staff advised that he was out of the building and would be back soon. Further tour of the department did not reveal any original container in which the eggs would have been stored. During an additional tour of the kitchen on 12/13/23, at 10:20 a.m., Cook Employee E23 was in the kitchen in the food prep area where the eggs were sitting on the counter. During an interview on 12/13/23, at 10:20 a.m. Cook Employee E23 confirmed that no Certified Dietary Manager (CDM) was employed at the facility, and that the eggs on the counter were used to make the eggs that were served to residents that had contained an undercooked yolk. Cook Employee E23 stated that they used to use pre-made eggs that had a cooked yolk, however the residents did not care for them as they preferred a runny yolk. When Cook Employee E23 was asked where the original packaging for the eggs was located, it was stated that it was already thrown out into the dumpster, however he would be able to pull up information on the eggs in the facility's computerized food ordering system. Review of facility documents on 12/13/23, at 10:21 a.m. revealed that the eggs that were used were not pasteurized to prevent foodborne illness. When Cook Employee E23 shared the documentation, he asked Is this the right kind? During an interview on 12/13/23 at 10:21 a.m., Cook Employee E23 confirmed that the facility failed to prevent foodborne illness by serving unpasteurized, undercooked eggs to residents. During an interview on 12/13/23, at 10:25 a.m., Nursing Home Administrator (NHA) was informed that undercooked, unpasteurized eggs were served to residents which had the potential to create foodborne illness. At this time a list of residents who received these eggs was requested. Review of facility documents revealed that four residents had received undercooked, unpasteurized eggs. They are as follows: Review of the clinical record revealed that Resident R40 was admitted to the facility on [DATE]. Review of Resident 40's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/9/23, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), and age-related physical debility. Review of the clinical record revealed that Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of multiple sclerosis (a disease that affects central nervous system), Squamous cell carcinoma (a type of cancer that starts as a growth of cells on the skin) of the scalp and neck, and muscle weakness. Review of the clinical record revealed that Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), malnutrition (lack of proper nutrition), and noninfective gastroenteritis (inflammation of the stomach and intestine that can cause nausea, vomiting, diarrhea and cramping). Review of clinical record revealed that Resident R73 was admitted to the facility on [DATE]. Review of Resident R73's MDS dated [DATE], indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), chronic respiratory failure (when not enough oxygen travels from the lungs into the blood). On 12/13/23, at 4:02 p.m., the NHA was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for four of 108 residents, who were at risk for food borne illness after being served undercooked, non-pasteurized eggs, and other residents who may have received these eggs in the past, and a corrective action plan was requested. On 12/13/23, at 6:52 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Unpasteurized eggs were immediately disposed. Residents: Four residents were identified who received unpasteurized, undercooked eggs and were assessed by Registered Nurse on 12/13/23. Residents' families and physicians were notified of having received unpasteurized, undercooked eggs and potential for foodborne illness on 12/13/23. Residents' care plans updated on 12/13/23 for monitoring of signs and symptoms of foodborne illness for seven days. System Correction: Food safety education conducted for all kitchen staff including Registered Dietitian (RD), and Regional Certified Dietary Manager (CDM), prior to the start of their next shift. Educate RD and Regional CDM on requirement for monitoring of daily kitchen operations. Conduct daily kitchen monitoring by RD, or Regional CDM. Regional float RD to assist with clinical needs as needed. Block the facility's ability to order unpasteurized eggs from computerized food ordering system. Educate all nurses prior to the start of their next shift on monitoring resident for signs and symptoms of foodborne illness and to monitor the above four residents. Monitoring: Audits of food handling and safety to prevent foodborne illness will be conducted by RD or designee daily for two weeks. Audits will then be conducted weekly for two weeks. Audits will then be conducted monthly for two months. Ongoing results will be submitted to Quality Assurance and Process Improvements Team. During a review of clinical records on 12/14/23, the above four residents had documentation that supported that doctors and families were notified of the incident, and that care plans included information to obtain vital signs and monitor for symptoms of foodborne illness for seven days. Review of the clinical record indicated that monitoring was completed as ordered. Review of facility documents on 12/14/23, revealed that 35 out of 37 licensed nurses had received education on monitoring residents for signs of symptoms of foodborne illness, and 15 out of 17 dietary employees had received education on food safety and prevention of foodborne illness. During employee interviews on 12/14/23, from 9:40 a.m. through 2:00 p.m. 20 licensed nurses confirmed that they had received education of monitoring residents for signs and symptoms of foodborne illness. 12 of these employees had received education in person, seven had received education over the phone, and one had received education via email. Those who received education over the phone or email confirmed that they will be signing the training sheet once they are in the building. Four dietary employees confirmed that they received food safety education in person, and one confirmed that they received education over the phone and will be signing the training sheet once they are in the building. This is a total of 25 employees who verified that education was received. Review of facility documents revealed that daily monitoring of the kitchen for food safety was conducted by RD Employee E25 or Regional CDM Employee E24 and signed off by NHA. This documentation also included verification that no unpasteurized eggs were present in the kitchen. Review of documentation signed by RD Employee E25 revealed that the above mentioned four residents were the only resident who had received the undercooked, unpasteurized eggs. Review of facility documents verified that unpasteurized eggs have been blocked from the facility's computerized food ordering system and can no longer be ordered, and that previous orders did not contain unpasteurized eggs. The Immediate Jeopardy was lifted on 12/14/23, at 2:31 p.m., when the action plan implementation was verified. During an interview on 12/14/23, at 2:32 p.m., the NHA confirmed that the facility failed to comply with food safety regulations by serving undercooked, unpasteurized eggs creating the potential for foodborne illness. During an interview on 12/14/23, at 2:45 p.m. Resident R73 confirmed that she had received undercooked eggs on 12/13/23 and stated, I've been getting 'dippy' eggs here since last November. Resident R73 confirmed that she was being monitored by staff for signs and symptoms of foodborne illness. During an interview on 12/14/23, at 2:48 p.m. Resident R40 also confirmed that she had consumed undercooked eggs on 12/13/23, and that she has been getting them twice per week for the past year. During an observation on 12/15/23, at 9:38 a.m. in the Third-Floor Pantry, a Styrofoam container that contained fruit cocktail did not have a label with a date. A plastic bag containing yogurt, pudding and fruit cocktail did not contain a label with a date. A plastic bowl of cereal in the cupboard did not have a label with a date. During an interview on 12/15/23, at 9:42 a.m., Licensed Practical Nurse (LPN) Employee E9 confirmed that the facility failed to properly label/date the above food items to prevent foodborne illness. During an observation on 12/15/23, at 10:23 a.m. in the Fourth Floor Pantry, four plastic bowls of cereal were in the cupboard without a label or date. During an observation on 12/15/23, at 10:25 a.m. in the Fourth Floor Nurses Station, the snack cart was located and contained seven cookies on Styrofoam plates that were wrapped in plastic wrap and did not have a label with a date. During an interview on 12/15/23, at 10:25 a.m., LPN Employee E9 confirmed that the facility failed to properly label and date the above items on the Fourth floor to prevent foodborne illness. During an interview on 12/18/23, at 11:55 a.m. Regional CDM Employee E24 confirmed that the facility failed to properly label and date food items, utilize beard restraints, and failed to comply with food safety regulations by serving undercooked non-pasteurized eggs creating the potential for food borne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services.

Based on a review of facility policy, closed resident clinical record, staff interviews, and physician interview, it was determined the facility failed to ensure staff initiated CPR (cardiopulmonary resuscitation - a life saving procedure that is done when breathing or the heartbeat has stopped) to an unresponsive resident resulting in an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) for one of 70 residents reviewed, Closed Record Resident R1 (CR1). Findings included: Review of facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation last reviewed [DATE], informed Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation (controlled electric shock to restore normal heart rhythm), for victims of sudden cardiac arrest. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis [stiffening of joints and muscles of a body a few hours after death]). If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Continue with CPR/BLS until emergency medical personnel arrive. Review of CR1's clinical recorded revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (reduced blood flow to the limbs), dysphagia (difficulty in swallowing food and liquids), hypoglycemia (deficiency of glucose/sugar in the bloodstream) , diabetes (the body's inability to produce or control the hormone insulin resulting in elevated levels of glucose in the blood and urine), end stage renal disease (temporary or permanent damage to the kidneys resulting in loss of normal kidney function), and acquired absence of left leg below the knee (left leg amputation below the knee). Review of CR1's current physician orders dated [DATE], included the resident's code status as CPR, full treatment, use antibiotics, long term intravenous fluids and tube feeding effective [DATE]. Review of CR1's clinical record revealed a POLST (Physician's Order for Life Sustaining Treatment-a medical order specifying the type of medical treatment a person wants in the event of a serious illness) dated [DATE], that indicated the resident wanted CPR initiated with full treatment (CPR, Full Code) to include antibiotics, airway interventions, antibiotics, long term artificial nutrition and hydration. The POLST included the resident's signature. Review of CR1's Minimum Data Set (MDS-periodic assessment of care needs) dated [DATE], indicated a Brief Inventory for Mental Status (BIMS- a screening tool used to determine cognition) score of 15, indicating the resident had no cognitive impairment. Review of CR1's care plan initiated [DATE], included the resident had the potential for alteration in cardiovascular status related to arteriosclerotic heart disease (thickening and hardening of the coronary arteries), coronary artery disease (build up of plaque in the coronary arteries), chronic kideny disease and renal failure. Interventions included to monitor and document for signs and symptoms of cardiac complications: altered mental status, altered level of consciousness, pallor (pale looking), diaphoresis (excessive and abnormal sweating), nausea and vomiting, and to notify the physician for further interventions. Review of CR1's progress notes documented the following: [DATE], at 4:05 a.m. - Resident is nauseated, vomiting, and dry heaving and unable to take anything by PO (by mouth) at this time. [DATE], at 4:06 a.m. - Resident refused dialysis today as they are nauseated, vomiting and dry heaving. [DATE], at 12:36 p.m. - Resident refused PO medications due to nausea. [DATE], at 2:00 p.m. - Resident was administered Zofran Oral Tablet 4 mg for nausea. [DATE], at 10:06 p.m. - Resident in bed all day. Refused dialysis due to nausea. Refused breakfast, lunch, did agree to try clear liquids at dinner, took in hot tea, gingerale, and a few bites of Jello. Physician was contacted due to ongoing nausea, new order for Zofran, adminstered at 2:00 p.m. Re- fused medications throughout day. Complained at 7:00 p.m. of generally not feeling well, achiness all over, feeling hot, sweating, moaning and calling out several times, holding basin due to nausea. Vital signs included blood sugar at 284 (elevated), temperature 97.3 (normal) degrees, pulse 88 beats per minute, respirations 20 breaths per minute, 95% oxygen level, and blood pressure ,d+[DATE] (low). Call placed to physician at 7:20 p.m. and updated on complaints and vital signs, advised to administer Percocet for pain and re- assess. Percocet not on hand to administer, offered Tylenol with resident replying maybe in a little while. Offered Tylenol and cold water at 7:45 p.m. and declined. Entered room at 8:15 p.m. to re-assess resident and was noted to be slumped over to the left side in bed. Extensive mottling (a blotchy red- purplish marbling of the skin occuring when the heart is no longer able to pump blood effectively) noted to entire body, no spontaneous pulse or respirations noted. Per POLST, CPR, Full Treatment. Physician contacted and updated that resident was beyond means of resuscitation and advised to not initiate CPR. Time of death was 8:17 p.m. During an interview on [DATE], at 2:22 p.m. Registered Nurse Employee E1 reported working the 7:00 a.m. to 7:00 p.m. shift on [DATE]. The previous shift relayed that CR1 refused dialysis. The resident reported feeling tired, did not eat or drink. Zofran was administered and the resident had clear liquids. At about 7:00 p.m. the resident felt hot, and the resident's blood sugar was on the lower side. The physician was contacted and requested a pain medication be administered. At 8:15 p.m. Registered Nurse Employee E1 reported finding CR1 slumped over in their bed and found the resident to not be breathing, had no pulse, and was extensively mottled. The nurse left the resident to check the code status and found the resident to be CPR, Full Code. CPR was not initiated. Registered Nurse Employee E1 then called the physician at 8:17 p.m., relayed the observations of the resident, and was instructed to not initiate CPR. Registered Nurse Employee E1 reported Registered Nurse Employee E2, Nursing Assistant Employee E3, Nursing Assistant Employee E4, and Nursing Assistant Employee E6 were also on the unit. Registered Nurse Employee E1 reported Registered Nurse Employee E2 was tied up passing medications and Registered Nurse Employee E1 did not give any instructions to assist as it would have taken more time to explain to registered Nurse Employee E2 on what to do. Registered Nurse Employee E1 reported that the Nursing Assistants were not in plain site. Registered Nurse Employee E1 also reported having to work past the end of their shift, until about 11:00 p.m. During an interview on [DATE], at 3:05 p.m. Registered Nurse Employee E2 reported working the 3:00 p.m. to 3:00 a.m. shift on [DATE]. The nurse reported another nurse came to report CR1 had ceased to breathe. Registered Nurse Employee E2 reported to be passing medications and was behind in passing medications. Registered Nurse Employee E2 reported Registered Nurse Employee E1 did not request any assistance with CR1 and completed passing medications for a different resident. Registered Nurse Employee E2 then went to CR1's room but did not check the resident for a pulse or respirations, observed mottling, reported the resident's hands were cold, and went back to passing medications to other residents. Registered Nurse Employee E2 also reported three Nursing Assistants were assigned to the unit. On [DATE], at 1:40 p.m., the Nursing Home Administrator was made aware Immediate Jeopardy was called as the facility failed to ensure staff initiated CPR to an unresponsive resident. The Immediate Jeopardy template was provided at that time and a corrective action plan was requested. Attempted phone contact made [DATE], at 3:48 to Nursing Assistant Employee E3. Message left requesting a return call. No response received. During an interview on [DATE], at 3:53 p.m. Nursing Assistant Employee E4 reported beginning their shift at 7:00 p.m. on [DATE]. The Nursing Assistant did not remember any staff person calling out for assistance for an unresponsive resident. On [DATE], at 5:54 p.m. an Immediate Action Plan was accepted with the following actions: Immediate Action: Cited resident R1 was not administered CPR, has passed away and is no longer in the facility. Residents: Whole house audit will be conducted by DON (Director of Nursing) or designee on code status availability in same location in Point Click Care (electronic health record) and code binders on units with POLST/orders/advanced directives to ensure they match. NHA or designee will conduct a 6 month lookback to determine if residents code status/advanced directives were honored. System Correction: Facility policy reviewed. All licensed staff will be re-educated on the need to start CPR timely per AHA (American Heart Association) and facility policy/guidelines. This education will be completed by DON or designee by [DATE] in person and via telephone calls, with any staff not reached receiving the education prior to their next shift. Monitoring: Audits of code status as well as code drills will be conducted by DON or designee of weekly x4 weeks then monthly x3 months to ensure code status is correct and available to staff and that licensed staff are following the AHA and facility policy/guidelines. Ongoing results will be submitted to center Quality Assurance and Performance Improvement committee. During an interview on [DATE], at 10:46 a.m. Physician Employee E5 reported Registered Nurse Employee E1 phoned twice on [DATE], once in the morning as CR1 was not feeling well and refused dialysis, and again in the afternoon as CR1 was nauseated and an order for Zofran was given. Physician Employee E5 reported at approximately 8:00 - 8:15 p.m. Registered Nurse Employee E1 phoned to report CR1 was mottled and unresponsive and did not report the resident had any trauma or rigor mortis. Physician Employee E5 reported CPR should have been initiated and a call to 911 should have been placed. During observations, facility provided documentation, and staff interviews on [DATE], at 3:15 p.m., the whole house audit of resident code status was updated in Point Click Care (facility's electronic medical record), the resident's records and in code binders on the units, the 6 month lookback period to determine if residents code status/advanced directives were honored, audit forms and code drill forms were created and to be implemented on [DATE], were completed, and Quality Assurance and Performance Improvement committee was notified. Policy on Emergency Procedure - Cardiopulmonary Resuscitation was updated to include locations where code status could be found and obvious signs of irreversible death completed. Forty-five percent of the staff were re-educated on the updated facility policy and AHA guidelines on CPR and location of code status for residents. During an interview on [DATE], at 1:30 p.m. Registered Nurse Employee E7 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 1:35 p.m. Registered Nurse Employee E8 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 1:40 p.m. Registered Nurse Employee E9 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 1:45 p.m. Registered Nurse Employee E10 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 2:22 p.m. Registered Nurse Employee E1 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During a telephone interview on [DATE], at 2:24 p.m. Registered Nurse Employee E11 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 3:40 p.m. Registered Nurse Employee E12 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 3:45 p.m. Registered Nurse Employee E13 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. During an interview on [DATE], at 3:50 p.m. Registered Nurse Employee E14 reported training was received on new CPR protocol, locations of code status, DNR (do not resuscitate), and obvious signs of death. On [DATE], at 3:35 p.m. one hundred percent of staff were re-educated on updated facility policy and AHA guidelines on CPR and location of code status for residents. Fourteen of twenty-eight staff confirmed receiving training on resident code status locations, CPR protocol, POLST, and obvious signs of death. On [DATE], at 4:30 p.m. the Nursing Home Administrator was made aware the Immediate Jeopardy was lifted. During an interview on [DATE], at 1:40 p.m., the Nursing Home Administrator confirmed the facility failed to administer CPR to an unresponsive resident which resulted in an Immediate Jeopardy situation for one of 70 residents reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

Based on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in an elopement (elopement occurs when a resident leaves the premises or a safe area without authorization, i.e., an order for discharge or leave of absence and/or any necessary supervision to do so). This failure created an immediate jeopardy situation for 1 of 10 residents (Residents R1). Findings include: Review of facility policy Missing Resident/Elopement Procedures dated 1/26/23, indicated an elopement occurs when a resident leaves a safe area without staff knowledge, or the patient enters an unsafe area without staff knowledge or presence. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. Review of the Admission Record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Annual Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/2/23, indicated the current diagnoses of Vascular Dementia (a group of symptoms that affects memory, thinking and interferes with daily life), major depressive disorder and stroke (damage to the brain from interruption of its blood supply). The resident was assessed as having a BIMS score of 6, which indicated severe cognitive impairment. Review of Elopement/Exit Seeking Evaluation Form dated 2/28/23, indicated that Resident R1 had a score of 17 indicating elopement risk. A resident is at risk for elopement if the total score is 9 points or higher. Review of Resident R1's care plan dated 3/26/23, indicated resident was at risk for elopement/exit-seeking with a goal of remaining safe through next review. Interventions included the following: Anticipate my needs to the extent possible. I will be evaluated on admission and weekly x 3, on a quarterly basis, and with a change of condition. Reassure me when I am distressed. Refer to social services as needed. Use diversional activities when behavior is occurring, i.e., offer companionship, food, activities. Use verbal cues for redirection. Review of Resident R1's physician order dated 2/28/23, indicated wander guard system (equipment to prevent a resident from exiting to an unsupervised and unauthorized location without staff's knowledge) for safety, elopement, and exit-seeking. Check placement and function of wander guard system every eight hours, and to notify supervisor if wander guard is not in place or non-functional. Resident R1's care plan was not updated until 3/26/23, to include an intervention regarding the wander guard system. Review of Resident R1's progress notes dated 2/28/23 - 4/19/23, indicated behaviors as follows: 2/22/23, 9:53 a.m. This RN observed resident attempting to get on the elevator. She had her coat on and her purse and she stated she needed to get to the airport to pick up her daughter. This RN was able to redirect her to her room, and then called and spoke to Resident Family RF1. Obtained verbal consent to apply a wander guard to the resident. 3/5/23, 2:27 p.m. resident having increased confusion, she got out of bed @ 1:00am fully dressed w/her coat looking for her family, she was redirected and has returned to her room. 4/19/23, 1:38 p.m. Patient observed sitting outside on bench in the front of the building. Police made aware and patient assisted back into the building by DON, and three other staff members. Patient cooperative and understands that she is not to go outside without someone being with her. 15-minute checks initiated. Head to toe assessment completed at this time. All vitals within normal limits. Denies pain. Spoke with Resident Family RF2 and Resident Family RF1. During an interview on 4/25/23, at 12:24 p.m. Administrative Assistant Employee E1 indicated she was on the phone when Resident R1 come to the desk, signed herself out as another resident's family member was leaving, approximately 12:45 p.m. on 4/19/23. Administrative Assistant Employee E1 was unaware that Resident R1 was a resident in the facility. During an interview on 4/26/23, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E5 indicated the she last saw Resident R1 before leaving for her break around 12:20 p.m. During an interview on 4/26/23, at 10:45 a.m. Nurse Aide (NA) Employee E7 indicated her assignment was on the other side of the hall and she did not hear the elevator alarm sounding. During an interview on 4/26/23, at 10:52 a.m. Nurse Aide (NA) Employee E9 indicated she was feeding another resident in room [ROOM NUMBER] and did not hear the elevator alarm sound. During an interview on 4/24/23, at 10:24 a.m., the Nursing Home Administrator (NHA) stated That around 12:44 p.m. the resident was observed signing out in the front lobby with another resident's family member. She sat outside on the front bench but refused to come in, so they had to call the police. She stated that the elevators do not lock down when someone enters with a wander guard, they just alarm. Facility is staffing the elevators 24 hours a day until the elevator company can come and give a quote. On 4/26/23, at 2:56 p.m. the NHA was made aware that Immediate Jeopardy (IJ) existed for one of 10 residents (Residents R1). The IJ template was provided to NHA and a corrective action plan was requested. On 4/26/23, at 10:40 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Cited resident R1 from elopement incident dated 4/19/23 was brought back inside within approximately 20 minutes from front of facility safely with no negative outcome from cited incident. Wander alarm did sound, staff responded appropriately with an immediate head count, and it was discovered that R1 was unaccounted for. An immediate search was initiated, and R1 was located outside on a bench. R1 was brought back inside safely with no negative outcome and was placed on Q15 min checks and until elevator monitor was established to monitor all residents. Family and physician notified. Facility put additional measures in place immediately such as locking front door and initiating visitor badges. These were all implemented within 30 minutes of the resident being brought back inside. An ad hoc QAPI committee was convened immediately with these and other measures implemented by the IDT, which also included LOA sign out policy, whole house audit of elopement risks, DON or designee reviewed elopement binders which are available to all staff and located on each unit and at front desk and are available to staff, audits of wander guard orders and care plans, making additions to elevator including code key pads to the elevator system to further lock the elevators in addition to existing wander system. Elevator monitor (staff) in place until work can be completed. Residents: DON/designee conducted whole house update of elopement risks on 4/21/23, DON or designee reviewed elopement binders which are available to all staff and located on each unit and at front desk, completed whole house audits of wander guard orders and care plans, are making additions to elevators including code keypads to the elevator system to further lock the elevators in addition to existing wander system. Elevator monitor in place until work can be completed. Policy updated. Exits were secured and door alarm audits continue. All residents who are identified as exit-seeking by whole house exit-seeking assessment completed on 4/21/23 by DON or designee received updated activity assessment on 4/26/23 to identify routines and hobbies. Front line team members interviewed 4/26/23 to identify possible triggers for elopement for all residents identified as exit-seeking. Care plans updated on 4/26/23 for wander/exit seeking residents to add person-centered interventions (such as enjoying reading, music, sports, etc) to assist with diversion when a resident is experiencing increased exit-seeking behavior, and to include possible triggers (such as putting on coat and purse when they are experiencing increased exit-seeking behavior) and person-centered interventions based on activity assessments when a resident is identified as exit seeking. System correction: Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, front desk staff, social services, and activities from SNF including agency and hospice staff was conducted and completed on 4/22/23 regarding elopement policy, LOA process and policy including residents having sign out and in sheets on the units, residents having appropriate LOA orders and residents/visitors checking in with staff prior to leaving unit, visitor badges to identify residents who may be exit seeking vs visitors. Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, front desk staff, social services, and activities from SNF including agency and hospice staff was conducted and completed on 4/24/23 regarding identifying exit seeking and wandering behaviors, trigger behaviors, and person-centered interventions for wandering/exit-seeking. Education was conducted by DON or designee via in person meetings and phone calls. In-person education was completed Tuesday 4/25/23 for in-house staff and the remaining staff will receive prior to shift. Phone system upgraded to an automated answering system on 4/24/23. Monitoring: Audits of residents who are identified as exit seeking will be completed by DON or designee then continued by RN supervisor to recognize potential signs of elopement/wandering. RN supervisor or designee will continue auditing weekly x 4 weeks then monthly x 3 months. DON or designee will audit new admission/returns and quarterly exit-seeking assessments to ensure care plan with appropriate interventions daily x2 weeks by May 10, 2023, weekly x2 weeks by May 24, 2023, then monthly x2 months by July 24, 2023. Elevator 1:1 monitor will continue until key code pads installed 4/27/23. Ongoing results will be submitted to QAPI. During interviews on 4/25/23, from 11:30 a.m. through 2:00 p.m. 35 employees confirmed they had received education on elopement policy, LOA process and policy including residents having sign out and in sheets on the units, having appropriate LOA orders and residents/visitors checking in with staff prior to leaving unit, visitor badges to identify residents who may be exit seeking vs visitors, regarding identifying exit seeking and wandering behaviors, trigger behaviors, and person-centered interventions for wandering/exit-seeking. The IJ was lifted on 4/28/23 at 10:40 a.m. when the action plan implementation was verified. During an interview on 4/28/23 at 11:30 a.m. the NHA confirmed the facility failed to provide adequate supervision for one resident resulting in elopement (Resident R1). This failure created an immediate jeopardy situation for one of 10 residents (Residents R1). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code: 201.29(a)(b)(c)(I)(n) Resident rights. 28 Pa. Code 201.18(b)(1) Management.

Based on facility policy review, clinical and facility record review, facility provided documents, hospital records, and staff interviews, it was determined that the facility failed to provide adequate supervision for two residents resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for 10 of 10 residents (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10 and R11) and allowing two of those residents to elope from the 4th floor (Resident R1 and R2). Findings include: Review of facility policy Missing Resident/Elopement Procedures dated 1/26/23, indicated an elopement occurs when a resident leaves a safe area without staff knowledge, or the patient enters an unsafe area without staff knowledge or presence. Review of facility's Wander guard monitoring system test tool dated March 2023, indicated initial every A.M. and P.M. that system is functioning. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the Admission Record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/23, indicated the diagnoses of Alzheimer's Dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Legal Blindness (no vision or sees only light, colors or shapes; eyes do not appear to follow objects), and diabetes (too much sugar in the blood). Section C: Cognitive Patterns, Question C0100 indicated a BIMS score of 3 - severe cognitive impairment. Section D: Mood, Question D0200 indicated resident had feelings of being down, depressed, or hopeless, feeling tired or having little energy, and poor appetite or overeating. Section E: Behavior, Question E0900 Wandering indicated a score of zero, which indicated the behavior was not exhibited. Review of Elopement/Exit Seeking Evaluation Form dated 11/10/22, indicated that Resident R1 had eight of 14 total factors/contributors indicating elopement risk. Review of the clinical record on 3/28/23, failed to include a more recent Elopement/Exit-Seeking Evaluation Form. Review of Resident R1's care plan dated 11/3/22, indicated resident was at risk for elopement/exit-seeking with a goal of remaining safe through next review. Interventions included the following: Anticipate my needs to the extent possible. I will be evaluated on admission and weekly x 3, on a quarterly basis, and with a change of condition. Reassure me when I am distressed. Refer to social services as needed. Use diversional activities when behavior is occurring, i.e. offer companionship, food, activities. Use verbal cues for redirection. Review of Resident R1's physician order dated 11/7/22, indicated wander guard system (equipment to prevent a resident from exiting to an unsupervised and unauthorized location without staff's knowledge) for safety, elopement, and exit-seeking. Check placement and function of wander guard system every eight hours, and to notify supervisor if wander guard is not in place or non-functional. Resident R1's care plan failed to include an intervention regarding the wander guard system. Review of Resident R1's progress notes dated 2/22/23 - 3/18/23, indicated behaviors as follows: 2/22/23 - Resident sitting in hallway talking to himself, states I'm the X-ray technician and I'm here to fix the x-ray machine. 2/23/23 - Resident found on floor in neighboring resident room. 2/24/23 - Physician Employee E1's Progress note references hallucinations (a perception of having seen heard touched, tasted, or smelled something that wasn't actually there) and an increase in falls the past few weeks. 2/27/23 - Haldol (medication to treat mental disorders) ordered to be given at bedtime related to agitation and behaviors; however, did not describe the agitation or behaviors exhibited. 3/16/23 - at 11:54 p.m. Resident restless, ambulating the unit, talking about a dog, escorted to his room by staff who attempted to cover him up with a blanket, resident became agitated, stated staff was insubordinate, that he was the boss, and this was his boat. Resident was found on floor ten minutes later. 3/16/23 - at 2:58 p.m. alert with confusion 3/16/23 - at 9:54 p.m. alert with confusion 3/18/23 - 1:28 p.m. Late entry: resident noted to be in the basement. Staff member from 3rd floor assisted resident to transfer back to the 4th floor where his room is located. Review of facility provided documents, dated 3/23/23, indicated that on 3/18/23, at 1:30 p.m. Nursing Assistant (NA) Employee E2 reported I was approached in the basement and asked if I knew where Resident R1 belonged, as Resident R1 could not recall. NA Employee E2 returned Resident R1 to unit on the fourth floor. Interview on 3/28/23, at 2:00 p.m. NA Employee E2 indicated Somebody approached me on my way back from break in the basement coming to the elevator and said I think he (Resident R1) is lost. NA Employee E2 indicated I knew who it was and took Resident R1 to the fourth floor. He can see some, I guided him. When we got on the elevator in the basement the wander guard activated. I have no idea how Resident R1 got down there. Interview on 3/30/23, at 2:45 p.m. Regional Director of Operations (RDO) Employee E3 indicated the last staff member to last see Resident R1 was NA Employee E4, on the unit shortly after finishing lunch around 1:00 p.m. Telephone interview on 3/30/23, at 2:50 p.m. with NA Employee E4 unsuccessful, a voice message was left and never returned. Review of written statement from NA Employee E5 dated 3/25/23, indicated they did not hear or disable the alarm on 3/18/23 in relation to Resident R1. Review of written statement from NA Employee E6 undated, indicated they did not disable the wander guard system on the elevator on the 11:00 a.m. - 3:00 p.m. shift on 3/18/23. Review of written statement from NA Employee E7 dated 3/18/23, indicated they did not shut wander guard off in the main elevator on 3/18/23 during the daylight shift. Review of written statement from NA Employee E8 undated, indicated on 3/18/23, on the daylight shift they did not disable the wander guard alarm by the elevator. Review of written statement from NA Employee E9 dated 3/24/23, indicated while working the daylight shift on 3/18/23, they did not shut off the wander guard alarm on the main elevator. Review of written statement from NA Employee E10 dated 3/24/23, indicated they did not hear the alarm go off. They were on break after lunch trays and when they gave care to Resident R1 they didn't see any marks on him. During an observation and interview on 3/28/23, at 10:20 a.m., the Nursing Home Administrator (NHA) stated The vendor was out and discovered the sensitivity of the range was not far enough to reach the lateral edge of the elevator and that's when the wander guard would not lock if a wander guard was near it and that's how we think Resident R1 got downstairs to the basement. Review of Scenic Heights and the Gardens Page 3 of the 24-hour report (a form shared between nursing shifts to share resident information and changes with staff) dated 3/18/23, indicated Registered Nurse (RN) Employee E11 initialed ten of the ten areas where wander guard monitoring devices were located and were functioning. Telephone interview on 3/30/23, at 2:30 p.m. RN Employee E11 indicated We hold a wander guard up to the door and it locks and then an audible alarm. You don't have to open the door. We just hold it up to it. You hold the sensor up to the elevator and an alarm goes off, but it doesn't prevent the elevator from going down. That definitely is not a lock down unit up there, and they have lock down people. It's not enough for that unit. There's only one nurse for the floor. Third or fourth floor staffing is really bad sometimes; days and evening sometimes alone this past Saturday for night shift. If my initials were on the form then I probably checked it before midnight that day, that's when I usually check them. Review of facility's Wander guard monitoring system test tool dated March 2023, indicated the facility failed to test the monitoring system on the following dates for both A.M. and P.M. checks: 3/4/23, 3/19/23, 3/24/23, 3/25/23, 3/26/23, 3/27/23 and 3/28/23. During an interview on 3/30/12, at 11:20 a.m. the NHA confirmed the wander guard system test tool was not consistently completed and could not provide documentation to prove otherwise on the dates listed above. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the diagnoses Alzheimer's Dementia with severe agitation, paranoid schizophrenia (delusions and hallucinations that blur the line between what is real and what isn't), and atrial fibrillation (irregular heart rhythm). Section C: Cognitive Patterns, Question C0100 indicated a BIMS score of zero - severe cognitive impairment. Section D: Mood, Question D0200 indicated resident was not experiencing symptoms of depression. Section E: Behavior, Question E0900 Wandering indicated a score of zero, which indicated the behavior was not exhibited although behaviors relating to rejection of care were indicated. Review of Elopement/Exit Seeking Evaluation Form dated 3/8/23, indicated that Resident R2 had seven of 14 total factors/contributors indicating elopement risk. Review of Resident R2's physician order dated 3/8/22, indicated wander guard system for safety, elopement, and exit-seeking. Check placement and function of wander guard system every eight hours and notify supervisor if wander guard is not in place or non-functional. Review of Resident R2's care plan dated 3/23/23, indicated resident was at risk for elopement/exit-seeking with a goal of remaining safe with a wander guard monitoring system. Interventions included the following: Consent obtained for wander guard. Wander guard monitoring system per facility policy. Resident R2's care plan failed to include interventions relating to exit-seeking and wandering behaviors. Review of Resident R2's progress notes dated 3/12/23 - 3/26/23, indicated behaviors as follows: 3/12/23 - refusal of medication 3/13/23 - Physician Employee E1 progress note worsening dementia and wandering 3/16/23 - minimal responses today with some paranoia 3/17/23 - get out of bed independently to bathroom frequently upsetting roommate by closing the door 3/23/23 - alert with confusion 3/26/23 - NA Employee E12 brought Resident R2 to the 4th floor unit at 3:40 p.m. She was found on the 3rd floor at stairwell. Resident R2 stated she wanted to go to the first floor Villa. Re-directed to room, re-oriented to room and 15-minute checks initiated. Family, Supervisor, and MD notified. Review of written statement from NA Employee E4 dated 3/26/23, indicated at approximately 3:30 p.m. or 3:40 p.m. I was the only aide on the floor and was writing out a work order at the time I saw Resident R2 walk towards her room and around the bend. I did not hear an alarm or anything that would alert me Resident R2 went through the stairwell and I did 15-minute checks afterwards. Interview on 3/28/23, at 9:17 a.m. LPN Employee E19 indicated I took care of Resident R2 a couple times. She'd come out and sit at nurse's station. She seems lost and asks where should she be. She was in 457 door until they moved her. She has dementia and poor memory. Review of facility submitted documents, dated 3/26/23, indicated at approximately 3:40 p.m. NA Employee E12 was approached on level three by Resident R2 who was coming from the back hallway and asked if NA Employee E12 knew how to get to the first floor. The wander guard alarm on level three's back stairwell was alarming which initiated NA Employee E12 to respond. Resident R2 was escorted back to the fourth floor unharmed. Resident R2 was last seen at approximately 3:30 p.m. at the nurse's station on the fourth floor and then observed ambulating toward her room. Review of written statement from NA Employee E12 dated 3/26/23, indicated I was sitting at the nurses' desk around 3:35 p.m. or so charting. While I was sitting there, the alarm for the rear door went off. As I shut it off, I went to go see who it was. Resident R2 came walking from the back hall, walked to the desk asking how to get to the first floor. I instructed Resident R2 to come with me and escorted her to the fourth floor via elevator. The alarm, when we got off the elevator on the fourth floor, did not go off. Review of written statement from RN Employee E14 dated 3/26/23, indicated she just finished getting report a moment prior. She heard the alarm going off. She looked to the left and saw Resident R2 walking towards nursing station on 3rd floor. NA Employee E12 assisted Resident R2 back to unit. The doors on both floors though, open and do not lock, they just easily open. RN Employee E14 indicated she called Maintenance Employee E15 who responded Yeah, we already know and there's nothing we can do about it right now. Review of written statement from RN Employee E16 dated 3/26/23, indicated at approximately 3:40 p.m. NA Employee E12 from the third floor brought Resident R2 up to her unit on the fourth floor and stated Resident R2 set back stairwell alarm off on third floor and was found wandering. Review of written statement from RN Employee E17 dated 3/26/23, indicated NA Employee E12 came to nursing station at 3:40 p.m. and presented Resident R2 to staff at the nursing station on the fourth floor. Resident R2 was observed on the third floor entering via stairwell, Resident R2 stated she wanted to go to the first floor, The Villa (Personal Care floor). Review of written statement from Licensed Practical Nurse (LPN) Employee E18 dated 3/26/23, indicated she came to the fourth floor from third floor to take Hilltop team at 3:30 p.m. At 3:40 p.m. NA Employee E12 brought Resident R2 to nurses' station and stated Resident R2 was observed on third floor entering through stairwell. Interview on 3/28/23, at 9:19 a.m. RN Employee E20 indicated Resident R2 walks with a walker, had recently moved to the 4th floor from the first floor where the personal care home The Villa is located. Resident R2 made it down one floor through the stairs and likely did not have her wheeled walker. RN Employee E20 gave Resident R2 a wander guard the first day she was admitted to the nursing home and nursing checks the batteries, maintenance checks the doors. Interview on 3/28/23, at 11:00 a.m. the NHA indicated At the time, maintenance was called by RN Employee E15, the facility was not aware the mag lock was not engaged, and wander guard system would have worked if bed sled (sleds that slide residents down stairwells) was not depressing the release button. Interview on 3/28/23, at 10:00 a.m. Maintenance Employee E15 indicated This past Sunday I got a call from the facility that the fourth-floor stairwell door was opening without entering a code. They were going to try and do a one-to-one to the doorway. I passed it on to the NHA. The staff didn't mention the wander guard not functioning. Maintenance Employee E15 continued, The medical sleds for bariatric emergency procedures somehow had removed itself from the anchor on the wall and it was leaning on the mag lock against the exit button, which is why the wander guard did not work, and it disabled the entire thing. They ripped out the small voltage sensor on that door as part of the old system. It would send an alert to the nurse's station that someone went through a fire door without putting in a code. That was disabled back in November. I didn't realize the annunciator was turned off. Interview on 3/30/23, at 3:34 p.m. NA Employee E12 indicated I was at the nurse's station charting and heard the alarm at the back stairwell as it also alarms at the nursing station. I went to see what was going on, NA Employee E12 stated, and here was Resident R2 walking to desk confused, not crying, asking if the stairs go to the first floor. I noticed the wander guard on her arm, confirmed with the nurse that Resident R2 belongs on the fourth floor and escorted her to the nurses' station there. Staff on fourth floor asked where was Resident R2 at? I told them she came down the back stairs. When we got to the fourth floor the elevator alarm did not go off. I told the Assistant Director of Nursing (ADON) Employee E13 and she stated she'd call maintenance. Telephonic interview on 3/29/23, at 1:55 pm with RN Employee E16 unsuccessful, a voice message was left and never returned. Telephonic interview with NA Employee E4 on 3/30/23, at 2:00 p.m. unsuccessful, a voice message was left and never returned. Telephonic interview attempted on 3/30/23, at 2:22 p.m. and 3:00 p.m. with RN Employee E14 was unsuccessful. Wireless caller not available, unable to leave a voice message. Interview on 3/30/23, at 2:47 p.m. LPN Employee E18 indicated I had my coat on to leave, and I heard them saying Resident R2 got through the stairwell. I remember at 8:00 a.m., when I was down by the back stairwell of the fourth floor that day, another resident walking by the exit door, and I heard it click from that resident's wander guard. Interview on 3/30/23, at 3:20 p.m. NA Employee E21 indicated Resident R2 was up four times last night and had to be redirected and the alarms were working then. Interview on 3/30/23, at 3:25 p.m. the NHA confirmed the events of the facility submitted documents and confirmed she did not have a 24-hour report for 3/26/23 to indicate anybody checked the wander guard function that day. Review of facility provided documentation identified that 10 residents wear wander guards and this created an immediate jeopardy situation for 10 of 10 residents (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10 and R11) On 3/29/23, at 1:05 p.m. the NHA and the RDO were made aware that Immediate Jeopardy (IJ) existed for 10 of 10 residents residing of the fouth-floor (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10 and R11). The IJ template was provided to facility administration and a corrective action plan was requested. On 3/29/23, at 2:50 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Cited resident from incident dated 3/18/23, is no longer in facility and had no negative outcome from cited incident. This resident was identified as a wander risk and wore a wander guard and was able to bypass existing and functioning wander guard system on elevator due to a small window where the sensor did not reach. Sensitivity has been increased and audits confirm that condition no longer exists as of 3/27/23. Residents: -A review of residents currently living in the center using the Elopement Evaluation will be completed by the Director of Nursing (DON) or designee by 2/28/23, at 3:00 p.m. to identify other residents who are at risk for wandering/exit- seeking. If a current resident is identified as exit-seeking, an alert bracelet will be applied, and care plan updated. Ad Hoc QAPI completed 3/24 Whole house audit was conducted by nurse managers and reviewed by NHA and ADON on elopement risk with updated assessments done on every resident. No further residents identified to be at risk. Wander guards are audited every shift. System correction: Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, social services, and activities from SNF including agency and hospice staff was conducted and completed regarding incidents and accidents, reporting incidents via chain of command and to DOH, incident reports, putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering, interventions for behaviors and wandering/exit-seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. Education to include missing person and elopement policy and checklist as updated 2/27/23 and was educated to same group as above. Education was conducted by regional RN or designee via emails, in person meetings and regular mail. In person education was completed on 3/24 through 3/28, with any remaining staff mailed on 3/29. Education is completed. Missing person and elopement policy and checklist was updated on 3/24/23, with revisions completed 3/27/23. Monitoring: Audits of the doors were initiated by Maintenance staff and ADON then continued by RN supervisor to ensure proper functioning for wander guard for elopement risks and locking mechanism for residents not identified as wander risks, with no further issues noted. RN supervisor or designee will continue auditing doors daily x 4 weeks then weekly x 3 months. ADON or designee will audit new admission/returns and quarterly exit-seeking assessments to ensure care plan with appropriate interventions daily x 4 weeks then weekly x 3 months. Ongoing results will be submitted to QAPI. During interviews on 3/30/23, from 9:00 a.m. through 3:55 p.m. 51 employees confirmed they had received education on incidents and accidents, reporting incidents via chain of command and to DOH, incident reports, putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering, interventions for behaviors and wandering/exit-seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. Education to include missing person and elopement policy and checklist as updated 2/27/23. The IJ was lifted on 3/30/23, at 4:02 p.m. when the action plan implementation was verified. During an interview on 3/30/23, at 4:02 p.m. the NHA confirmed the facility failed to provide adequate supervision for two residents resulting in elopement (Resident R1 and R2). This failure created an immediate jeopardy situation for 10 of 10 residents residing of the fouth-floor (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10 and R11). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code: 201.29(a)(b)(c)(i)(n) Resident rights. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of 44 residents. This failure created an immediate jeopardy situation for one of 44 residents (Resident R1). Findings include: Review of the facility policy, Dementia Care dated 1/26/23, indicated the facility will provide appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. This policy further stated that the care plan interventions will be related to each resident's symptomology. A review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Minimum Data Set (MDS, periodic review of resident needs) dated 2/12/23, revealed that Resident R1 was admitted to the facility on [DATE], resident has the current diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), non-traumatic brain injury, and unsteadiness on his feet. Question C0500 BIMS Summary Score revealed Resident R1's score to be 3, severe impairment. Review of Resident R1's February and March physician orders included: -Quetiapine fumarate (Seroquel, an anti-psychotic medication) 12.5 mg, twice daily for psychosis with hallucinations, dated 11/11/22. -Haloperidol (Haldol, an anti-psychotic medication) 0.5 mg sublingually at bedtime for agitation/ behaviors, dated 2/28/23. -Haloperidol 0.5 mg every one-hour as needed for nausea, vomiting, and agitation dated 12/19/22. -Sertraline (Zoloft, an anti-depressant medication) 25 mg daily for depression, dated 11/4/22. Review of Resident R1's medication administration record for February and March 2023, revealed that Resident R1 has needed Haldol on 2/25/23, and 3/7/23. Review of Resident R1's plan of care for alteration in cognition dated 9/6/22, did not include interventions for behaviors related to dementia, delusional thoughts, or audio and visual hallucinations. Review of Resident R1's plan of care for have potential for adverse reactions from ongoing use of psychotropic meds. Diagnosis of major depressive disorder dated 9/6/22, included to: -Provide medication as ordered, Seroquel and Zoloft -Monitor for and document behaviors. Notify MD (Doctor of Medicine) as needed for further interventions. -Psych consult as indicated. Review of Resident R1's behavior tracking from 1/1/23, though 3/18/23, included one instance of entering someone else's room, and five instances of refusals of care. Review of Resident R1's progress notes indicated the following: 8/31/22: Entering other rooms. 9/18/22: Delusion that family member having surgery. 10/19/22: Provider note indicted current hallucinations during evaluation. 10/20/22: Delusion he was in the Army and needed to go to work. 11/6/22: Delusional statements, I am not going anywhere with you. I am getting out of here. I am not listening to Hitler or any of them. 11/10/22: Resident looking for a lady and my dog. 12/19/22: Slamming doors, hitting and spitting on staff members, throwing medication, there, now get the hell out of here. 1/1/23: Threw drinks and attempted to strike staff. 2/4/23: Barricaded himself in his room. They are coming to kill me. Oh, you know who, and you two are in on it. Resident R1 walked down the hall, stopped and said, look at those kids over there standing in line. They are waiting to be hung. 3/16/23: (Resident R1) became somewhat restless, ambulating unit, talking about his dog, and wanting ice cream, this LPN (licensed practical nurse) offered him a popsicle, he said no that he likes ice cream. I walked him to his room. He sat on bed, and I attempted to cover him up when he got agitated. He stated that I was insubordinate, and he was the boss, that I was on his boat. I explained to him that he was in (facility). He decided he was going to sit up. Approximately 10 minutes later his roommate was yelling out. Staff goes in, and resident was on the floor. Review of a late entry progress note dated 3/18/23, at 1:28 p.m. (created 3/24/23, at 3:29 p.m.), indicated resident was noted to be in the basement. Staff member from 3rd floor assisted resident to transfer to the 4th floor. Zero injuries noted visually. Review of facility provided information dated 3/23/23, revealed that on 3/18/23, Resident R1 eloped to an unsupervised area, and that Resident R1 did not recall where he resided. Review of a progress note dated 3/18/23, at 6:15 p.m. indicated staff calling out from room that resident was breaking glass in his window in his room. This nurse entered room and Resident R1 was pounding his recorder into window and glass breaking. I was afraid he would either go out window on 4th floor or cut self on pointed edges of broken glass still hanging in window and tried to pull him away from window as he was hollering out for his son. He became belligerent and combative and elbowed me in my face and scratched down my arm and continued to break the glass and yell out the window. Review of a progress note dated 3/18/23, at 6:28 p.m. indicated: RN (Registered Nurse) was notified of Resident R1 becoming combative. Upon entering the room, the Resident R1 was in the room yelling that the building was on fire and he needed to get out. Staff reports that the resident had become agitated and removed the fire extinguisher from the case and pulled the pin and proceeded to spray the area in an attempt to extinguish a fire. It was then that Resident R1 went into his room and used a piece of medical equipment to break the window and attempting to exit the building through the broken window. A nurse and three nurse aides were present keeping the resident from going towards the broken window and Resident R1 was elbowing and swinging at the staff. Local police had been called prior to RN arriving in the room. Local police arrived on scene. They assisted in getting the patient out of the room safely and assured him that the building was not on fire. Emergency Medical Service was called and Resident R1 was transported to the Emergency Department for psychiatric evaluation. Review of an employee statement written by NA Employee E22 dated 3/20/23, at 10:37 a.m. indicated I could hear Resident R1 yelling fire engine number 9 repeatedly. I stepped round the curtain and he was standing close to the window. I said, what's wrong (Resident R1)? When he said look at that fire, Don't you see all those people? I approached the window to look. Resident R1 then placed his hand on my back, pushing me towards the window. I stepped back and said I don't see anyone, and there is no fire. I tried to reassure him that everything was OK. He then picked up an object, which was attached to an electrical cord and started swinging it at the window. I became afraid and ran screaming for help. Two nurse aides and a nurse came rushing into the room with me. It was too late. Resident R1 was standing at the window holding the object in both hands breaking the window. When the nurse approached him to stop him, he smacked her in the face and elbowed her in the face as well. The other two aides finally got him to stop and sat him down. He was then taken out of the room in a chair. We then began to move the other patient to another room. Review of employee statement written by Licensed Practical Nurse (LPN) Employee E23, dated 3/20/23, at 11:07 a.m. indicated: on Saturday I hear someone yelling for help. Please someone help me with this resident. I walked back into the activities room, and the room was smoky. Activities Aide Employee E24 said that Resident R1 had pulled the pin to the fire extinguisher. Resident R1 was in the room holding a wooden welcome sign, and tried to hit me with it as I approached him. I was able to get the sign off him and told him come. Let's go to your room. Resident R1 followed me to his room. I told him it was OK; to sit down and relax. He stood at the foot of the bed for a second looking out the window. He began to say look at all the people. I explained to him that nobody was out there. He sat down on the bed with the walker in front of him and seemed to be calm talking with his roommate. I stayed in his room for a minute. He was calm. I left him sitting on his bed. Review of an employee statement written by Activities Assistant Employee E24 dated 3/20/23, at 11:44 a.m. indicated on Saturday, March 18th, in the evening, Resident R1 was outside the activity room tapping on the window aggressively with a wooden sign that was used for decoration by the door. When I opened the door, there was a cloud of something in the air, and he frantically stated we needed to leave. He entered the activity room, and I noticed his hand was bleeding. I yelled for help. RN Employee E23 ran over with me and noticed the cloud in the air too which was the powder from the fire extinguisher. She looked at his hand that was bleeding and told him to come with her so she could help him. We tried to redirect him out of the activity room. He was not hearing her or seeing her. He was in the room. He broke a file tray. RN Employee E23 successfully got him to leave with her. As I entered the room NA Employee E9 asked me to take a phone call. I had just ended the call when a family member approached (NA Employee E9) and asked if it was normal for glass to come from our rooftop. RN Employee E25 and RN Employee E20 were there as well. And the three of us ran up to 4th floor to see where the glass was coming from. We saw several staff in Resident R1's room cleaning up glass. I saw the situation was under control and left the room at this time. Review of hospital paperwork dated 3/20/23, indicated Resident R1 had been admitted to the hospital for hallucinations and dementia. While in the hospital, Resident R1 had received a TDAP (tetanus/diphtheria/acellular Pertussis) booster vaccine. The hospital history indicated the chief complaint to be increased aggression, with information provided by family that Resident R1 had been having more frequent episodes of hallucinations that have been worsening over the past few weeks. He has a history of longstanding dementia. He is currently on hospice. He was hallucinating the building was on fire. He became more agitated and swung a metal object at a glass window and then cut himself on the hand. He has a small abrasion there. During an interview on 3/29/23, at 12:35 p.m. the Nursing Home Administrator (NHA) confirmed that the facility had not provided education on dementia training to its staff. The NHA further confirmed that Resident R1 had not previously attempted to elope from the facility, and that this was not recognized as a possible change in condition and confirmed that the approaches staff utilized with Resident R1 were not appropriate (refuting the hallucinations while the resident was in crisis, leaving the resident unsupervised and alone with his roommate after aggressive behaviors, not providing additional interventions related to hallucinations, and not providing ordered as needed medications). During a follow-up interview on 3/29/23, at 3:30 p.m. NA Employee E22 stated Resident R1 stated Fire engine number nine, fire engine number nine, fire engine number nine. Don't you see those people, NA Employee E22 said what people? Resident R1 said look, and he was telling me to look out the window. I walked up thinking I could [NAME] this in the bud. I said, I don't see anybody. Resident R1 put his hand on her back and she started backing away from him. NA Employee E22 stated Resident R1, I don't see anyone. (He said) look at all those people, they're going to get burned. It's a fire. NA stated she again told Resident R1 there was no fire, there was no one there. This was reiterated multiple times. She stated she went back to the curtain, thinking that he was going to be ok. Resident R1 stated, We gotta get out of here, we gotta get out of here. NA saw him with the electrical object in his hand, swinging it towards the window. NA Employee E22 stated she went down the hall to get other staff. I went down the hall and turned the corner. NA Employee E22 stated that she observed Resident R1 elbow and punch a nurse. NA Employee E22 stated, I was afraid, I'm not trained to stop this and that from going on. I've never worked with mental patients. NA Employee E22 stated that she has not been provided specific training on dementia and had no training for violent residents. On 3/29/23, at 2:50 p.m. the NHA was made aware that Immediate Jeopardy (IJ) existed for one of 44 residents in the facility. The IJ template was provided to facility administration, and a corrective action plan was requested. On 3/29/23, at 5:45 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Cited resident from incident dated 3/18/23, is no longer in the facility. Resident was ordered routine Haldol, which had been administered per order at bedtime. During the incident, the nurse attempted to utilize non-pharmacological interventions which was effective [sic]. Following the incident, the nurse was educated on interventions including the use of as needed medications. Residents: Whole house audit completed for residents with a diagnosis of dementia to ensure appropriate behavior, tracking by NHA with nurse management team. System Correction: Whole house education for all departments, including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, social services, and activities from skilled nursing facility, including agency and hospice staff was conducted regarding advanced and specialty care environments, specific behavioral symptoms and interventions (behavior examples include: agitation, anxious behaviors, depression, insomnia, wandering, delusions, hallucinations, etc.) Support for residents with dementia, types of dementia, and positive approaches for residents with dementia. Dementia education was added to in-person meetings conducted by regional registered nurse on 3/29/23, and mailings/emailing by NHA with completion on 3/29/23. Monitoring: Audits will be completed by the NHA three time per week for four weeks, then weekly for three months for residents with dementia to ensure appropriate care plan and behavior monitoring is in place. Results will be submitted to QAPI (Quality Assurance and Performance Improvement). During interviews on 3/30/23, from 9:00 a.m. through 3:55 p.m. 51 employees confirmed they had received education on types of dementia, dementia symptoms and interventions, and positive approaches for dementia. The IJ was lifted on 3/30/23, at 4:02 p.m. when the action plan implementation was verified. During an interview on 3/30/23, at 4:02 p.m. the NHA confirmed that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of 44 residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code: 201.29(a)(b)(c)(i)(n) Resident rights. 28 Pa. Code 201.18(b)(1) Management.