Every finding on record at Roosevelt Rehabilitation and Healthcare Center

Based on observations, staff interviews, and clinical record reviews, it was determined that the facility failed to administer medications in accordance with physician orders for two of two residents reviewed. (Residents R1, R4)Findings include: Review of Literature on 'Administering Medications,' indicates that the individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Review of Medication Administration Record of Resident R1 revealed that the following medications were administered beyond the allowable time window for medication administration: Nifedipine ER Tablet Extended Release 24 Hour 90 MG Give 1 tablet by mouth one time a day, Schedule Date and Time: 8:00a.m.; Administration Time: 04/26/2026 10:23 a.m. Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD *DO NOT CRUSH; 04/26/2026 8:00 a.m.; Administration Time: 04/26/2026 10:22 p.m. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day; 04/26/2026 8:00 a.m.; Administration Time: 04/26/2026 10:24 p.m. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 26 unit subcutaneously with meals diabetes mellitus (failure of the body to produce insulin), call physician if glucose level is above 400 or below 70. Hold insulin dose if not eating meal or glucose level less than 150. 04/26/2026 8:00 a.m.; Administration Time: 04/26/2026 10:24 a.m. Labetalol HCl Tablet 200 MG Give 1 tablet by mouth every 12 hours, 04/26/2026 9:00 a.m.; Administration Time: 04/26/2026 10:20 a.m. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 26 unit subcutaneously with meals for Diabetes mellitus call physician if glucose level above 400 or below 70; Hold insulin dose if not eating meal or glucose level less than 150. ROTATE SITE; 04/26/2026 12:00 p.m.; Administration Time 04/26/2026 2:08 p.m. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 26 unit subcutaneously with meals for DM CALL MD IF GLUCOSE LEVEL ABOVE 400 OR BELOW 70; Hold insulin dose if not eating meal or glucose level less than 150. ROTATE SITE, 04/27/2026 8:00 a.m., Administration Time: 04/27/2026 10:03 a.m. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day, 04/27/2026 8:00 a.m.; Administration Time: 04/27/2026 10:08 a.m. Review of the physician's order for Resident R4 indicated that the following medications were to be administered at 9:00 a.m. On May 6, 2026, at 11:30 a.m., it was observed that Licensed Nurse Employee E8 administered those medications to Resident R4 at 11:30 a.m., which is one and a half hours beyond the allowable time window for morning medication administration. Glucophage Tablet 1000 MG (MetFORMIN HCI) Give 1 tablet by mouthAspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouthBumex Oral Tablet 1 MG (Bumetanide) Give 1 tablet by mouthCholecalciferol Tablet 1000 UNIT Give 1 tablet by mouthcloZAPIne Oral Tablet Disintegrating 150 MG by mouthDocusate Sodium Capsule 100 MG Give 1 capsule by mouthEliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouthFenofibrate Tablet 145 MG Give 1 tablet by mouthFerrous Sulfate Tablet 325(65 Fe) MG Give 1 tablet by mouthFolic Acid Oral Tablet 1 mg, Give 1 tablet by mouthMetoprolol Tartrate Tablet Give 12.5 mg by mouthoxyBUTYnin Chloride Oral Tablet 5 MG (Oxybutynin Chloride) Give 1 tablet by mouthPhenazopyridine HCI Oral Tablet 200 MG (Phenazopyridine HCI) Give 1 tablet by mouth On May 6, 2026, at 1: 43 p.m., the above findings were confirmed with the Director of Nursing. Pa Code 211.12(d)(1)(2)(5) Nursing Services.

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with the Enhanced Barrier Precautions for one of one resident treatment reviewed (Resident R3).Findings include: A review of the literature indicates that Enhanced Barrier Precautions (EBP) are infection prevention measures used to reduce the transmission of multidrug-resistant organisms (MDROs). The literature further indicates that staff are expected to follow established infection control practices, including proper hand hygiene, appropriate use of personal protective equipment (PPE), and changing gloves as needed during care to prevent cross-contamination between body sites. Review of clinical records indicated that on March 25, 2026, the physician ordered EBP for the resident R3 due to the presence of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly, used when oral intake is not possible), and a Suprapubic tube (a thin, flexible tube surgically inserted through a small abdominal incision directly into the bladder to drain urine), which required the use of gowns and gloves during high-contact resident care activities, including bathing and hygiene care. On May 6, 2026, at 11:15 a.m., observed that while providing cleansing care to Resident R3, Employee E7, a nurse aide, wore gloves but did not wear a gown and did not change gloves between cleansing the resident's face, eyes, and various areas of the body, which was not consistent with recommended infection control practices under EBP. The finding was confirmed with E7 and Director of Nursing on May 6, 2026, at 11:35 a.m. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the emergency care of residents with tracheostomy tube (opening in the trachea to help air and oxygen reach the lungs) for four of four employee records reviewed (Employee E8, E9, E10, E11). Findings Include: Review of facility policy titled Emergency Tracheostomy Tube Change and Decannulation dated September 2020, revealed An emergency tracheostomy tube change can become necessary for a variety of reasons. An experienced clinician should be able to quickly assess and identify the need for such procedure. Implementation includes: 1. If current trach is blocked, remove the inner cannula first. If still occluded, deflate the tracheal cuff and removed obstructed tube. 2. If the current tube's cuff failed, then proceed to the next step first. 3. Open the bedside resuscitation bag and mask. Apply the mask to the resuscitation bag. 4. Open the back up same sized trach tube and prep for insertion. Replacing the new inner cannula with the provided obturator. 5. Test the cuff. 6. Quickly lube the distal end of the trach tube. 7. Suction trach and mouth if needed and the situation permits. 8. To remove the problem trach tube, first undo the trach ties, next deflate the trach cuff completely. 9. If possible, position the resident in a flat supine position with the shoulders slightly elevated from beneath to allow slight neck hyperextension. 10. You may require an assistant to help stabilize the resident's head and neck during the removal and insertion. 11. Place a thumb and finder of one hand just outside either side of the stoma and apply light pressure. This support to the peri-stoma will help to stabilize the area while you withdraw the failed trach. 12. With the cuffed trach tube, you may feel some resistance upon removal of the failed tube. This is usually [NAME] to the greater diameter of the deflated cuff having to push through and stretching the stoma. This is when considerable stoma tissue trauma can occur. Use the peri-stoma finger support described above. If breathing, wait for the resident to inhale and remove the trach with a motion midline with the neck. And following the path of the tube. 13. Once removed, insert the new tube directly into the center of the stoma. The rounded tip of the obturator should be poking out the end of the trach tube to help smoothly guide the tube through the stoma. Note: If you do not have an obturator with the tube you will want to insert the trach at a right angle to the stoma, rotating downward as it is inserted. 14. Once inserted, the obturator is immediately removed and replaced with the appropriate inner cannulas. 15. Inflate the cuff and fasten trach ties. 16. Administer a few breaths directly to the new tube with a manual resuscitator and listen for equal breath sounds over the lung fields. You may also see the resident cough through the tube projecting mucus which is an indication of proper placement. 17. Place resident back on ventilator, check vitals and ventilator, provide trach care and document findings and actions. Further review of policy revealed The insertion of a new trach tube should take no longer than 30 seconds. If needed give the resident some mask/ bag breaths during difficult insertions. If the difficulty continues beyond 30 seconds have a trach one size smaller. Review of staff competencies related to Tracheostomy Care revealed that Employee E8, Licensed Practical Nurse; Employee E9, Licensed Practical Nurse; Employee E10, Registered Nurse; Employee E11, Licensed Practical Nurse did not have competencies related to Emergency Tracheostomy Tube Change and Decannulation. Interview with Employee E2, Director of Nursing, on April 7, 2026, at approximately 2:00 p.m. confirmed no Emergency Tracheostomy Tube Change and Decannulation competencies provided for Employee E8, Licensed Practical Nurse; Employee E9, Licensed Practical Nurse; Employee E10, Registered Nurse; Employee E11, Licensed Practical Nurse. 28 Pa. Code: 211.12 (d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services

Based on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors.Findings include:On April 7, 2025, at 10:42 a.m., a Resident Council meeting was conducted with thirteen alert and oriented residents (R2, R5, R39, R27, R22, R40, R229, R127, R208, R210, R234, R151, R58). During the meeting, residents reported that they were not aware of the survey binder.On April 8, 2025, at 1:35 p.m., a facility tour was conducted with the Administrator, Employee E1, to confirm the placement of the Department of Health survey binder on the first floor behind the receptionist desk. Copies of the survey binder were also located on the 2nd, 3rd, and 4th floors behind the nursing stations and were not readily accessible to residents. The survey results in the binders on the 2nd, 3rd, and 4th nursing units were last dated April 29, 2025.28 Pa. Code 201.14(a) Responsibility of licensee

Based on interview with resident, and review of facility provided documentation, it was determined that facility did not ensure to provide evidence that all alleged violation was thoroughly investigated related to incident during smoke break between two residents (Resident R53, R232)Findings include:Review of facility policy 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' revised April 2021, indicates one of its objectives is to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.Further review of facility policy revealed that its purpose is to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents.Review of Resident R53 clinical record revealed medical history of low back pain, anxiety disorder, major depressive disorder, right artificial hip joint, osteoarthritis of right knee and hip, nicotine dependance, psychoactive substance use.Review of Resident R232 clinical record revealed medical history of bipolar disorder, joint replacement surgery, osteoarthritis, antisocial personality disorder, schizoaffective disorder, tobacco use, psychoactive substance use.Review of Resident R53 interim smoking evaluation, completed on February 4, 2026, indicates that he is not able to smoke independently/follow facility policy Review of facility provided investigation report, completed on March 10, 2026, revealed that during 1:00 pm smoke break, there was an altercation between Resident R232 and R53. Resident R53 reported that Resident R232 hit R3 with his walker and knocked his cup out of his hand during a smoke break. Resident R232 was placed on one hour safety checks for 12 hours.Interview with Resident R53 on Tuesday, April 7th, 2026, at 9:15 am, revealed that at the time of altercation - there was no staff present on patio.Further review of investigation report revealed that recreation aide, employee E5, was on 1:00 pm smoke break and was walking around the patio area. Further stating that while I was outside I did not witness any type of verbal confrontation. All residents came back together.However, the investigation report also included in-service education provided to employees on 'Abuse,' which included any action/failure to act that causes harm, physical, verbal, sexual, mental, financial, abuse, neglect and misappropriation of property. Protecting residents is everyone's responsibility and zero tolerance for abuse is our standard.Further review of facility provided investigation report revealed no evidence of additional interviews of residents and staff regarding which employee and how many employees were supervising residents during 1:00 pm, smoke break, on March 10, 2026.28 Pa Code 201.18(b)(1) management

Based on observations, review with resident and staff, and review of clinical record, it was determined that facility did not ensure to develop and implement a resident centered care plan resulting in falls for one of 36 residents reviewed (Resident R144)Findings include:Review of facility policy 'Comprehensive Person - Centered Care Plans,' revised March 2022, indicates that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Further review of policy indicates that the comprehensive, person centered care plan reflects currently recognized standards of practice for problem areas and conditions.Review of Resident R144 clinical record revealed medical history of displaced intertrochanteric fracture of right femur, dementia with agitation, dizziness and giddiness, benign neoplasm of cerebral meninges ( non-cancerous tumor that develops in the meninges-the protective layers covering the brain and spinal cord), anxiety disorder, osteoarthritis, falls, gait and mobility abnormalities, cerebral infarction.Review of minimum data set/resident assessment and care screening, completed on March 18, 2026, revealed brief interview for mental status (BIMS) score of 6.Review of resident R144 clinical record revealed she is awake, alert and oriented x 2, forgetful.Further review of Resident R144's clinical record revealed she had three falls since admission on [DATE]; R144 had a fall on March 12, 2026 at approximately 4:45 am, on March 30, 2026 at 4:00 am, and on April 9, 2026 at 12:05 am.Interview with Resident R144 on Thursday, April 9, 2026, at 11:45 am, revealed that she attempts to use restroom during over night shift.Further review of Resident R144 progress notes, dated April 9, 2026, at 12:05 am, revealed that R144 was found laying on her right side next to her low bed. From observation, it looked as if resident used the trash can as a toilet and fell.Review of interim fall risk evaluation completed on march 30, 2026 (score 16) and on April 8, 2026 (score 20) revealed Resident R144 is at high risk for falls.Review of physical therapy evaluation, completed on March 12, 2026, revealed Resident R144 requires maximum assistance with transfer and bed mobility.Review of resident R144 care plan revealed no evidence of goals or interventions post initial fall on March 12, 2026; no evidence of implemented interventions related to repeated falls during night shift.28 Pa Code 211.10(d) resident care policies

Based on clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to develop a comprehensive, person-centered care plan related to enhanced barrier precautions for 1 of 3 residents reviewed (Resident R250).Findings include:Review of the facility policy titled Care plans, Comprehensive Person-Centered last dated 2001, revealed A comprehensive, personal-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement for resident. It further explains under bulletin #2. The comprehensive , person-centered care plan is developed within seven (7)days of the completion of the reired MDS assessment (Admission, Annual or significant change in status), and no more than 21 days after admission.Review of the clinical record of Resident R250 revealed that the resident was admitted to the facility on [DATE], with diagnoses of encephalopathy (brain dysfunction) and encounter for attention to tracheostomy (a hole in the neck created to help a person breathe).On April 7, 2026, at 9:45 a.m., observation confirmed that the Enhanced Barrier Precautions sign was posted outside Resident R250's door, and personal protective equipment (PPE) was available.On April 8, 2026, at 10:23 a.m., an interview with the Infection Preventionist, Employee E6, confirmed that the clinical record did not contain a comprehensive care plan developed for Enhanced Barrier Precautions.28 Pa Code 211.10 (d)Resident Care Policies28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (ADL) (shaving and nail care) for two of 4 sampled residents. (Residents 246, R155)Findings include:Review of the facility policy titled Shaving the Resident, last revised in 2001, revealed, The purpose of this procedure is to promote cleanliness and to provide skin care.Review of the facility policy titled Fingernails/toenails, care of, last revised in 2001, revealed, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Review of the clinical record of Resident R246 revealed admission date of April 3, 2026 with diagnosis of frostbite with tissue necrosis of right and left foot (severe cold injury causing tissue death in both feet), of acute kidney failure, other disorders of phosphorus metabolism (imbalance of phosphate levels in the body affecting bone and cellular function), Hidradenitis suppurativa (chronic skin condition that causes painful lumps under the skin).A review of the comprehensive care plan dated April 4, 2026, indicated an ADL focus area: I have an ADL self-care performance deficit related to deconditioning and frostbite to bilateral lower extremities. It further included interventions for personal hygiene: I require supervision/setup with grooming and personal hygiene and require one staff assist with bathing.Review of the clinical record of Resident R155 revealed admission date on February 3, 2026, with diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery (stroke), Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis on the left side after a stroke).Further review of the factsheet of the clinical record indicated I prefer showers . A review of the comprehensive care plan dated February 3, 2026, indicated an ADL focus area: I have an ADL self-care performance deficit related cva left hemi. It further included interventions for ambulation: I am non-ambulatory and require one staff assist with bathing.On April 6, 2026, at 11:26 a.m., observations of Resident R246 revealed long nails on both hands and facial hair. Resident R246 reported that their nails could be cut and facial hair could be shaved.At the same time, an observation of the roommate, Resident R155, was also conducted, which showed that Resident R155 had facial hair and expressed a desire to shower. When asked when the last shower occurred, Resident R155 reported that it it's been a while since I had a shower and I'll take a shower over a bed bath any time.On April 6, 2026, at 11:46 a.m., above observations were confirmed by the license nurse, Employee E8 who was covering both residents.On April 7, 2026, at 1:56 p.m., the licensed nurse, Employee E10, confirmed that Resident R155 had facial hair and had not received a shave, and that Resident R246 had long nails and facial hair that had not been shaved.On April 8, 2026, at 11:08 a.m., the unit manager, Employee E9, confirmed the observation that Resident R155 had been shaved on the cheeks, but facial hair remained on the neck. Employee E9 reported that the neck hair was long and that the shaving razor needed to be soaked to continue shaving Resident R155's neck. Employee E9 stated that they would personally complete the full shave for Resident R155. Resident R246 also continued to have facial hair, and Employee E9 reported that Resident R246 would be set up for a shave today. Employee E9 also confirmed that nail care and shaving of facial hair are part of the nursing assistants' morning ADL care tasks.On April 9, 2026, at approximately 10:31 a.m., an interview with Resident R155 revealed that their neck continued to have facial hair.28 Pa. Code 211.10 (d) Resident care policies28 Pa code 211.12.(d)(1)(5) Nursing services

Based on observations, review of facility provided documentation, and interview with staff, it was determined that facility did not ensure resident's environment was free from accident, and hazard for one of 36 residents reviewed (Resident R15)Findings include:Review of facility policy 'Homelike Environment,' revised February 2021, indicates that residents are provided with a safe, clean, comfortable and homelike environment Review of Resident R15 clinical record revealed medical history of vascular dementia (severe), pulmonary fibrosis (progressive lung disease characterized by scarring and stiffening of lung tissue, making it difficult to breathe and reducing oxygen absorption), immunodeficiency, unqualified visual loss of both eyes, glaucoma, history of falling, acquired absence of left toe, mononeuropathy ( the damage or dysfunction of a single peripheral nerve, causing localized pain, numbness, weakness, or tingling in the hands, arms, or feet), schizoaffective disorder/bipolar type.Observations on 3 North unit on Tuesday, April 7, 2026, at 12:49 pm, revealed Resident R15 in bed, room [ROOM NUMBER]-A, with three missing ceiling tiles above her bed, exposing plenum space and electrical wires.Further observations revealed call bell system partially detached from the wall in room [ROOM NUMBER]-A.Review of facility provided maintenance logs for month of March 2026, and April 2026, revealed no evidence of TELS work orders placed to repair ceiling tiles.Interview with licensed nurse, employee E4, on Monday, April 6th, 2026, at 11:00 am, confirmed that Resident R15 has been sleeping and residing in room [ROOM NUMBER]-A for past three or four days.Findings confirmed with facility's administrator, employee E1, on Monday, April 6th, 2026 at 2:15 pm.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18 (e )(1) management responsibility28 Pa Code 211.12(d)(3) nursing services

Based on review of facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to implement ordered treatment and services related to incontinence management for two out of 35 residents reviewed (Resident R125, R223).Findings Include:Review of clinical literature indicates that a catheter is a flexible medical tube inserted into the body to drain or deliver fluids, most commonly used to remove urine from the bladder when a person cannot void (urinate or empty the bladder) naturally. A Foley catheter and a suprapubic catheter are both types of urinary catheters but differ in placement and use: a Foley catheter is inserted through the urethra-the tube that carries urine from the bladder to the outside of the body-while a suprapubic catheter is surgically placed through the lower abdomen directly into the bladder, often for long-term use or when urethral catheterization is not appropriate; suprapubic catheters (SPCs) are generally preferred for long-term use, offering increased comfort, lower risk of urinary tract infections (UTIs), and less urethral trauma compared to Foley catheters. Catheter size is measured in French units (Fr), where 1 Fr equals 0.33 mm in diameter, and selecting the correct size helps ensure adequate drainage while minimizing trauma to the urethra and surrounding tissues. The catheter balloon, located near the tip, is inflated with sterile water to keep the catheter securely in place inside the bladder, with common balloon sizes usually inflated with 5 mL, 10 mL, or 30 mL for specific clinical situations; choosing the correct balloon size is important because an oversized balloon can cause bladder irritation, spasms, or tissue damage, while an undersized balloon may result in displacement or accidental removal. Administering the correct ordered catheter and balloon sizes is essential for patient safety, as incorrect sizing can lead to pain, urethral injury, leakage, ineffective drainage, and other complications.Review of the physician's order for Resident R125, dated January 3, 2025, revealed an order for, Urinary Catheter, maintain Foley catheter with 16 F, 10 mL balloon size.On April 8, 2026, at 12:57 p.m., in the presence of the Charge Nurse, a Registered Nurse (E7), assessed Resident R125 for the presence of the ordered Foley catheter, and observed that Resident R125 has Foley catheter with 16 F, 30 mL balloon size. At the time of the finding, the same was confirmed with E7.Review of the physician's order for Resident R223, dated November 22, 2025, revealed an order for, Supra Pubic Catheter #16 / 10mL balloon inflation to Urinary Drainage Bag, change monthly and as needed and monitor for signs and symptoms of infection or obstruction.On April 7, 2026, at 2:03 p.m., in the presence of the Charge Nurse, a Registered Nurse (E13), assessed Resident R223 for the presence of the ordered Supra Pubic Catheter, and observed that Resident R 223 has Supra Pubic Catheter with 16 F, 30 mL balloon size. At the time of the finding, the same was confirmed with E7.28 Pa. Code S211.12(d)(5).

Based on review of facility documentation, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to implement interventions consistent with resident assessed needs for one of two residents reviewed for nutrition (Resident R3).Findings Include:Review of Resident R3's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 20, 2026, revealed the resident was deemed cognitively intact, had diagnoses of muscle weakness and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and had an unhealed pressure ulcer (localized injury to the skin and/or underlying tissue).Continued review of Resident R3's comprehensive MDS dated [DATE], revealed the resident required setup or clean up assistance with eating, had an unplanned weight loss of 5% or more in the last month or weight loss 10% or more in the last six months, and was prescribed a therapeutic diet.Review of Resident R3's comprehensive care plan dated February 9, 2026, revealed the resident had a pressure ulcer and/or was at risk for pressure ulcer development. Interventions dated February 9, 2026, included to consult Registered Dietitian as needed, monitor nutritional status, and serve diet as ordered.Review of Resident R3's nutrition note dated March 11, 2026, by Registered Dietitian, Employee E11, revealed Resident R3's sacral wound had worsened, and baseline nutritional needs increased to support wound healing. Recommendations included adding double portions at mealtimes and fortified foods.Observations on April 6, 2026, at 12:17 p.m. revealed Resident R3 was served cottage cheese with diced peaches on top for the lunch time meal. A review of Resident R3's meal ticket, that was placed directly on the meal tray, indicated Resident R3 was ordered fortified foods. There was no evidence of other fortified food items added to the plate.Interview on April 6, 2026, at 12:17 p.m. with nurse aide, Employee E12, confirmed no additional fortified food items were served with Resident R3's lunch.Observations on April 8, 2026, at 12:34 p.m. revealed Resident R3 was served rice with gravy and a side toss salad. There was no evidence of other fortified food items added to the plate.Interview on April 8, 2026, at 12:34 p.m. with nurse aide, Employee E13, confirmed no additional fortified food items were served with Resident R3's lunch.Interview on April 9, 2026, at 10:30 a.m. with Registered Dietitian, Employee E11, revealed fortified food items include mashed potatoes, cereal, or pudding.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure medication regimen reviews were timely addressed by the physician for three of five residents reviewed (Resident R3 and R5).Findings Include:Review of facility policy Medication Regimen Reviews revealed medication regimen reviews (MRR) are conducted at least monthly by a licensed pharmacist. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, errors, and other irregularities.Review of Resident R3's Medication Regimen Review Recommendation to Prescriber dated December 22, 2025, revealed the following recommendation [Resident R3] currently receiving abilify (antipsychotic medication_. Abnormal involuntary motion scale (AIMS) test recommended every 6 months to assess for the development of side effects of neuroleptic medication. Last documented in May 2025. Due now, please consider ordering Further review of Resident R3's MRR dated 12/22/2025 revealed the physician agreed with the recommendations acknowledged by a signature but no date of when the MRR was reviewed.Review of Resident R3's clinical record revealed Resident R3 didn't receive an updated AIMS test until February 3, 2026. Review of Resident R5's Medication Regimen Review Recommendation to Prescriber dated February 23, 2026, revealed recommendations to reassess need for Pantoprazole medication (proton pump inhibitor). The physician did not review and acknowledge the MRR until April 1, 2026. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure to document the Code Status for one of 35 residents reviewed (Resident R4).Findings Include:Review of Facility Policy on Advance Directives, dated September 2022, revealed; Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by state law. Nursing staff will document information about whether or not the resident has executed an Advance Directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff, and the attending physician provides information to the resident and legal representative regarding the residents' health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan.Review of Literature indicated that the code status of a resident in a nursing home in Pennsylvania is a critical aspect of their care plan. It specifies the type of emergency treatment the resident would or would not receive if their heart or breathing stops. This information is essential for healthcare providers to determine the appropriate level of care, whether it involves life-saving interventions or comfort care based on the residents' wishes. The code status is documented in the medical record and is a resident's right and dignity issue that sets the tone for person-centered care.Review of Resident R4's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of Acute Renal Failure (the sudden, often reversible loss of kidney function), and Acute Respiratory Failure (a critical, rapid-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide)Review of Resident R4's electronic medical record revealed no information on the code status for R4.Interview with the Director of Nursing, on April 7, 2026, at 12:50 p.m. confirmed the electronic medical record did not accurately reflect the code status of Resident R4. 28 Pa Code 211.12(d)(5) Nursing services.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for 1 of the three residents reviewed. (Resident R250).Findings include:Review of the facility policy titled Enhanced Barrier Precautions, December 2024, revealed that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multidrug-resistant organisms (MDROs). Under bullet #2, Enhanced Barrier Precautions apply when a resident is infected or colonized with a CDC-targeted MDRO but does not have a wound or an indwelling medical device and does not have secretions or excretions that cannot be covered or contained; or when a resident not known to be infected or colonized with any MDRO has a wound or an indwelling medical device and does not have secretions or excretions that are unable to be covered or contained, and contact precautions do not otherwise apply. Under bullet #4, it further states that standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.Review of the clinical record of Resident R250 revealed that the resident was admitted to the facility on [DATE], with diagnoses of encephalopathy (brain dysfunction) and encounter for attention to tracheostomy (a hole in the neck created to help a person breathe). Resident R250 had a physician order dated March 31, 2026, for change disposable inner cannula once daily on the day shift. Inner cannula type: Shiley inner cannula size #6.On April 7, 2026, at 9:45 a.m., observation of tracheostomy care was conducted with Registered Nurse Employee E3, who performed a change of the disposable inner cannula and was not wearing an Enhanced Barrier Precautions gown during the care. The Enhanced Barrier Precautions sign was posted outside Resident R250's door, and personal protective equipment (PPE) was available.On April 8, 2026, at 10:23 a.m., an interview with the Infection Preventionist, Employee E6, confirmed that when providing tracheostomy care and changing the inner cannula, staff are required to follow Enhanced Barrier Precautions and Employee E3 should have been wearing a PPE gown.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on observation, review of facility policy, clinical record review and interview with staff and residents, it was determined that the facility did not maintain complete and accurate medical records for one of 12 records reviewed (R1)Findings Include: Review of clinical record revealed that resident R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to, low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis. The resident died in the facility on [DATE].Review of physician orders for resident R1 revealed an order for OxyCODONE HCl Capsule 5 MG Give 1 capsule by mouth every 4 hours as needed for Pain. The order was active from [DATE], to [DATE], when it was discontinued following her death.A nursing note for resident R1 signed by employee E3, dated [DATE], at 3:09 a.m. stated s/s (signs and symptoms) of pain. x1 prn (as needed) med oxycodone given. [Positive] result. Review of the narcotic reconciliation log revealed that an oxycodone was signed out on [DATE] at 1:38 a.m. Review of the medication administration record (MAR) revealed that the dose was not signed out in the MAR.An interview was conducted on [DATE], at 2:00 p.m., with employees E1, the Nursing Home Administrator, and E2, the Director of Nursing. They confirmed that no dose of oxycodone was signed out on [DATE], and that it is the expectation of the facility that all narcotics be signed out both in the narcotics log and the MAR.

Based on the review of facility documentation, clinical records and interviews with resident and staff, it was determined that the facility failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R2)Findings include: Interview with Resident R2 on January 26, 2026, at 11:00 a.m., stated she did not receive her medication muscle relaxant for the past two weeks, resident stated she was routinely taking it before sleeping to relive muscle spasm. Resident stated staff told her the medication was not available from the pharmacy. Interview with Employee E3 on January 26, 2026, at 12:00 p.m., confirmed that the medication was not available in the cart to give it to the resident. Review of physician orders for Resident R2 dated November 10, 2025, revealed medication orders for Cyclobenzaprine HCl Tablet 10 MG Give 1 tablet by mouth every 8 hours as needed for muscles spasms. Review of medication administration record (MAR) for Resident R2 for the month of December 2025 revealed that the resident received the medication, Cyclobenzaprine HCl Tablet, 15 times for the month, 11 of the 15 administration was at bedtime between 8 p.m. and 10 p.m. The last recorded administration was on December 28, 2025. Review of medication administration record for Resident R2 for the month of January 26, 2026 revealed did not receive, Cyclobenzaprine HCl Tablet for the month. Resident did not receive the medication after December 28, 2025. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(f)(2)(4)(k)Pharmacy services.

Based on interviews and record reviews, the facility failed to provide a resident environment free of accident hazards for one resident (Resident R1), resulting in Resident R1, who was diagnosed with dementia, accessing the facility's main kitchen unattended and unsupervised during nighttime/after-hours. One of five residents reviewed.Findings include:Review of the clinical record for Resident R1 revealed diagnoses that included dementia(a range of medical conditions characterized by a decline in memory, language, and thinking skills severe enough to reduce a person's ability to perform everyday activities) and anxiety.Review of the MDS (assessment of resident needs) dated August 22, 2025, revealed that the resident had a BIMS(Breif Interview for Mental Status) score of 3, which indicated that the cognitive status for Resident R1 was severely impaired.Review of the facility investigation dated August 27, 2025, revealed that staff responded to a fire alarm activated in the kitchen and found Resident R1 in the kitchen, seated in her wheelchair, stating she had been looking for a snack. Further review of the investigation revealed that the resident was on the third floor at 8:30 p.m., and at 8:45 p.m., staff could not locate the resident when they heard the fire alarm. The resident went to the first floor and stated she pulled something and did not know what it was.Observation of the first-floor kitchen with the Administrator on January 14, 2026, at 1:00 p.m., revealed that the fire alarm pull switch was located in the middle of the kitchen after passing through the stove and other kitchen equipment. There were two fire doors and one regular door next to the switch, which led to the exterior of the building.Interview with the Administrator on January 14, 2026, at 1:00 p.m., stated that Resident R1 was located in the kitchen after staff responded to the fire alarm that was triggered by the resident. The Administrator stated that after kitchen staff leave, the kitchen should be locked so residents do not enter or access the kitchen, which contains equipment that may place residents and/or others at risk. The Administrator confirmed that on August 27, 2025, kitchen staff did not lock the kitchen, which resulted in Resident R1 accessing the kitchen.28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to furnish an appointment for outside services in a timely manner for one of 5 residents reviewed (Resident R2).During an interview on September 17, at 10:30 a.m. Resident R2 stated he needed to see an outside provider for wounds on the lower extremity which was following him in the community. Resident stated staff missed his appointment and did not arrange the transportation two weeks ago and on September 16, 2025. Resident stated staff told him prior to the appointment that the transportation was arranged. He stated at the time of the appointment he was told there was no transportation and the appointment was not completed.Resident R2's clinical record revealed an admission date of August 28, 2025, with diagnoses that included cellulitis (infection of skin) of right lower extremity and chronic venous hypertension ulcer of right lower extremity. Review of hospital record for Resident R2 on August 28, 2025, revealed that an appointment request to follow up with podiatry on September 2, 2025.Review of clinical record for Resident R2 revealed no evidence that the resident was seen by an podiatry as ordered by the hospital discharge summary. There was no documented reason for the cancellation of the service.Review of clinical record for Resident R2 revealed a wound care/podiatry consult report dated September 9, 2025, which indicated a follow up appointment with the provider on September 16, 2025, at 1:30 p.m.Review of clinical record for Resident R2 revealed no evidence that the resident was seen by an podiatry on September 16, 2025, at 1:30 p.m. There was no documented reason for the cancellation of the service.During an interview with Employee E2, Director of Nursing, on September 12, 2025, at 12:00 p.m. could not give a reason for not sending Resident R2 the appointment. Employee E2 confirmed that the facility missed Resident R2's appointment on September 2 and September 16. 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of five clinical records reviewed (Resident R2).Findings include:Review of Resident R1's physician progress note dated September 6, 2025, indicated that resident was noted with elevated potassium level 5.5. and indicated that the blood likely hemolyzed (a condition where red blood cells (RBCs) burst, releasing their contents into the blood plasma or serum, which gives it a reddish tinge after centrifugation) and to repeat BMP (Basic Metabolic Panel) on September 8, 2025Review of Resident R1's physician progress note dated September 12, 2025, indicated that repeat BMP ordered for September 8, 2025, was not done and ordered for CMP (a blood test that measures multiple substances in the body to assess overall health and identify potential medical conditions).Continued review of clinical records for Resident R2 revealed no evidence that the lab ordered by the physician for September 8, 2025, and ordered on September 12, 2025, was completed.Interview with the Director of Nursing, Employee E2 on September 12, 2025, at 12:00 p.m. confirmed that the staff did not obtain lab work as ordered by the medical practitioner for September 8, 2025, and ordered on September 12, 2025.28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)Nursing services28 Pa. Code 211.12(d)(3) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on policy review, staff interviews, resident interviews, and clinical record review, it was determined that the facility failed to provide showers to Resident R1 and feeding assistance to Resident R3. These were two of eight residents reviewed who were dependent on staff for activities of daily living. (Resident R1, R3).Findings include:A review of the Activities of Daily Living (ADL) Supporting Policy, last revised in April 2025, revealed: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of adult failure to thrive, dementia (irreversible degenerative disease of the brain), muscle weakness, abnormal weight loss, and repeated falls. Review of Resident R3's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 17, 2025, revealed that Resident R3 was totally dependent on staff for activities of daily living to include bed mobility, transfers, toilet use and showers. The assessment further indicated that Resident R3 required supervision/assistance for eating.Continued review of the MDS revealed that the resident's cognition was severely impaired with a BIMS score of 00 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 00 which indicates the resident was unable to complete interview). The MDS indicated that Resident R3 was rarely/never understood by others when the resident attempted to speak and rarely/never understood when others spoke to the resident.Review of Resident R3's care plan, dated January 15, 2025, revealed that under the ADL's (activities of daily living) goal, the resident had deficits related to muscle wasting, atrophy, and dementia. The intervention task for eating stated: I require set-up assistance (opening packages, cutting meat, arranging plate, etc.) with eating and drinking.On August 26, 2025, at 10:25 a.m., Resident R3 was observed sitting in a Gerry (reclining) chair with her breakfast tray in front of her. The meal was barely touched. The tray contained two uncut pancakes, two uncut sausages, scrambled eggs, oatmeal, a nutritional supplement with a straw, juice without a straw, unopened milk with no straw, and unopened syrup. There was no assistant in the dining room who provided any supervision or assistance for eating.Unit Manager, Employee E3, confirmed the observation and asked nurse aide, Employee E5, whether Resident R3 had finished her breakfast. Employee E3 further reported that Resident R3 was not alert or oriented, did not speak English, and that her primary language is Chinese. Employee E3 acknowledged that the milk and syrup had not been opened, and that the sausages and pancakes should have been cut. In addition, straws should have been placed in both the juice box and the milk carton.Nurse aide, Employee E5, confirmed that Resident R3 was assigned to her and acknowledged that the resident's food should have been cut up and the packages opened. Employee E5 then cut the resident's food and poured syrup over the pancakes. Resident R3 immediately began eating independently, picking up cut pieces of food from the plate.A comprehensive review of the clinical record of Resident R1 revealed that admission of July 12, 2025, diagnoses included lack of coordination, protein calorie malnutrition, muscle wasting and atrophy, and muscle weakness.Review of Resident R1's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated July 14, 2025, revealed a Brief Interview for Mental Status (BIMS) of 13 which indicated that the resident was cognitively intact. A review of the comprehensive care plan, dated July 12, 2025, revealed that under the ADLs goal for bathing, it stated: I prefer showers, assistance with turning and repositioning every two hours as able, I require one staff assist with bathing, and I require the assistance of one staff member and a sheet for turning and repositioning.On August 26, 2025, at 12:55 p.m., an interview was conducted with the Unit Manager, Employee E9, who confirmed that Resident R1 should have been scheduled for showers twice a week, on Mondays and Thursdays. A review of the clinical record with Employee E9 did not indicate which days showers were originally scheduled. There was no documentation under Task Documentation showing that showers were provided on Mondays and Thursdays. Employee E9 then entered the resident's scheduled shower days into Task Documentation and confirmed that R1's clinical record had been missing documentation and confirmation that showers were given on Mondays and Thursdays.On August 26, 2025, at 1:00 p.m. an interview with Resident R1 revealed that Resident R1 receives showers only once a week on Mondays. Resident R1 stated I would like to get showers twice a week.On August 26, 2025, at 2:45 p.m., Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, confirmed that the facility did not provide showers to Resident R1 twice a week and did not provide feeding assistance to Resident R3.28 Pa. Code 211.12 (d)(1) (5) Nursing Services28 Pa. Code 211.10(d) Resident care policies

Based on the review of clinical records, facility investigation, facility policies, interviews with staff and facility documentation, it was determined that the facility failed to provide appropriate supervision for Resident R1 which resulted in Resident R1 eloping from the facility and remaining out of the facility for approximately 13 hours. This failure placed Resident R1 and other residents who were identified as high risk for elopement at risk for serious harm and resulted in Immediate Jeopardy situation for one of eight residents reviewed. (Resident R1) Findings include: Review of undated facility policy Wandering and Elopements, revealed that The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct other staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. If the resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify administrator and the director of nursing services, the resident's legal representative, the attending physician, the law enforcement officials and (as necessary) volunteer agencies. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident's medical record. Review of clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulations), disorders of brain and history of cocaine use. Review of clinical record also revealed that the resident was receiving mental health services in the community and was assigned a case manager. Review of Resident R1's hospital record dated [DATE], revealed that the resident had a history of on-going cocaine use. Resident was alert and oriented with increased processing time and decreased problem solving. Review of care plan meeting note for Resident R1 dated [DATE], revealed that resident and community support team from behavioral health agency attended the conference. Discharge planning was documented as long-term care. Review of physical therapy discharge summary dated [DATE], revealed that the resident was to reside in this long-term care facility. Review of Resident R1's Minimum Data Set (MDS-assessment of resident care needs) dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 11 which indicated that the resident's cognitive status was moderately impaired. Review of care plan for Resident R1 dated [DATE], revealed that the resident had impaired cognitive function and/or impaired thought processes related to other specified disorders of the brain, past history of gun shot wound that required craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain.), metabolic encephalopathy (a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), chronic ischemic change (a restriction in blood supply to any tissue,) currently alert oriented x 3 (person, place and time). Further review of the resident's care plan revealed that the resident required supervision and assistance with decision making, Monitor/document/report to physician of significant changes from cognitive baseline i.e., decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Review of physician orders for Resident R1 for the month of [DATE], revealed no evidence that the resident had an order for LOA (Leave of Absence). Review of a statement from Employee E5, Licensed Nurse, dated [DATE], revealed that during my shift ,d+[DATE](3pm-11pm) I did not see the resident in his room when I was doing my rounds. Residents lunch tray was in his room untouched. Later on I did called the charge nurse from the morning to find out if she has seen the resident. But she was not able to answer me. So later on, I did text her that I still haven't seen the resident. Then I did inform the night supervisor that I can't find the resident. I did text the charge nurse at 11:32 p.m. that I still haven't seen the resident. Interview with Employee E5, Licensed Practical Nurse, on [DATE], at 11:48 a.m. revealed that he started shift at 3 p.m. and he did not see Resident R1 in his room. His lunch tray was untouched. Employee E5 stated resident usually go down to smoke, so he thought the resident might be on the first floor. Employee E5 stated he then got busy with medication administration and new admissions. Towards the end of the shift around 11 p.m. he texted the morning shift Licensed Nurse, Employee E6, and asked if the resident was there at the end of her shift, but she did not respond. Employee E5 stated he reported it to the supervisor. Employee E6 responded close to midnight and stated the resident was there when she left. Employee E5 also stated then the facility-initiated elopement protocol, searched rooms, perimeter of the facility, reported to Director of Nursing, reported to Police and physician. Employee E5 confirmed that the resident was not accounted for at the start of the shift or during the safety rounds he performed. Review of a statement from Employee E7, Receptionist, dated [DATE], revealed that at 11:15 p.m. a code yellow (elopement alert) was called. Review of a statement from Employee E8, Nursing Assistant dated [DATE], revealed that she was assigned to him on [DATE], ,d+[DATE] shift, but she did not see him the entire shift. She did not pass him lunch or collect the trays. Employee E8 responded to a question of Upon leaving for the day, did you see Resident R1?. She did not recognize Resident R1 was not on the unit, resident was normally downstairs with other residents. Review of a statement from Employee E9, Nursing Assistant dated [DATE], who was assigned to resident on [DATE], for ,d+[DATE] shift revealed that she did not see Resident R1 and she charted Resident R1 for a bowel movement because she saw a bowel movement in the toilet and the room mate was incontinent. Further review of statement did not reveal if the employee made rounds at the beginning of the shift, completed safety rounds, or if she reported when Resident R1 was not accounted. A request for a written statement from Employee E6, Licensed Practical Nurse, who worked on [DATE], when Resident R1 allegedly eloped from the facility, was requested on multiple occasions to the Nursing Home Administrator and Regional Nurse, Employee E3 on [DATE], [DATE] and [DATE]. No statements were submitted by the facility for review. On [DATE], the Regional Nurse, Employee E3 stated that Employee E6, Licensed Practical Nurse, completed a statement, but the statement could not be located. A request was made to rewrite the statement by the Nursing Home Administrator to Employee E6, but no statement was provided during the survey despite several requests. An attempt to contact Employee E6, Licensed Practical Nurse was attempted via telephone on [DATE] and 24, 2023. Employee E6 did not respond to the phone calls. Review of a nurses note written by Employee E6, Licensed Practical Nurse, dated [DATE], which was written six days later on [DATE] revealed, Resident R1 received his medications this morning at approx 10:30 a.m., stated he did not want his nicotine patch anymore and upon checking resident's skin, no patch was found. Tolerated meds well and had tidied up his room. He had just come back from seeing business office where he said he got his money. Resident R1 then requested to leave facility and despite center guidance, he decided to leave AMA (Against medical Advice) and refused to sign AMA document. Physician was called and made aware. Review of text message communication between Employee E5 and E6 dated [DATE], revealed that Employee E5 asked Employee E6 if Resident R1 went home?, Employee E5 stated he didn't see him throughout the shift. He just checked the notes and no note showed that he went home. Further review of the communication revealed that Employee E6 replied Director of Nursing called her, No he didn't go home. He was there I gave him his medication. Review of clinical records, statements from staff worked on [DATE], interviews with staff including administrator revealed that the above late entry by Employee E6 was inconsistent with other documentation, statements, and interviews. Interview with Employee E10, Receptionist, on [DATE], 10:37 a.m. revealed that he worked on the morning of [DATE]. He did not recognize Resident R1 leaving, Resident R1 was a new resident, and he was not familiar with him. Employee E10 stated Resident R1 walked out without a walker or wheelchair, and he could have walked out with other family members or visitors. Employee E10 stated he knows most of the residents except new residents, if a resident walks out, he should stop him, and notify the nurses. Interview with Employee E8, Nursing Assistant, on [DATE], at 10:39 a.m. stated she saw Resident R1 on [DATE]. Resident R1 got dressed up and ate breakfast. Resident R1 normally eats in his room. She stated she then went to other residents' rooms and did not see him the remaining of the shift. Employee E8 also stated she was not aware of Resident R1 was leaving or Employee E6 who was the charge nurse did not inform her of Resident R1 not available or leaving the facility. Employee E8 stated she checks all residents every 2 hours. Employee E8 stated the resident came back to the facility after a week of the elopement but was not admitted . Interview with Employee E11, Business Office Manager, on [DATE], at 12:25 p.m. stated around 9:30 a.m. Resident R1 asked me for two checks that the office had received from Behavioral Health case manager. Resident R1 told Employee E11, Business Office Manager, that a friend would cash the check for him. Resident R1 was approved for Medicaid and his plan was to stay long term care. Interview with Nursing Home Administrator, Employee E1 on [DATE], at 12:41 p.m. confirmed that the facility did not recognize Resident R1's elopement until approximately 11:30 p.m. Facility staff failed to prevent Resident R1 from leaving the facility without appropriate supervision or physician order. Employee E1 also confirmed that Employee E6, Licensed Practical Nurse, and E8, Nursing Assistant, did not complete safety checks on Resident R1, Licensed Practical Nurse, Employees E5 and Nursing Assistant, E9 failed to complete initial check, routine checks throughout the shift on [DATE]. The Nursing Home Administrator confirmed that Employee E6's note which was written 6 days later was not an accurate documentation of incident happened on [DATE]. Review of clinical records for [DATE], revealed the resident possibly left the facility after 10:30 a.m. but prior to lunch time at noon. Interview with Nursing Home Administrator, Employee E1, on [DATE], at 4:00 p.m. stated all the exits doors were equipped with alarm and wander guard system, if the door is opened without access it would alarm. Employee E1 also stated there was no evidence of a door alarm on [DATE]. Employee E1 also stated facility assumed Resident R1 walked out the front door, which was locked and had receptionist present 24 hours a day. Review of nursing assistant documentation revealed that the staff did not document any evidence that the staff provided supervision, Activities of Daily Living assistance, documentation of intake and output, and skin check for 3p.m. to 11 p.m. shift on [DATE]. Review of clinical record revealed that the facility placed a physician order in the chart for AMA (Against Medical Advice) discharge on [DATE]. Clinical record revealed that the resident eloped from the facility on [DATE]. Review of Medication Administration Record dated [DATE], revealed that the staff documented staff consumed ensure supplement 100% on [DATE], at 9:00 a.m. A pain level of 0 was documented on [DATE], for Day shift. Review of vital signs documentation revealed that a pain level of 0 was documented by Licensed nurse, Employee E5 on [DATE] at 5:20 p.m. which was deleted at 11:43 p.m. The facility's failure to provide appropriate supervision put Resident R1 and other residents of the facility at risk for harm. The NHA was notified of the Immediate Jeopardy on [DATE], at 1:24 p.m. An Immediate Plan of Correction was requested. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE] at 1:24 p.m. The Immediate Plan of Correction was provided by the facility, on [DATE], at 4:35 p.m. and was accepted. On [DATE], the facility initiated a plan of correction to address the facility's failure to provide appropriate supervision which put Resident R1 and other residents of the facility at risk for harm. Facility plans of correction included the following: 1. Resident R1 no longer resides in the Center. 2. Night shift RN (Register Nurse) Supervisor on [DATE] into [DATE] completed a head count of all residents and compared it to the midnight census to ensure all residents were accounted for except [Resident R1] 3. Immediate Actions/Education - Nursing Administration reviewed all resident EHR (Electronic Health Record) for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. Elopement books found at reception desk and on every unit were reviewed to ensure that all residents identified as elopement risks were current and resident identifiers were available. - Review of Center elopement drills for completeness and staff participation. Plant Operations provided elopement drills held monthly for the last quarter. - RN Supervisors were educated on completion of head count of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee. Completed [DATE] for 90 %. Remainder will be educated prior to next shift - Nursing staff educated on importance of accurate documentation of meal consumption/absence of meal and immediate notification of Charge Nurse. - Staff educated on signs and symptoms that may indicate a risk of elopement. - Staff educated on Leave of Absence Policy including the use of a pass system that is initiated on the nursing unit and is verified by the reception/security team - Reception/security educated on process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. In addition, education provided on Leave of Absence Policy including the use of the pass system. - Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premise and the surrounding areas, notification processes including Philadelphia Police Department. -Staff educated on elopement drills including how often and expected responses. 4. Ongoing Compliance will be monitored by: - Auditing census compared to head count every 4 HRS (hours) for 3 days then every 8 HRS for 3 days then every shift for 14 days then daily. - Interviewing alert and oriented residents to ensure staff is checking in every 4 HRS for 3 days then every 8 HRS for 3 days then every shift for 14 days then daily - Reviewing leave of absences to ensure compliance to pass system every 4 HRS for 3 days, every 8 HRS for 3 days then every shift for 14 days then daily. 5. All ongoing compliance audits will be presented and reviewed at the QAPI (Quality Assurance Program Improvement) meeting monthly for the next 6 months. On [DATE] the action plan was reviewed and interviews were conducted with Licensed Nursing staff, Registered Nurses and Nursing Assistants regarding education related to elopement protocol and resident safety check according to the facility protocol. Staff also stated that they received sufficient trainings from the facility. Nurses verbally demonstrated knowledge of elopement prevention and facility safety check protocol. The Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on [DATE], at 5:59 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies

Based on clinical record review, review of facility policy, and interviews with staff, it was determined the facility failed to ensure one of three residents reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new pressure ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R455. Findings include : Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated stated, The nurse shall describe and document the full assessment of a pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. The purpose of the procedure is to provide information regarding identification of pressure ulcer/injury, risk factors, and develop interventions for specific risk factors. Review of Resident R455's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with Diabetes Type Two (A chronic condition that affects the way the body processes blood sugar ), high blood pressure, Traumatic Hemorrhage of cerebrum (bleeding in the brain) with loss of consciousness, volvulus (a loop of twisted intestine causing bowel obstruction), dementia, a history of falling, and cerebral infarction (stroke). Review of Resident R455's admission Minimum Data Set (MDS an assessment of resident's needs) dated August 19, 2022, revealed a brief interview for mental status (BIMS) was conducted revealing he was cognitively intact, was frequently incontinent of urine and used an ostomy for bowel, needed extensive assistance with 1-2 people for bed mobility, transfers, dressing, toileting, and bathing. Review of Resident R455's care plan revealed a potential impairment to his skin integrity and a potential to develop pressure ulcers related to his fragile skin, impaired mobility, and incontinence, dated August 15, 2022. Interventions included weekly preventative skin checks as ordered dated August 15, 2022. Review of Resident R455's Quarterly Minimum Data Set (MDS an assessment of resident's needs) dated November 18, 2022, revealed under Section M - Skin conditions revealed No was answered for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher. Review of Resident R455's physician orders dated August 15, 2022, instructed the nurses to perform weekly skin checks to assess the resident's skin for potential impairment or developing pressure ulcers as delineated in the resident's care plan. Review of Resident R455's nursing progress note dated January 10, 2023, revealed the resident had a deterioration in health. The resident was transferred to the hospital due to abnormal vital signs, fever, low/high blood pressures, increased heart rate, respiratory, weight changes and a skin wound or ulcer. Review of Resident R455's clinical record did not include further wound assessments and/or documentation related to the wound. Review of Resident R455's Weekly Checks revealed the last documented skin check completed by a licensed nurse was on December 23, 2022, 18 days prior to the resident's hospital transfer. Review of Resident R455's hospital notes dated, January 11, 2023, revealed a community-acquired, unstageable pressure injury to the resident's sacrum. The hospital note described the pressure ulcer extending to the resident's bilateral buttocks with 100% nonviable (necrotic) tissue, scant to moderate amount of serosanguineous (yellowish fluid mixed with blood) drainage. The resident was also documented positive for incontinence associated dermatitis (exposure to urine on the skin causing damage and increasing the risks of developing pressure ulcers). The lack of the facility performing weekly skin checks, wound assessments, and/or documentation related to the wound revealed the resident failed to receive the necessary services to prevent new pressure ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R455. During the survey, the surveyor requested from the Director of Nursing, the Assistant Nursing Home Administrator, and Registered Nurse, [NAME] President of Growth and Professional Development, Employee E4 the facility's policy on weekly skin checks, the nursing assessments for the missing weekly skin checks, the nursing assessment when the pressure ulcer was found on Resident R455's sacrum including the date, location, stage, length, width and depth, any presence of exudate or necrotic tissue. The facility failed to provide the surveyor the additional documentation and/or assessments. On April 20, 2023, at 3:30 p.m. Registered Nurse, [NAME] President of Growth and Professional Development, Employee E4, stated Resident R455 was very sick and needed to go to the hospital, the facility did not have time to measure wound. The VP stated she could not answer why the physician orders for weekly skin checks were not completed by nursing or why the pressure ulcer was found at such an advanced stage. The facility failed to ensure one of three residents reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new pressure ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R455. 28 Pa. Code 211.5 (f) Clinical Records 28 Pa. Code 211.12 (d) (1) Nursing Services

Based on a review of clinical records and facility policies, observations and staff interviews, it was determined that the facility failed to implement wound care practitioner's recommendation of heel protection and pressure reduction to Resident R1's bony prominence, to consistently provide pressure ulcer interventions in accordance with the resident's plan of care; to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who developed five new facility acquired pressure sores, for one of five clinical record reviewed. (Resident R1) Findings include: A review of an undated facility policy entitled, Pressure Ulcers/Skin breakdown-Clinical protocol, 1. The nursing staff and practitioner will assess and document an individual's significant risk factor for developing pressure ulcers; for example immobility, recent weight loss, and a history of pressure ulcer(s), 2. In addition the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue; b. Pain assessment; C. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of non traumatic intracerebral hemorrhage (bleeding into the brain tissue), acute embolism of the deep vein of the lower extremities, muscle weakness, lack of coordination, cognitive communication deficit and dysphagia (swallowing difficulties). Review of the admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 17, 2022, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living including bed mobility, transfers, and toilet use. The resident's cognition was severely impaired with a BIMS score of 99 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 99 which indicates the resident was unable to complete interview). The MDS indicated that Resident R1 was rarely/never understood by others when the resident attempted to speak and rarely/never understood when others spoke to the resident. Review of Resident R1's plan of care, dated November 11, 2022, revealed that a plan of care was developed related to pressure ulcers, and impaired mobility. Interventions included to cover left and right hip, bony prominence with large foam pads daily and as needed one time a day for preventative measures. Monitor and document changes in skin status such as: appearance, color, wound healing, signs and symptoms of infection, changes in wound size or stage to physician or designee as clinically indicated. Assistance to turn and reposition every 2 hours. Review of Resident R1's physician order dated November 12, 2022, revealed an order to apply large foam pads to left and right hip bony prominence daily and as needed for prevention. Continued review of physician order revealed an order dated November 27, 2022, for a wound treatment order to the sacrum. Review of wound care practitioner's documentation dated November 18, 2022, revealed that the resident had a pressure injury to the sacrum. Pressure reduction and turning precautions discussed with staff at time of visit and recommended heel protection and pressure reduction to bony prominence. Continued review of Resident R1's clinical record revealed that the resident was transferred to the hospital on November 19, 2022 and returned to the facility on the same day. Review of the resident's readmission orders revealed that there was no physician order for prevention of skin to left and right hip bony prominence. A skin observation of Resident R1 conducted on December 12, 2022, at 10:53 a.m. with Licensed nurse, Employee E4, revealed that the resident had a sacral wound with dressing in place. It was also observed that the resident had a right trochanter (around right hip bone area) wound with dressing in place. The right trochanter wound had moderate amount of drainage with slough at the wound base. Continued observation revealed that the resident had another open wound to his left trochanter area without dressing. The wound was not covered or appeared to have any treatment applied. Resident R1's heels were lying flat on the bed and there was no offloading devices used. Resident R1's feet were observed to be dry and cracked. Review of Resident R1's entire clinical record revealed no documented evidence that the facility assessed Resident R1's right trochanter and left trochanter wounds, including date of origin, location, stage, width, length, depth and presence of exudate. A review of the Resident R1's task (care card) documentation related to turning and repositioning revealed no documented evidence that nursing staff provided turning and repositioning consistently. There was no evidence that the staff provided turning and reposition on December 11, 2022, 7a.m.-3p.m. and 3p.m.-11p.m shift, December 10, 2022 on 7a.m.-3p.m. and 3p.m.-11p.m. shift, December 9, 2022 3p.m.-11p.m. shift, December 8, 2022, 7a.m.-3p.m. and 3p.m.-11p.m. shift, December 7, 2022, 7a.m.-3p.m. and 3p.m.-11p.m. shift, December 6, 2022, 3p.m.-11p.m. shift, December 5, 2022, 7a.m.-3p.m., 3p.m.-11p.m. and 11.-7a.m. , December 4, 2022, 7a.m.-3p.m., 3p.m.-11p.m. and 11.-7a.m. , December 3, 2022 7a.m.-3p.m., 3p.m.-11p.m. and 11.-7a.m. , December 2, 2022 7a.m.-3p.m. shift and December 1, 2022 7a.m.-3p.m. and 3p-11p.m. shift. A review of a turn and reposition record for November 2022, revealed the form was incomplete and revealed multiple days and times throughout the month of November 2022 that the resident was not turned and repositioned according to the resident's care plan. A review of a preventative skin care record to be completed by the nursing staff for November 2022, through December 12, 2022, revealed the form was incomplete and revealed multiple days and times throughout both months that there was no evidence that preventative skin care to the resident was provided according to the plan of care. Interview with Assistant Director of Nursing, Employee E3, on December 12, 2022, at 2.12 p.m. stated that there were no documented evidence of an assessment of the right and left trochanter wounds including location, stage, length, width and depth, presence of exudate or necrotic tissue. Further, there was no evidence that the physician was notified of these wounds. Interview with Licensed nurse, Employee E5, on December 12, 2022, at 2.53 p.m. confirmed that the facility did not have any documentation of Resident R1's right and left trochanter wounds, date of origin, wound assessment, family and physician notification. There was also no treatment ordered for right and left trochanter open wounds. A wound measurement provided by Licensed nurse, Employee E5 on December 12, 2022, at 2.53 p.m. revealed that the right trochanter wound measured 4.2 centimeter (cm) x 6.6 cm with slough and appeared as an unstageable wound. Employee E5 confirmed that the wound appeared deep and advanced. Left trochanter wound measured 2.3cm x 0.6 cm. with eschar (dead tissue that falls off (sheds) from healthy skin). During an interview with Wound Care Practitioner, Employee E6, on December 13, 2022, at 11:05 a.m. stated right and left trochanter pressure ulcers confirmed that the pressure ulcers were unstageable. Employee E6 also stated she found another wound during rounds to the resident's left heel. Wound Care Practitioner, Employee E6 identified it as DTI (Deep Tissue Injury- an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Employee E6 stated all the wounds identified on Resident R1 were classified as pressure ulcers. A review of Wound Care Practitioner's documentation, dated December 13, 2022, revealed that five new pressure ulcers were identified on Resident R1 as follows: bilateral trochanter unstageable pressure injury, right elbow unstageable pressure injury, left heel suspected DTI and left plantar foot suspected DTI. The facility failed to implement wound care practitioner's recommendation of heel protection and pressure reduction to bony prominence, to consistently provide pressure ulcer interventions in accordance to the resident' plan of care, to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who development five new facility acquired pressure sores. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(a)(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on interviews with residents and staff, review of clinical records, review of facility policies and review of facility documentation, it was determined that the facility failed to implement interventions to assure one resident (Resident R151) was free from physical abuse and mental anguish resulting in actual harm to Resident R151 who was hit on the face on two separate instances for one of 39 resident records reviewed (Resident R151). Findings include: Review of the facility's policy titled, Abuse Prevention Program, not dated, revealed that the facility's residents have the right to be Free from abuse and neglect. This includes, Verbal, mental, and physical abuse. The same policy stated that their implementation protocol consists of Protecting our resident from abuse by anyone including .other resident. Further review of the facility's policy revealed Implement measures to address factors that may let to abusive situations . understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Review of Resident R151's clinical record revealed that the resident was admitted on [DATE], with the diagnosed of septo-optic [CONDITION(S)] of the brain (underdeveloped optic nerves), legally blind, muscle weakness, [CONDITION(S)] and anxiety. Review of Resident R151's admission Minimum Data Set (MDS is an assessment of resident's care needs) dated May 18, 2022, revealed the resident was cognitively intact and needed limited assistance of one person for bed mobility, transfers, walking in room, corridor, and locomotion on the unit. Continue review of the MDS assessment revealed that the resident used a walker for mobility. Review of Resident R151's care plan, initiated on May 18, 2022 identified the resident with a potential mood problems related to [CONDITION(S)], and Anxiety Disorder. The care plan noted that Resident R151 was hit by a resident. The goals listed included for the resident to have no signs and symptoms of depression, anxiety, or sadness through the next review date scheduled on August 25, 2022. The interventions included medication administration, monitor and document for side effects and effectiveness, assist the resident to identify and reinforce strengths and positive coping skills. Interventions also included Behavioral health consults as needed (psycho-geriatric team and psychiatrist), to monitor/record mood to determine if problems seem to be related to external causes, to monitor/record/report to the physician as needed acute episode feelings or sadness: anxiety, and sad mood. On May 27, 2022, the care plan interventions were updated to include psychology consult and treatment as needed. There were no other updated interventions to the resident's care plan since May 27, 2022. Review of Resident R151's nursing notes dated May 17, 2022, revealed that the resident had an altercation with another resident. Resident R151 was hit in the face x 2 by a confused resident who has dementia. Resident is AAOx3 (people, place, and time), denies pain or discomfort. No redness, bruising, or swelling noted. Resident stated that he is ok. Continue review of nursing notes dated June 4, 2022, noted resident was hit in the face x 3 by another resident. Both residents immediately separated. Resident is awake, alert and oriented x 2-3. Resident assessed. No visible injuries. C/o (complaint) pain to left side of face. PRN (as needed) Tylenol given by charge nurse with positive effect. Further review on nursing documentation dated June 5, 2022, revealed Resident states that another resident rolled over his left foot with his wheelchair while sitting outside on the patio. Nursing supervisor assessed left foot and toes, no apparent injuries, no swelling or redness noted. Vital WNL (within normal limits) Review of the facility reported incident related to the altercation of May 17, 2022, revealed Resident R151 came to visit Resident R34's roommate, Resident R36. Resident R151 knew Resident R36 from outside in the community. Resident R34, whom the facility report described as Demented and suffered from cognitive impairment went over to Resident R151 and hit him in the forehead with his fist. Interview conducted with the Nursing Home Administrator on June 10, 2022, at 9:30 a.m. revealed that Resident R151 and R36 were once life partners. Resident R34 was Resident R36's roommate. Resident R34 would visit at night and Resident R34 would see Resident 151 on Resident R36's bed. Resident R34 did not like seeing them together, that was why Resident 34 hit Resident 151. After the incident the facility moved Resident 36 to another floor. As a result of the change in rooms Resident R36's new roommate on the 3rd floor of the facility is Resident R178. Review of Resident R178's clinical record revealed that the resident was admitted on [DATE], with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R178 admissions MDS, dated [DATE], revealed the resident was cognitively intact, needed extensive assistance of two people for bed mobility, limited assistance of one person for transfers, dependent on staff for locomotion on the unit, and used a walker and wheelchair for mobility. Resident R178's care plan initiated June 4, 2022, revealed a focus for the potential to demonstrate physical behaviors. The goals included for the resident to demonstrate effective coping skills through the review date, to seek out staff/caregiver when agitation occurs, and will not injure self or others. Interventions dated June 4, 2022, included to administer, and monitor the effectiveness of medications per physician order, evaluate for side effects of medications, and intervene as needed to protect the rights and safety of others; approach in a calm manner; divert attention, remove from situation, and take to another location. Review of the facility's reported incident dated Saturday, June 4, 2022, stated, Resident R151 frequently visited his former life partner, Resident R36. Continuing the same report indicated that Resident R178 went to the 2nd floor to utilize the patio area and saw Resident R151 going into his room. Resident R178 went into the room and punched Resident 151 two times in the face and kicked him once. The report continues to state that when Resident R178 was asked why he did it he stated, 'He does not condone that sexual preference. The follow-up action was for Resident R178 not to go to the 2nd floor. During interview with the Nursing Home Administrator on June 9, 2022, at 9:30 a.m. it was confirmed that Resident R178 was not restricted to go on to the 2 nd floor since Resident R178 always had unsupervised access to the 2nd floor and to all floors in the facility. Observation on June 9, 2022, at 1:00 p.m. revealed Resident R178 alone, unsupervised, in his wheelchair using the elevator, getting off onto the 2nd floor. The resident appeared confused and said he just came from the 4th floor but got back on the elevator to the first floor with the surveyor. June 9, 2022 at 2:30 p.m. the surveyor observed Resident R178 in his wheelchair coming off the elevator onto the 2nd floor unsupervised and wheeled himself to the nurse's station. Registered Nurse (RN) Employee E17 spoke to Resident R178 and tried assisting him. He appeared confused and said he was looking for the elevator. Immediately afterwards the surveyor asked the RN if she knew anything about the resident. The RN stated she did not know who the resident was or what floor he lived on. Review of Resident R178's clinical record revealed a psychiatric consultation dated, June 7, 2022, which confirmed that the resident was diagnosed with Adjustment Disorder with mixed disturbance of emotions and conduct, related to his inappropriate behaviors, lacking impulse control and the need for intensive services due to his physical altercation with Resident R151 and his inappropriate expressions of anger. Continue review revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatric consultation also made referenced of the resident's last facility's diagnostic evaluation which stated that Resident R178 presented with, Anger, irritability, inappropriate expressions of anger, inappropriate sexual comments towards staff and difficulties with compliance. The treatment plan was to continue psychological support. Interview conducted with Resident R151, on June 7, 2022, at 1:32 p.m. revealed the resident was able to describe the altercation with Resident R178 on June 4, 2022. Resident R151 stated I am legally blind, so I really didn't see him coming. He hit me in the face a few times and kicked me. The resident explained that Resident R178's room was on the 3rd floor but comes down to his floor to smoke. (The second-floor patio is the designated smoking area for the residents). The resident then stated that the next day, on Sunday, June 5, 2022, Resident R178 saw him sitting at the top of the ramp, near the smoking area. He kept on taunting me and calling me names. Then ran his wheelchair over my foot and it wasn't an accident. I went to the bottom of the ramp but he kept staring at me, making faces. I went to the nurses, and they took a report and I also got x-rays. I would like the facility to protect me! Review of Social Worker (SW), Employee E24's progress notes dated June 7, 2022, revealed SW visited with [Resident R151] to follow up on recent encounter. He informed SW that he is ok and had no concerns at this time. No psychosocial stressors observed during visit. He also informed SW that he feels safe in the facility. Interview conducted on June 9, 2022, at 12:00 p.m. with Resident R151 stated I never told anyone I felt safe. He (Resident R178) has me so paranoid. I hear his voice and go the other direction. Resident R178 has always been nasty to me. He would always call me a Faggot when I went to visit Resident R36 on the third floor. Review of Resident R151's nursing note, dated June 5, 2022, from Registered Nurse (RN), Employee E25, which was struck out for incorrect documentation revealed Resident states that another resident rolled over his foot with his wheelchair. They had a previous altercation and resident feels afraid for his life, and that he is being terrorized. Interview conducted on June 10, 2022, at 2:00 p.m. with Registered Nurse, Employee E25, revealed I crossed out my initial note and rewrote it because I did not indicate what foot was injured. I might not have included that part in the rewritten note but the resident did tell me he feels afraid for his life and that he is being terrorized. Interview conducted on June 9, 2022, at 9:30 a.m. the Nursing Home Administrator (NHA) revealed I spoke with Resident R178 and he told me that when he went to the second floor to smoke, he saw Resident R151 on the floor and it 'Triggered him' so he punched him. The NHA continued, I told him he can't do that and he said okay. The NHA was asked what interventions the facility had put in place to protect Resident 151 from further physical abuse and mental anguish from Resident R178. The NHA indicated that a psychological evaluation was obtained for Resident R178's and that the facility was in the process of obtaining a psychological evaluation for Resident R151. The facility failed to protect Resident R151 for further physical abuse and mental anguish from Resident R178 after the June 4, 2022, when Resident R178 punched Resident R151 on the face. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, review of facility documents and interviews with staff and residents, it was determined that the facility failed to ensure Resident R1 was free from resident to resident abuse, resulting in actual harm to the resident who was sexually abused for one of five residents reviewed (Resident R1). Findings include: A review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident utilized a wheelchair for ambulation. A review of Resident R1's Quarterly Minimum Data Set (MDS-a periodic assessment of needs) dated February 11, 2020 revealed that Resident R1 had a Brief Interview for Mental Status (a brief screening tool that aids in detecting cognitive impairment.) score of 12, indicating that the resident had moderate cognitive impairment. A review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident utilized a walker for ambulation and was not able to ambulate without the walker. A review of the most recent Annual Minimum Data Set assessment for Resident R2 dated February 2, 2020, revealed that Resident R2 had a BIMS score of 15 which indicated that the resident was cognitively intact. The resident was not assessed as experiencing any behavior or mood symptoms. Review of Resident R2's clinical record revealed a nurse progress note dated February 24, 2020, which revealed Aide reports to this nurse that resident exhibited sexual inappropriate behaviors during this shift. Aide states that after lunch resident was observed lying in bed rubbing his chest with both of his hands. She then observed him thrusting his hips in the air as if he were engaging in sexual intercourse. Aide then reports that resident continued to touch himself. Review of Resident R1's clinical record revealed a nurse progress note dated May 4, 2020, which revealed Informed by staff member resident reports that she had a negative interaction with another (Resident R2). Review of a facility investigation dated May 4, 2020, revealed Resident R1 was asked the following Can you tell me what happened . He (Resident R2) came into my room I sitting in my wheel chair waiting for my dinner. He started to grab both of my thighs. He said he liked me I told I liked him too that he was a cool person. He then started lift up my shirt and touch me on my chest and sucked on my right breast. I told him I don't like it to stop it. I used my hand to push him away then he stopped. Then dinner came, the lady that came saw him in my room and he left. Was he aggressive with you? . yes he wouldn't leave . Review of Resident R1's clinical record revealed a nurse progress note dated May 5, 2020, which revealed Narrative nurse was summons to the resident as the resident is being monitored for behavior. Resident was observed during breakfast screaming, crying, pulling her hair and reaching for the butter knife on the tray expressing that she did nothing wrong and that she wants to speak to psych. Sharp objects removed from the residents area and the resident was calmed after a phone called was placed to her aunt and her girlfriend. An interview with Resident R1 on May 7, 2020, at 12:15 p.m., where she stated that Resident R2 touched up here on my top (pointing to her breast), then down where she pointed her finger to her crouch area. She said she didn't like that it happened to her. She said that she doesn't like guys and that she deals with females He started to feel on my body and I told him that it wasn't right, but he still started to feel my body. I didn't like it from the start I don't deal with guys like that. She said a different time it happened. She said I stopped him and he did, so I didn't tell anybody. She said the second time, I didn't know it was going to escalate. He sat on my roommates' bed. He asked to sit on my bed and I said no. Staff came in and he stopped. During an interview with the Nursing Home Administrator on May 7, 2020, at 10:45 a.m., the Nursing Home Administrator stated that Resident R2 would not talk or be interviewed regarding the incident involving Resident R1 on May 4, 2020. The administrator stated that he reviewed the hallway's camera tape log, where he was able to see on the camera that Resident R2 went into Resident R1's room at 6:16 p.m. and left the room at 6:31 p.m. on May 4, 2020. Review of Resident R2's clinical record revealed no plan of care with interventions developed regarding Resident R2's verbalized and demonstrated sexually behaviors, During an interview on May 7, 2020, at 12:30 p.m. with Employee E3, nurse aide, she indicated that Resident R2 likes to walk around on the unit and he doesn't like to be told to do things . he talks and curses to himself . he lifts up his shirt and scratches his body. During an interview on May 7, 2020, at 12:37 p.m. with Employee E4, licensed nursing staff indicated that Resident R2 often appears agitated. During an interview on May 7, 2020, at 1:35 p.m. with Employee E5, nurse aide, indicated that Resident R1 is scared, she's jumping, she wants to be out in the hallway with me. I told her to stay in her room because it's safer and we can watch out for her. She's very shook up . after incident her anxiety is more pronounced. During an interview on May 7, 2020, at 1:45 p.m. with Employee E6, nurse aide, indicated that Resident R2 usually walks in the hallway. He doesn't want to put mask on (COVID-19) related to paranoid thinking that medicine is going through the mask. He would say your looking good today . oh she has a big butt when referring to other women on the unit. During an interview on May 7, 2020, at 2:00 p.m. with Employee E7, licensed nursing staff confirmed that Resident R1 on the morning of May 5, 2020, was upset screaming and crying stating that she didn't do anything. The facility staff failed to ensure that Resident R1 was free from sexual abuse which resulted in actual harm to Resident R1 being sexually abuse by Resident R2. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, facility documentation, facility policy and procedure and interviews with residents and staff, it was determined that the facility failed to ensure that one of 44 residents reviewed were protected from neglect which resulted in actual harm to one resident (Resident R192) who was hospitalized with significant head trauma. Additionally, this failure put the health and safety of all residents at risk for neglect and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled Abuse Prevention Program dated revised (MONTH) 22, (YEAR), revealed that residents . have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. ( Collectively hereinafter abuse). Further review of the policy revealed that the facility defined neglect as . failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. Review of the clinical record for Resident R192 revealed that the resident was admitted to the facility (MONTH) 21, 2011 with [DIAGNOSES REDACTED]. blood pressure). A review of a quarterly Minimum Data Set (MDS- assessment of resident needs) dated (MONTH) 14, 2019 revealed that the resident had severly impaired vision and was totally dependent on staff for all activities of daily living. The resident required the physical assistance of two persons with bed mobility, transfers, dressing and full body bath/shower. A review of Resident R192's care plan indicated that the resident required the physical assistance of two persons for bed mobility, dressing and transfers. Continued review of Resident R192's clinical record revealed nurses' notes dated (MONTH) 30, 2019, at 9:00 a.m. which indicated that the nursing supervisor was called to assess Resident R192 for the presence of a hematoma (a collection of blood outside of a blood vessel) on top of the forehead to the right side. The injury was described as a non-tender bump, blue in color. Further review of Resident R192's clinical record revealed that on the following day (MONTH) 31, 2019, at 6:59 a.m. the nurse had noted: right side of face, eye and forehead hematoma. On (MONTH) 31, 2019, at 9:26 a.m., approximately one and a half hours later, the nurse noted that the resident was assessed for worsening of right forehead hematoma of unknown origin. Resident observed to have periorbital (above and below the eye) swelling with bruising to right side of face which was not observed upon initial assessment. Resident appears to be more lethargic (difficult to arouse). Unable to perform pupillary assessment due to swelling of right periorbital and resident is uncooperative with assessment of left eye. Physician notified, order given to send resident to the hospital for a CT (Computerized Tomography-CAT scan) of the head. A review of hospial records revealed that Resident R192 was admitted to hospital on (MONTH) 31, 2019, with facial contusions (bruises) and [MEDICAL CONDITION] (excessive body/lung fluid caused by weakened heart muscle). The results of a CT scan of the head dated (MONTH) 31, 2019, revealed the presence of . a large right frontal scalp hematoma. A repeat CT Scan completed on (MONTH) 2, 2019, indicated an increased density in the left lateral occipital lobe adjacent to the table of calvarium (skullcap) likely representing hemorrhagic contusion (damaged or broken blood vessels as the result of a blow to the skin). The right frontal scalp hematoma slightly smaller. Hospital records further indicated that on (MONTH) 2, 2019, a neurology consultation was done. The neurologist stated that the resident presented with significant head trauma with scalp hematoma over the right temple, right periorbital ecchymosis and ecchymosis over the mastoid area. She might have sustained contrecoup head trauma ([MEDICAL CONDITION] that occurs both at the site of trauma and the opposite of the brain) as noted on the CAT (Computerized Axial Tomography) scan of the head on the repeat imaging with increased density noted in the left lateral occipital lobe adjacent to the calvarium representing hemorrhagic contusion. As far as history of ecchymotic areas over the right face, need to rule out any physical abuse. She apparently did not fall out of the bed, but did sustain significant injury. She is not on any antiplatelets or anticoagulants (blood thinners) . she has severe ambulatory dysfunction (difficulty walking) and is bedridden. Further review of Resident R192's clinical record record revealed that in addition to the injury listed above the resident had sustained three previous injuries of unknown origin. These injuries include: a bruise to the resident's mid-chest area on (MONTH) 26, 2019, a new bruise on the right side of her face, multiples discolorations on both arms, left side, inner knees and thighs on (MONTH) 25, (YEAR), and bruises under her chin, bilateral breast, chest area, under her right arm and right hand on (MONTH) 11, (YEAR). Interview with Nursing Home Administrator on (MONTH) 5, 2019, at approximately 12:15 p.m. revealed that the facility had not determined how Resident R192 had sustained the bruises to her chest on (MONTH) 26, 2019. Continued interview with the administrator confirmed that the facility had not conducted an internal investigation into Resident R192's bruises of (MONTH) 26, 2019, as they did not consider them significant. Further interview with the nursing Home Administrator on (MONTH) 5, 2019, at approximately 8:20 p.m. revealed that the facility had conducted an internal investigation into the cause of Resident R192's injuries found on (MONTH) 30, 2019. The administrator reported that from their investigation the facility had determined that while the resident had been assessed as needing the physical assistance of two staff persons for bed mobility and transfers, some of their CNAs (nursing assistants) had been moving the resident by themselves. The administrator further indicated that he suspected the resident had sustained her injuries as a result of a staff person bumping her head against a siderail while moving her without the required physical assistance of another staff person. Based on the above findings an Immediate Jeopardy situation was identifed to the Nursing Home Administrator on (MONTH) 5, 2019, at 2:41 p.m. An Immediate Action Plan was accepted on (MONTH) 5, 2019, at 10:00 p.m. and included the following: 1. All current residents will have skin assessments completed by (MONTH) 6, 2019, to identify any injuries of unknown origin. The results of the skin assessments will be reviewed by the Director of Nursing. 2. Social Services will interview any residents with a BIMS of 8 or higher to rule out any complaints of Abuse or Neglect. The Administrator will be notified immediately if any residents do have a complaint of Abuse or Neglect. Completion date by end of (MONTH) 5, 2019. 3. The Vice President has completed re-education to the Administrator and Director of Nursing regarding the Abuse/Neglect policy, incident and accident reporting, injuries of unknown origin and subsequent investigation to ensure that the allegations are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury. This is completed on (MONTH) 5, 2019, to include a post test. 4. Administrator will re-educate all Leadership staff in relation to Abuse/Neglect policy, incident and accident reporting, injuries of unknown origin and subsequent investigation to ensure that the allegations are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury. This is completed on (MONTH) 5, 2019, to include a post test. 5. The Staff Development Coordinator/DON/ADON/NHA/ANHA/UM will re-educate all disciplines in relation to the Abuse/Neglect policy, incident and accident reporting, injuries of unknown origin and subsequent investigation to ensure that the allegations are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury. This is completed on (MONTH) 11, 2019, to include a post test. Staff will not work until education is completed. 6. This education will be provided fact-to-face to monitor staffs understanding of facility policies and regulatory requirements. This is to include Abuse/Neglect policy, incident and accident reporting, injuries of unknown origin and subsequent investigation to ensure that the allegations are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury. This education will be completed on (MONTH) 6, 2019, by 7 am for approximately 70 direct care staff, therapists, and housekeepers. Any staff that does not receive this re-education by 7 am on (MONTH) 6, 2019, will receive this re-education prior to working their next shift which will be completed by (MONTH) 19, 2019 except in cases where incidental staff who are currently on LOA, extended vacation or out of the country. 7. An Ad Hoc QAPI meeting is held on (MONTH) 5, 2019, regarding the above with the inclusion of the Medical Director. 8. Social services will interview 20 residents a week for two weeks that have a BIMS score of eight or greater to rule out any complaints of abuse. The Administrator will be notified if any residents do have a complaint of Abuse. 9. The Staff Development Coordinator/DON/ADON/NHA/ANHA/UM will monitor staffs understanding and retention of Abuse/Neglect policy, incident and accident reporting, injuries of unknown origin and subsequent investigations by repeating the post-test encompassing all disciplines. To include Immediate Reporting of serious physical or bodily injury will be reported to the administrator or designee and consequently to the Pennsylvania Department of Health and other reporting agencies. This will be a sample of 20 people weekly for a time frame of two weeks. 10. All incident reports resulting in an injury of unknown origin will be reviewed with the DON/ADON or NHA every shift to rule out abuse/neglect for a period of two weeks. 11. During the morning clinical meeting (M-F) the Administrator, Assistant Administrator, Director of Nursing, or Assistant Director of Nursing will review all incident reports to assure that alleged abuse is identified and investigated. On Saturday and Sunday, the Shift Supervisor will call the Administrator or Director of Nursing to report any incidents that have the possibility of an injury of unknown origin, abuse or neglect. On (MONTH) 6, 2019, following review of facility inservice education documentation, documentation of skin assessments, documentation of resident interviews, and interviews with staff, it was verified that the facility had implemented their action plan and the Immediate Jeopardy was lifted at 3:52 p.m. The facility failed to ensure that one resident identifed as requiring the physical assistance of two persons received that assistance which resulted in actual harm to the resident who sustained significant head trauma and was hospitalized as a result of this omission. Additionally, this failure put the health and safety of all residents at risk for neglect and resulted in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/11/17, 05/25/17, 03/17/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 05/16/18, 08/11/17, 05/25/17, 03/17/17 28 Pa. Code 201.18(b)(2)(e)(1) Management Previously cited 05/16/18, 03/17/17 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 05/25/17 28 Pa. Code 211.12(c) Nursing services Previously cited 11/29/18, 05/16/18, 03/17/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 05/16/18, 03/10/18, 08/11/17, 05/25/17, 03/17/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/29/18, 05/16/18, 03/10/18, 08/11/17, 05/25/17, 03/17/17

Based on clinical record review, facility documentation and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident with a high risk for falls resulting in two falls with lacerations that required transportation to the hospital and sutures for one of two residents reviewed (Resident R2). Findings include: A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of nurses' notes dated October 28, 2016 revealed that, the resident was admitted to the facility with a self releasing seat belt, the belt was to be check every two hours and the resident was to be monitored for safety. There was no documentation in the care plan prior to the first fall to provide direction to staff of how the resident was to be transferred. A review of the documentation submitted by the facility on October 31, 2016, revealed that at 7:40 p.m. on October 31, 2016, the resident sustained [REDACTED]. The NA stated she pushed the resident in her wheelchair into the bathroom and removed the resident's self-releasing seat belt latch that is located in front of the resident. The NA released the latch as she was standing behind the resident. The resident immediately stood up and before the NA could walk around to the front of the wheelchair, the resident fell and hit her head on the toilet, causing a laceration on the forehead. The resident was sent to the emergency room , received sutures to the laceration and then returned to the facility. A review of the resident's admission Minimum Data Set assessment (MDS - a periodic review of the resident needs) dated November 1, 2016, revealed that the resident's Brief Interview for Mental Status (BIMS - a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact: 8-12 moderately impaired: 0-7 severe impairment) score was 11 indicating that the resident was moderately impaired with decision making skills. The MDS assessment also revealed that the resident required extensive assistance with transfers, dressing, hygiene and bathing. Continued review of the MDS assessment revealed that the resident required extensive assistance with all care and was a two person assist for transfers and toilet use. A review of the resident's current care plan dated January 18, 2017, for falls included various dates making it difficult to determine what assistance the resident should or did receive when admitted to the facility related to transfers and the fall on October 31, 2016. An interview with the Director of Nursing on February 13, 2017 at 12:00 p.m., revealed that he/she was unable to retrieve the original care plan because once the facility staff update the care plan the computer system takes out the original care plan. An interview with Employee E15, the Resident Assessment Coordinator (LNAC- Licensed Nurse Assessment Coordinator), on February 13, 2017, at 2:00 p.m. confirmed that the information on the November 1, 2016, MDS was gathered from the NA that provided care and services to the resident and was assigned to the resident. The NA documented that most of the time the resident needed the assistance of two staff members and that was reflected on the MDS. A review of the fall risk assessment dated [DATE], revealed that the resident was at high risk for falls. A review of the resident's current care plan, revised on January 4, 2017, revealed that, the resident uses a self releasing alarming seat belt (a self releasing alarming seat belt is defined as a seat belt that the resident wears while in a wheelchair, the resident needs to be able to release the belt by herself. When this occurs the seat belt will alarm alerting the staff that the resident is attempting to get up.) related to history of falls related to anoxic brain injury. Apply self releasing seat belt when out of bed, release belt every two hours for 15 minutes under supervision. Review of documentation submitted by the facility on January 18, 2017, revealed that on January 7, 2017, the resident was in the dining room at 5:45 p.m. with one staff member present when the staff member heard a thump and observed the resident in front of her wheelchair on the floor with a laceration over her left eyebrow. The resident was sent to the hospital and received seven sutures. This was the second fall in which the resident received sutures to the head. Further review of the nurses' notes and the social service notes revealed that the fall occurred on January 17, 2017. A review of the social service notes dated January 25, 2017, revealed that the resident had a fall on January 17, 2016, and sustained trauma to her face. The resident was in the dayroom with a staff member and the staff heard a loud thump behind her as she was assisting another resident. The resident was observed on the floor with a laceration above the left eye measuring 0.8 centimeters by 3.0 centimeters by 0.3 centimeters. First aid was applied and the resident was transferred to the hospital and received seven sutures. An interview with the Director of Nursing on February 13, 2017, at 12:00 p.m. confirmed that the fall was actually on January 17, 2017, not on January 7, 2017, as stated in the documentation submitted by the facility on January 18, 2017. A review of the facility investigation for the fall that occurred on January 17, 2017, revealed that the staff member who was in the dinning room had her back to the resident while feeding another resident. The resident does have a self releasing alarming seat belt which the resident released herself but the alarm did not sound. Maintenance examined the seat belt and found a wire was disconnected. In an interview with the Director on Nursing on February 13, 2017, at 12:00 p.m. it was confirmed that it is the facility procedure that when a resident is in the day room/dinning room, a staff member is present to monitor the residents in the area, however, the employee's back was to Resident R2, the alarm failed and the Resident fell sustaining an injury. The facility failed to provide adequate supervision and assistance for a resident who was at high risk for falls and had a history of [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 03/27/15, 02/26/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/27/15, 02/26/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 03/27/15, 02/26/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/25/15, 02/05/16, 02/26/16

Based on review of clinical records, observations and interviews with staff, it was determined that the facility failed to ensure an environment to residents that was free from accident hazards and adequate supervision for two of 30 residents reviewed (Resident R115 and Resident R160). Findings include: Review of facility policy Falls-Clinical Protocol, Reviewed/Revised February 2013, revealed that under Comprehensive care plan: 1. Based on assessment an initial plan of care will be developed and implemented to address identified risk, this will be revised as necessary. 6. The care plan and nurse aid care card should be updated as interventions change. Additionally, under monitoring and follow up: 4. If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the Resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Review of Resident R115's clinical record revealed that the Resident had been admitted from the hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Review of Resident R115's clinical record revealed an admission minimum data set (MDS-periodic assessment of needs), dated October 15, 2015 which indicated the Resident was severely cognitively impaired, required extensive assisstance of one person for transfers, dressing, hygiene and bathing. A fall assessment completed on October 8, 2015 indicated that the Resident had a Fall Risk score of 16 (a score of 10 or higher indicate high risk of fall). A plan of care for fall prevention due to fall in the previous 30 days was developed on October 9, 2015. Interventions included to have call bell in reach, encourage rest periods, evaluate medication regime with physician and /or pharmacist, report behaviors to nurse/physicians, appropriate footwear and to monitor the Resident for side effects of medications. Nursing documentation dated October 9, 2015 for 3:15 stated that the Resident was found on the dining room floor lying on the right side. Results of an investigation of the fall dated October 9, 2015 determined the Resident was found several inches away from the wheelchair, that the fall was unwitnessed and that Resident R115 would now be in a highly visible area for frequent checks and observation. The Care plan was revised to include keeping her in a highly visible area with frequent checks. A nursing note on October 21, 2015 at 8:15 a.m. stated that the Resident was found on the floor in her room. An investigation dated October 21, 2015 stated that the Resident had been found on the floor at 5:30 a.m. near the side of the bed. Staff notified the physician who ordered placement of a bed alarm and checks on the resident every 30 minutes for the next 24 hours. The Residents Fall Risk assessment was revised and increased to a score of 18 (a score of 10 or higher indicate high risk of fall). The Care plan was revised to include an alarm to be placed on the Residents bed. An October 24, 2015, nursing note stated that around 3:45 p.m. while staff was getting report for the shift, the Resident was observed sitting on the floor of the dining room. The documentation stated further that on assessment the Resident was noted to have guarding and decreased range of motion to right leg, was unable to bare weight, had pain in the right thigh and was medicated for pain with Oxycodone and that the Residents Responsible party had arrived at the facility. Staff noted a call was placed to the physician around 5:15 p.m. who ordered that the Resident should be transferred to emergency room if a portable Xray would not be done in 2 hours. Nursing documentation at 8:40 p.m. noted that they were still waiting for the arrival of the portable Xray, and that Resident's Responsible party requested that the resident be transferred to the hospital at 8:40 p.m. and was admitted with a right femur fracture. An investigation on October 24, 2015 noted that the fall was unwitnessed, that the Resident was placed in the wheelchair and taken to the nursing station for further evaluation and to be monitored due to history of falls. Resident R115 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Director of Nursing stated in an interview on February 25, 2016 at approximately 1:00 p.m. that no staff were present in the dining room at the time of resident R115's fall. Review of Resident R160's clinical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the resident's admission MDS, dated [DATE] ( minimum data set- a periodic review of a residents needs), revealed that the resident was independent in decision making skills. A review of nurse's notes dated November 30, 2015 revealed that the resident refused dialysis and when asked why he did not want to go to dialysis he became anxious and attempted to flip his bedside table over. The resident then grabbed scissors and held them to his left shunt graft site( area used for dialysis access), and starting yelling I'll do it, I'll do it I want to go to the hospital. The resident then pointed the scissors at the staff in the room while making jabbing motions. The resident initially refused to hand over the scissors. The resident then did hand over the scissors and was sent to the hospital. The resident was admitted to the hospital for end stage renal disease and return to facility on December 3, 2016. Observation of Resident R160 in his room on February 25, 2016 at 10:00 a.m. revealed a 10 ounce bottle of hand sanitizer and a disposable razor on his bed side table. An interview with Employee E11, the unit manager on February 25, 2016 at 12:00 p.m. confirmed that the resident was not being monitored for unsafe items including but not limited to hand sanitizer and disposable razors. The facility failed to provide adequate supervision of a Resident with a known history of falls with a fracture causing harm, failed to follow the established plan of care of keeping the Resident in a highly visible area and caused a delay in treatment by waiting 5 hours before transferring Resident R115 who sustained a re-fracture of the hip. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 3/27/2015.

Based on observation, review of clinical records, facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to obtain physician's orders [REDACTED]. Findings include: Review of Resident R194's admission physician orders, dated April 4, 2014, revealed [DIAGNOSES REDACTED]. The physician ordered [MEDICATION NAME] (pain medication) every 6 hours whenever needed. Review of admission nurses' notes, dated April 4, 2014, revealed that the resident had been admitted after 9:00 p.m. and stated the resident "refused weight and further assessment secondary to level of pain", which was described as a "9 out of 10". This note indicated that the resident did fall to sleep. Nurses' notes dated April 5, 2014, timed at 5:00 a.m., revealed that the resident was complaining of pain, however the pain medication had not arrived from the pharmacy. This note stated the resident was offered Tylenol but refused. Nurses' notes dated April 5, 2014 titled 7-3, revealed the resident had "pain level of 9 but no narcotics available" ([MEDICATION NAME] is a controlled medication). This note continued that the pharmacy was called for the [MEDICATION NAME] but stated that they needed a narcotic sheet signed by the physician. The nursing supervisor and the assistant director of nursing were notified and "advised that there were no narcotics in the Pyxis (medication dispensary). The physician was notified to request a three day supply of pain medication. The nurses' note stated that the resident's sacral pressure ulcer dressing was changed and that the resident was requesting "to go to the hospital with a complaint of pain throughout the entire body and severe agitation." Review of the Medication Administration Record [REDACTED]. (approximately 19 hours after the first complaint). Interview with the director of nursing on April 24, 2014, verified that there was no [MEDICATION NAME] available, resulting in actual harm to Resident R194. Review of facility policy, "Weight Assessment and Intervention," dated reviewed/revised March 21, 2011, indicated that resident weights will be measured as ordered and recorded in the resident's medical record. Review of the clinical record for Resident R35 revealed nursing documentation indicating the resident was readmitted to the facility from an acute care hospital on February 28, 2014, with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. (milligrams) orally daily for a [DIAGNOSES REDACTED]. Review of facility documentation and the clinical record for Resident R35 revealed that the resident was weighed on a weekly basis on March 10, 17, 24, and 31, 2014, and April 7, 14 and 21, 2014. Further review of facility documentation and the clinical record revealed no evidence that Resident R35 was weighed twice a week per physician's orders [REDACTED]. Observation of Resident R174 during the initial tour of the facility on April 22, 2014, at 10:10 a.m., revealed the resident's left closed hand wrapped in Kling gauze, dated April 21, 2014. Review of Resident R174's clinical record found the physician initially ordered, on July 25, 2013, for the second finger of Resident R174's left hand to be washed, dried, foam applied, and wrapped with Kling gauze every Monday. A physician's orders [REDACTED]. Observation of Resident R174's hands, with nurse Employee E6 on April 23, 2014, at 1:50 pm, found the left hand still completely wrapped with Kling gauze, dated Monday April 21, 2014, no gauze roll in either hand. Review of the resident's TARs (treatment administration records) found the left hand order previously discontinued in August, reappeared in September 2013, and continued through the current April 2014 treatments, along with the order for daily [MEDICATION NAME] and hand rolls to each hand. Both conflicting orders of the daily and weekly treatments were signed as completed from September 2013 through the current date. Interview with nurse Employee E6 on April 23, 2014, confirmed that the hand rolls were not applied as ordered to prevent further contractures, and the treatment which was discontinued in August 2013 was still being done, and incorrectly. Review of Resident R139's clinical record found physician's orders [REDACTED]. The order detailed that the family was to provide and administer Nootropil. There was no evidence available for review to indicate the dosage to be given (available in 800 mg, 1200 mg), if the drug is administered daily, who monitors for side effects/adverse reactions. Interview with nurse Employee E6 on April 25, 2014, at 11:30 am, confirmed that there was no evidence that the pharmacy reviewed the drug for administration, or that the facility monitored if or how often it was administered as the daughter does not visit daily. Review of Resident R139's clinical record revealed physician's orders [REDACTED]. Review of the resident's medication and treatment administration records found the gel was discontinued March 2014 (undated). There was no evidence that a physician's orders [REDACTED]. Interview with nurse Employee E6 on April 25, 2014, confirmed that the as needed topical gel was discontinued without an order. Review of documentation by the consultant psychiatrist found no notation that the gel is recommended or reviewed, in consults dated September 3, 2013, January 14, , February 25, 2014, or April 15, 2014. Clinical record review of Resident R69, revealed a physician order [REDACTED]. The resident assessment indicate's that the resident required total assistance with activities of daily living, received tube feeding for nutrition. A review of the physician's orders [REDACTED]. A review of nursing documentation dated February 21, 2014, stated Resident R69, did not receive the prescribed [MEDICATION NAME]. A review of February 2014, Medication Administration Record [REDACTED]. Nurses notes indicated that there was difficulty in having the physician submit a current prescription for the pharmacy to provide to the facility for this resident. Interview with Employee E11, Licensed Nurse, on April 23, 2014 at 1:00 p.m., confirmed that the Medical Director should have been informed of prescription necessity for this resident's pain medication for management. Review of Resident R179's minimum data set (MDS-periodic assessment of needs), dated March 11, 2014, revealed [DIAGNOSES REDACTED]. Review of the April 2014 physician orders [REDACTED]. Further review of these orders revealed that the resident was ordered [MEDICATION NAME] and [MEDICATION NAME] mini-nebulizer treatments every 4 hours (pulmonary medication). Review of the Medication Administration Record [REDACTED]. 483.25 Quality of Care. Previously cited state deficiency 5/02/13. 28 PA Code: 211.5(f) Clinical records. 28 PA Code: 211.12(d)(1)(3)(5) Nursing services. Previously cited 5/02/13. 28 PA Code: 211.12(d)(2) Nursing services.

Based on a clinical record review, observations and staff interviews, it was determined that the facility failed to assess and treat a resident exhibiting psychosocial distress occuring during treatments and leisure activities for one of 30 residents reviewed (Resident R1) resulting in actual harm. Findings include: Review of the annual assessment (Minimum Data Set) dated March 22, 2014 indicated that Resident R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed to be severely impaired cognitively. A review of Resident R1's clinical record revealed that the Resident's supra pubic was replaced monthly by a urologist who came to the facility to perform the procedure. A review of consultation notes dated March 3, 2014, February 28, 2014, January 31, 2014, December 12, 2013, December 6, 2013, September 13, 2013, September 13, 2013, August 6, 2013, July 19, 2013 and June 21, 2013 indicated that on each consult that the resident was aggitated, struggled and required 2 to 3 staff member to restrain him during the procedure. There was no evidence that the staff had developed or implemented interventions to address Resident R1's aggitation and behaviors other than having the staff restrain the resident during these procedures. Additionally, an observation of the resident on April 23, 2014, at 10:15 a.m. revealed that Resident R1was sitting in the day/activity room by himself looking at a magazine. Three alert and oriented residents entered the room and sat at another table to talk. When a fourth person, a visitor, entered the room Resident R1 became physically agitated and yelling that continued to escalate and and became louder and louder. Eventually the four alert individuals left the room and Resident R1 immediately quieted down and became less agitated. This whole episode lasted for 30 minutes and no staff were observed attempting to approach, calm or redirect Resident R1. A review of the residents care plans dated April 16, 2013, indicated that the resident was resistant to care and had inappropriate social behaviors related to agitation and aggression. Interventions developed for the resident included distraction, intervene to alleviate the symptoms, offer calm reassurance and psych referral. It also states that if the resident is resistive to care, leave alone and approach later. Nursing documentation did not indicate that any of the interventions were implemented. A review of the clinical record indicated that the last time the resident had been seen or evaluated by a psychiatrist was February 16, 2011 at which time the physician recommended adding [MEDICATION NAME] (an antipsychotic medication) to the resident's medication mix. There was no documentation that this was done or what the effect was. An interview on April 23, 2014 at 1:00 pm with the Unit Manager, Employee E12, confirmed that either she or administrative staff were aware that the staff was retraining the resident. It was also confirmed that the facility had not been assessing or treating the resident to improve Residents R1's quality of care. It was also confirmed that a psych evaluation had not been done for the resident to determine if the resident was on the correct medication regimen resulting in actual harm to the residents pscyhosocial well being. 28 PA 201.18 (b) Management 28 PA 211.8 (a) Restraints 28 PA 211.12(d)(1)(5) Nursing services

Based on review of clinical records, investigation documents, facility policy and procedures, and staff interviews, it was determined that the facility failed to implement its policy for reporting and adequately investigating incidents/injuries to prevent resident neglect that resulted in actual harm for one of 30 residents reviewed (Residents R108). Findings include: A review of Resident R108's Quarterly MDS (periodic assessment of needs) dated February 16, 2011 revealed [DIAGNOSES REDACTED]. The MDS also indicated that the resident was severely impaired cognitively and totally dependent on staff for ambulation, dressing and personal hygiene. A review of nursing progress notes dated March 11, 2011 at 7:20 p.m., revealed that the nurse was called to Resident R108's room by the CNA and observed that the resident's left ankle was swollen and reddened and the foot was turned inward at the ankle. According to the nursing note dated 3/11/11 at 7:20 pm, the resident cried out when nursing tried to move the foot. The nurses note dated 3/11/11 at 7:20 pm indicated that the physician was notified and ordered the resident sent to the hospital for evaluation. A nurses note dated 3/12/11 at 3:35 am revealed that the resident was admitted to the hospital with [REDACTED]. A nursing progress note dated 3/14/11 at 2:30 pm, revealed that the resident returned to the facility on [DATE] with a splint/cast in place. A review of the facility incident and accident investigation dated 3/11/11, revealed that the facility obtained statements from the CNA and nurse who identified the injury on March 11, 2011. The facility also obtained statements from two CNA's (Employees E9 and E10) who worked day shifts. These statements revealed that they had identified the injury on March 8, 2011, three days earlier, during a shower and notified a charge nurse. There was no documentation to indicate that the nurse on March 8, 2011 assessed the resident, notified the physician that an injury had been identified or notified nursing management. This resulted in neglect to the resident that included a lack of pain management for at least three days. During an interview on April 13, 2011 at 1:30 p.m. with the Administrator and Director of Nursing it was revealed that they were currently not aware that the injury had actually been identified three days earlier than the incident report stated. They also confirmed that a thorough investigation, including a conclusion, had not been completed. A review of the facility policy "Resident Abuse Prohibition" dated December 1, 2006 defines neglect as a failure to provide services necessary to avoid physical harm. The policy states that any employee who is aware of suspected neglect must report the incident immediately to Nursing Management or Administration. There was no evidence that the facility began an investigation of the injury of unknown origin until March 11, 2011. There was no evidence that the facility completed a thorough investigation as to the cause of this injury. An interview on April 14, 2011 at 9:30 a.m. with the Director of Nursing confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/4/2010, 3/31/2011 28 Pa. Code 201.18(a)(b)(1)(3) Management Previously cited 5/4/2010, 3/31/2011 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services Previously cited 5/4/2010, 10/25/10, 1/3/11, 3/31/2011

Based on review of clinical records, facility documentation, policy and procedures and interviews with staff, it was determined that the facility failed to monitor and assess one resident for the development of pressure ulcers resulting in actual harm (Resident R108). Findings include: A review of Resident R108's Significant Change MDS (periodic assessment of needs) dated March 21, 2011 revealed [DIAGNOSES REDACTED]. The MDS also indicated that the resident is severely impaired cognitively and totally dependent on staff for ambulation, dressing and personal hygiene. Nursing progress notes dated March 14, 2011 at 2:30 pm, revealed that the resident was readmitted to the facility from the hospital with a fractured left tibia/fibula (ankle) with a splint and an ace wrap in place from the knee to the foot. physician's orders [REDACTED]. There was no evidence that the skin checks were being performed as ordered. Nursing progress notes dated March 21,2011 at 11:30 a.m. indicated that the resident was noted with two wounds on the back of the left thigh: first an unstageable wound with necrosis (dead/black tissue), slough (separation of dead and living tissue) and drainage and a second fluid filled blister. A nursing progress note dated 3/21/11 at indicated that the physician was notified and ordered the resident sent to the hospital for evaluation. A review of physician's orders [REDACTED]. A review of the wound consultant report dated March 25, 2011 revealed an unstageable wound on the left lateral thigh that measured 1.5 cm. by 3.2 cm by 0.2 cm. that had a moderate amount of drainage and slough. The report also documented another unstageable wound on the left posterior thigh that measured 3.0 cm. by 6.0 cm. by 0.1 cm. with a moderate amount of drainage and slough. The wound consultant report stated that the resident developed the unstageable ulcers on the left thigh due to a combination of bilateral lower extremity contractures (a permanent shortening of the muscle) and the splint the resident was wearing for the fracture. During an interview on April 12, 2011 at 9:00 am with Employee E8, the splint that the resident returned from the hospital with was described as two single hard splints on either side of the resident's leg that were held in place by an ace bandage. Employee E8 also stated that because of the severe contractures in the residents legs the splints were too long and dug into the back of the residents left thigh causing the skin breakdown. Interview with Employee E2 on April 14, 2011 at 9:30 am confirmed that the wounds the resident sustained [REDACTED]. There was no evidence that the facility accurately monitored or assessed the resident to prevent the development of pressure ulcers in a timely manner, resulting in actual harm. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/4/10, 10/25/10, 1/3/11, 3/31/11