Every finding on record at Rose City Nursing and Rehab at Lancaster

Based on observations, facility record review, as well as resident and staff interviews, it was determined the facility failed to ensure resident smoking materials were stored securely and monitored for four residents (Residents 18, 74, 92, 93) on two units, posing a risk for fire, resulting in immediate jeopardy to the residents (first and third floor units).Findings include:Interview with the Nursing Home Administrator (NHA) during the entrance conference on May 17, 2026, at approximately 10:30 a.m., revealed the facility is a non-smoking facility and have no smoking policy. Further interview with the NHA revealed there were four residents in the building who were permitted to smoke if they had a physician's order allowing them to leave the facility unaccompanied. Continued interview with Nursing Home Administrator revealed, the four residents were assessed for smoking which demonstrated each could independently use smoking materials safely, and they signed a smoking agreement that stipulated the resident agreed to keep smoking materials in a locked box provided by the facility. The resident was allowed to keep the key, and a nursing supervisor would have a copy of the key. Observation of Resident 4 on May 18, 2026, at approximately 1:00 p.m. revealed Resident 4 ambulating on the first-floor unit, although Resident 4 resides on the second-floor unit. Review of Resident 4's May 2026 quarterly Minimum Data Set (mandatory assessment of resident needs and condition) revealed resident is cognitively impaired and ambulates independently throughout the nursing units. Interview and observation with Resident 18 on May 19. 2026 at approximately 10:45 a.m. revealed the resident resides on the fourth floor and keeps smoking materials in a compartment on her walker. Observation conducted of Resident 18 revealed the walker's compartment does not have a locking mechanism and smoking paraphernalia which includes cigarettes and lighter could easily be accessed. Interview and observation of Resident 74 on May 19. 2026 at approximately 10:50 a.m. revealed the resident resides on the fourth floor and the smoking materials were stored in an unlocked drawer at the resident's bedside. Observation of Resident 92 on May 19, 2026, at approximately 10:50 a.m. revealed that the resident resides on the fourth floor and the smoking materials were kept on top of his dresser. Smoking material would be in plain view of anyone walking by the resident's room. Interview and observation of Resident 93 on May 19. 2026 at approximately 10:50 revealed the resident resides on the first floor and the resident has a lock box for storing her smoking materials but stated I don't use it. I know I should. Resident 93 opened her hand to reveal one cigarette and lighter. Review of Resident 18's clinical record revealed resident had a smoking assessment completed on May 12, 2026, to verify the resident was safe to smoke. Review of Resident 18's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 18, clinical record revealed that Resident 18 had a physician's order dated November 12, 2025, allowing the resident to leave the facility by herself. Review of clinical record for Resident 74 revealed that Resident 74 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 74's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 74, clinical record revealed that Resident 74 had a physician's order dated October 31, 2025, allowing the resident to leave the facility by himself. Review of clinical record for Resident 92 revealed that Resident 92 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 92's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 92' clinical record revealed that Resident 92 had a physician's order dated January 23, 2026, allowing the resident to leave the facility by himself. Review of clinical record for Resident 93 revealed that Resident 93 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 93's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 93's clinical record revealed that Resident 93 had a physician's order dated April 12, 2026, allowing the resident to leave the facility by herself. Review of Resident 104's care plan revealed that Resident 104 had a history of problematic behaviors characterized by wandering .[and] trespassing into other resident's rooms. Resident 104 resides on the first floor, but free to ambulate around facility. Interview with Nursing Home Administrator on May 19, 2026, at approximately 11:00 a.m. revealed facility staff are not responsible for monitoring or ensuring the residents' smoking materials are secured to prevent cognitively impaired or mentally ill residents access to flammable items. Based on the above findings an immediate jeopardy situation was identified to the NHA on May 19, 2026, at 2:35 p.m. The Facility failed to ensure that residents who smoked adhered to the facility policy of locking smoking materials away when not in use. Staff were not monitoring location of the smoking materials causing a situation where a cognitively impaired or mentally ill resident could obtain flammable smoking materials. An immediate action plan was requested. On May 19, 2026, at 5:29 p.m., an acceptable action plan was approved, which included the following interventions: Facility staff conducted a facility wide audit to ensure no other residents possessed smoking materials. No smoking materials were found. All facility staff and Residents 18, 74, 92, and 83 were educated and informed that smoking materials would be secured near the front door in a lock box. An RN supervisor and receptionist will have the key to the lock box. The residents must sign out each time they take smoking materials from the lock box and sign the materials back in when they return to the facility. Smoking materials cannot be taken into the resident care areas. The residents must leave the property to smoke, following leave of absence procedures. The residents must never smoke on the property nor inside the building. The resident will never share nor give nor hand out any smoking materials to any other residents. The residents will not ask others for any smoking materials from other residents. The procedure of smoking agreement was signed by each resident identified as a smoking resident (Residents 18, 74, 92, 93) on May 19. 2026. Observations conducted on May 20, 2026, of the smoking material sign out procedure, as well as review of facility staff education documentation and interviews conducted with 14 nursing and ancillary staff confirmed the facility's action plan was implemented and immediate jeopardy was lifted on May 20, 2026, at 11:48 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for 2 of 22 (Resident 13 and Resident 14) residents reviewed and failed to practice infection control prevention and mangement during tracheostomy (A surgical procedure that creates an opening through the neck directly into the windpipe) care and Gastrostomy tube (GT- A medical device inserted directly through the abdomen into stomach) care. For one of 22 residents reviewed (Resident 5). Findings: A review of the facility policy Tracheostomy Care, undated revealed the following: Aseptic technique (A collection of medical practices and procedures that helps protect patients from dangerous germs) must be used: during cleaning and sterilization of reusable tracheostomy tubes; during all dressing changes until tracheostomy wound healed; and during tracheostomy tube changes, either reusable or disposable. Sterile gloves must be used during aseptic procedures. The same policy revealed perform hand hygiene before the procedure, after removing old dressing, after removing the old cannula, after placing a new cannula, after cleaning the stoma and surrounding site. Review of facility policy, Enhanced Barrier Precautions, reviewed December 2024, indicated that enhanced barrier precautions (EBP) apply when a resident is infected or colonized CDC- targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. Personal protective equipment and alcohol-based hand rub are readily accessible to staff. A review of Resident 5's physician order revealed the following: Tracheostomy care every shift for infection prevention and Cleanse GT with normal saline solution, apply Zinc Oxide (barrier cream), apply Calcium Alginate (Are absorbent, non-adhesive dressings made from seaweed fibers used to mane moderately to heavy exuding wounds), cover with split gauze two times a day. A tracheostomy and GT care observation for Resident 5 was conducted on May 19, 2026, at 2:15 p.m., with licensed nurse Employee E7, the following were observed: Employee E7 put on mask, gown, and gloves (clean) then proceeded to the resident's bedside where tracheostomy and GT care supplies were already prepared. Employee E7 took a white towel from the cabinet and went to the bathroom to wet it. Upon returning, Employee E7 removed the resident's old necktie and old dressing then cleansed the back of the neck with the wet towel. Employee E7 took off their used gloves and put on a new clean glove without performing hand hygiene. Employee E7 removed the old cannula, discarded it and without changing their gloves proceeded in opening the sterile package of cannula then placed it to the resident's tracheostomy. Employee E7 took off their glove, applied a new clean glove then suctioned the resident. Employee E7 took off their glove, applied a new clean glove then applied a sterile slit gauze below tracheostomy, placed the tracheostomy collar back then discarded all used tracheostomy supplies. Employee E7 removed used gloves, without performing hand hygiene applied a new clean glove then proceeded into cleaning the resident's GT with normal saline with gauze, placed the ointment on their gloved fingertip then applied it into the GT's surrounding area, then applied the calcium alginate then covered with gauze. Employee E7 completed both tracheostomy and GT care without performing hand hygiene before starting the procedure and in between procedures. An interview was conducted with Employee E7 on May 17, 2026, at 2:30 p.m. Employee E7 acknowledged that hand hygiene was not performed during the tracheostomy and GT care. The above was conveyed with the Director of Nursing on May 20, 2026, at 10:00 a.m. The facility failed to ensure infection control prevention and management were implemented during tracheostomy and GT care procedures. Review of Resident 14 quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated March 10, 2026, revealed under section M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, that the resident was marked as having two stage 3 pressure ulcers. Observation of Resident 14's room on May 17, 2026, at 9:50am; May 18, 2026, at 12:10 pm and May 19, 2026, 9:51 am revealed no signage indicating EBP was in place and no personal protective equipment available in or outside Resident 14's room. Interview with licensed staff Employee E10 on May 19, 2026, at 9:47 a.m. confirmed that Resident 14 should have EBP signage outside of room. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to ensure staff were provided with a safe, functional, sanitary, and comfortable environment for three of the three medication rooms observed (Second, Third, and Fourth Medication Rooms). Findings: An observation of the Second-Floor medication room was conducted on May 18, 2026, at 9:20 a.m., in the presence of licensed nurse Employee E9. The observation revealed the following: The medication refrigerator's bottom shelves were covered with a dry brown substance. Further observation revealed a black substance on the edges of the washing sink. Employee E9 acknowledged that the medication refrigerator and washing sink were dirty and required cleaning. An observation of the Third-Floor medication room was conducted on May 18, 2026, at 9:51 a.m., in the presence of licensed nurse Employee E10. The observation revealed empty medication refrigerator had multiple dry, dark brown substances on the top and bottom shelves. Further observation revealed a dark brown substance on the edges of the washing sink. In addition, the cabinet below the sink does not close, exposing the bottom of the sink that has used/dirty winter gloves, empty plastic bottles, and black substances on the floor. An interview with Employee E10, conducted at 9:55 a.m., revealed that they are agency staff. Employee E10 does not know what the dark brown substances on the sink were, but acknowledged that the room needs to be cleaned. An observation of the Fourth-Floor medication room was conducted on May 18, 2026, at 10:00 a.m. and revealed multiple white and orange dry substances in the washing sink. Further observations revealed broken cabinets. The above was conveyed to the Nursing Home Administrator on May 19, 2026, at 2:00 p.m. The facility failed to ensure staff were provided with a safe, functional, sanitary, and comfortable environment in the Second, Third, and Fourth Floor medication rooms. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services 28 Pa. Code 201.18(b)(1) Management

Based on observation and staff interview, it was determined that the facility failed to ensure safe, clean and homelike environment was provided for one of four units observed (Second Floor Unit). Findings:An observation conducted in Resident 5's bathroom on May 20, 2026, at 9:36 a.m., in the presence of licensed nurse Employee E7 revealed two broken tiles behind the toilet bowl exposing an approximate one foot by half foot hole on the wall.Interview with Employee E7 on May 20, 2026, at 9:40 a.m., revealed that they were not aware of the hole on the wall until shown by surveyor.The above was conveyed with the Nursing Home Administrator on May 20, 2026, at 3:00 p.m.The facility failed to ensure safe, clean and home-like environment was provided to the residents on the Second Floor Unit. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to create a comprehensive care plan with interventions for one of 22 residents reviewed (Resident 1).Findings include:Review of Resident 1's face sheet revealed medical diagnoses that included dementia (general loss of cognitive abilities, including memory).Review of the Resident 1's progress note of 3/20/2026 atv19:36 nursing note stated Resident exit seeking and getting angry at staff. Redirection and 1:1 effective. Review of Resident 1's clinical records revealed physician orders dated March 25, 2026, for Wanderguard (wearable bracelets and door sensors to track at-risk individuals, prevent them from leaving secure areas, and instantly alert caregivers if a boundary is breached) to Left Wrist A-1425-3796 every nightshift check for proper function AND every shift check for proper placement.Review of Resident 1's clinical records failed to reveal a care plan for wander guard and elopement.Interview with Director of Nursing on May 20, 2026, at 10:35 a.m. confirmed the above findings.28 Pa. Code 211.5(f) Clinical records28 Pa Code 211.11(d) Resident care plan28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that the ordered medication to promote comfort was administered to a resident with a terminal diagnosis for one of eight residents reviewed (Resident 71). Findings: A review of Resident 71's admission progress notes dated April 3, 2026, at 4:30 p.m., revealed the resident was admitted to the facility with a recent left parietal intraparenchymal hemorrhage to CAA (Cerebral Amyloid Angiopathy- A spontaneous bleed in the outer brain tissue). The resident also had a diagnosis of cognitive impairment and seizure disorder (A chronic neurological condition characterized by recurrent seizures caused by abnormal electrical activity in the brain). The same note revealed Patient was admitted to TNU (Transitional Neurology Unit) with TACS (Trauma and Acute Care Surgery) consult for critical management. During this 12-day hospitalization, the family decided, after physician recommendation, to place [them]on end-of-life/hospice care. The same note revealed that hospice was aware, waiting for insurance information/authorization. admission assessment revealed the following: Unable to move right upper and lower extremity; Resident is awake and alert, mumbles in Spanish but was aphasic (A neurological language disorder that impairs the ability to speak, write, and understand both spoken and written language); with foley catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine); and a wound to the right buttock and left hip. A review of Resident 71's physicians order dated April 3, 2026, revealed the following orders: Lorazepam (anti-anxiety medication) give 1 mg by mouth two times a day for restlessness / agitation for 10 days - terminal condition: and Morphine Sulfate (An opioid medication used for the management of severe pain) oral solution give 10mg/ml give 2.5 ml by mouth every six hours as needed for pain, discomfort, restlessness, SOB (shortness of breath), hospice/end of life. A review of the nursing progress notes dated April 3, 2026, at 5:13 p.m., revealed Writer calling the pharmacy right after faxing, re (regarding) controlled medication order (prior to 1700). [Name] at the pharmacy says they pulled them in the queue, so we can request a script from Cubex (automated medication storage). A review of the facility's emergency medication list, Inventory on Hand, revealed that both Morphine and Lorazepam were available in the facility. A review of the nursing progress notes dated April 3, 2026, at 9:50 p.m., revealed: Resident is noted to be anxious and keeps on touching the foley catheter. Due meds (medications) are given, though some are still pending for delivery. Called pharmacy to speed up the delivery. A review of Resident 71, April 2026, MAR (Medication Administration Record) revealed that residents were not administered with as-needed Lorazepam and Morphine ordered for discomfort and restlessness on the evening of April 3, 2026. A review of Resident 71's nursing progress notes dated April 4, 2026, at 7:22 p.m., revealed: Resident is noted to be anxious and keeps touching the foley catheter. Needs anticipated and due nursing care given. Monitoring continues. A review of the nursing progress notes dated April 4, 2026, at 9:09 p.m., revealed Family contacted this writer, concerned about pt (patient) pain medications. PT was provided PRN (as needed) Tylenol for pain from the nurse present and PRN for anxiety. This writer contacted the on-call pharmacist. The same notes revealed family reports they had contacted hospice, but pt is not admitted yet (to hospice). A review of the nursing progress notes dated April 4, 2026, at 22:16 p.m., revealed: Family resident requested pain medication because they think the [resident] is in pain. A review of Resident 71's MAR revealed the resident was not administered the ordered Lorazepam until the morning of April 4, 2026. MAR revealed ordered Morphine as needed for discomfort and restlessness was not administered until April 4, 2026, at 10:16 p.m., with a PAINAD (A tool used to assess pain for cognitively impaired person) pain level of 6 (moderate pain). The above was conveyed to the Director of Nursing on May 20, 2026, at 11:00 a.m. The facility failed to ensure that Resident 71's ordered medication to promote comfort for a terminal condition was followed. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of three residents reviewed for nutrition (Resident 10 and Resident 106).Findings include: Review of facility policy, Weight Assessment and Intervention, revised March 2019, revealed that Any weight gain or loss of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician or Dietician. The Dietician and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Review of Resident 10's clinical record revealed recorded weights of 243.5 pounds on March 1, 2026; 234.4 pounds on April 3, 2026; (loss of 9.1pounds in one month). There was no re-weigh conducted to address the weight loss. Further review of Resident 10's clinical record failed to reveal recommendations to address the weight loss. Interview with Employee E4 on May 20, 2026, at 9:20 a.m. confirmed that further dietary interventions should have been implemented to address Resident 10's weight loss. Review of Resident 106's weights showed documented weights of 170.6 pounds on March 06,2026, and 161.5 pounds on April 09, 2026, reflecting a loss of 9.1 pounds in one month and three days. The clinical record did not contain evidence that staff re-weighed Resident 106 to confirm the weight loss as required by facility policy. Further review of Resident 106's clinical record showed no documented recommendations or interventions to address the weight loss. An interview with the Nursing Home Administrator (NHA) conducted on May 20, 2026, at 12:36 p.m., confirmed that Resident 106 was not re-weighed after the documented loss and no additional dietary interventions were implemented to address Resident 106's weight loss. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Service

Based on a clinical records review and interview with residents and staff, it was determined that the facility failed to ensure medication orders for dialysis residents were followed for one of two residents reviewed (Residents 11).Findings: A review of Resident 11's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). A review of Resident 11's physician's order revealed: Dialysis every Tuesday, Thursday, Saturday (11:15am pick-up for 12pm arrival). A review of Resident 11's physician's order dated December 11, 2025, revealed an order for Calcium Acetate (A phosphate binder medication used to treat excess phosphate in the blood) 667, give two tablets three times a day. The medication was scheduled at 8:00 a.m., 12:00 noon, and 4:00 p.m. A review of Resident 11's April and May 2026, Medication Administration Record (MAR) revealed that Calcium Acetate was not administered at 12:00 noon on the following dates April 2, 4, 7, 9, 11, 14, 16, 18, 21, 23, 25, 28, 30, 2026, and May 5, 7, 9, 12, 16, and 19 2026. MAR review revealed medication was not administered due to the residents being on Leave of Absence. There was no documentation indicating that the physician was notified of missed Calcium Acetate due to the resident being out for Dialysis. The above was conveyed to the Director of Nursing (DON) on May 20, 2026, at 11:00 a.m. The facility failed to ensure Resident 11's medication order was followed. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on review of the facility's policy, observations, and staff interviews, it was determined that the facility failed to properly stored medications in one of three medication rooms observed (Second Floor Medication Room). Findings: A review of the facility's policy titled Medication Labeling and Storage, undated, revealed If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The same policy revealed The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. An observation of the Second-Floor medication room was conducted on May 18, 2026, at 9:20 a.m., in the presence of licensed nurse Employee E9. The observation revealed the following: The medication refrigerator's bottom shelves were covered with a dry brown substance. Further observation revealed five Insulin Glargine pens with an expiration date of February 25, 2026. An interview with Employee E9 conducted on May 18, 2026, at 9:22 a.m., revealed that 11-7 shift staff are responsible for cleaning and checking the medication refrigerator. Employee E9 was unable to provide an explanation for why outdated medications were still stored in the medication refrigerator. Employee E9 confirmed that the refrigerator was dirty and required cleaning. The above was conveyed with the Nursing Home Administrator on May 19, 2026, at 2:00 p.m. The facility failed to ensure medications were properly stored on the Second-Floor medication room storage. 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Service

Based on clinical records review and staff interview, it was determined that the facility failed to follow laboratory orders for two of 22 residents reviewed (Resident 3 and 109).Findings include: Review of Resident 3's quarterly minimum data set (MDS – a mandatory assessment of a resident's physical condition and care needs) dated February 26, 2026 revealed that Resident 3 was cognitively intact and had the diagnoses anxiety disorder (a group of serious mental health conditions characterized by persistent, excessive fear or worry that is out of proportion to the actual situation) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 3's medication administration record revealed physician order for Depakote (an anti-seizure medication often used to manage mood disorders) 125 MG (milligrams) twice a day for depression. A psychiatric progress note dated January 12, 2026 at 5:52 p.m. revealed: Recommend valproic acid serum level (a blood test ordered for patients taking Depakote to determine if the substance valproic acid is at optimal levels) be drawn this week and every 6 months, for monitoring related to Depakote pharmacotherapy (treatment that uses pharmaceutical drugs to address a health condition). Review of physician orders dated January 16, 2026 revealed an order for bloodwork that included Valproic acid serum level q3 (every 3) months. Review of laboratory records revealed no evidence that Valproic acid levels were obtained. Review of psychiatric progress note dated February 23, 2026 at 4:29 p.m. revealed: recommend valproic acid serum level be drawn this week and every 6 months for monitoring related to Depakote pharmacotherapy. Review of nursing progress notes dated February 24, 2026 at 4:01 p.m. revealed Psych (psychiatric provider) in for resident visit and review , with n.n.o. (no new orders) for med changes. Psych suggesting to check valproic acid level with next labs and labs q 6 months, however, request these labs routine q 3 months. Notification to be sent to psych regarding labs. Review of laboratory records revealed no evidence that Valproic acid levels were obtained. Interview with the DON and NHA on May 20, 2026 at approximately 12:30 p.m. revealed that there were no results because the bloodwork had not been obtained. A review of Resident 109's physician's order dated December 25, 2025, revealed and order for CBC (complete blood count), CMP (complete metabolic count), Vitamin b12, Vitamin D, Ferritin level every night shift every three month (s) starting on the 1st related to Myotonic Muscular Dystrophy (A genetic disorder that causes progressive muscle weakness, wasting, and inability to relax muscle). The laboratory order was scheduled for January 1, 2026, and April 1, 2026. A review of the laboratory result page revealed that there was no blood work done for April 1, 2026. A review of Resident 109's physician order dated April 14, 2026, revealed an order for CBC with differentials and CMP today. A review of the laboratory result page revealed that there was no blood work done for April 14, 2026. There was no documentation indicating that physicians were notified of the missed laboratory orders. An interview with the Director of Nursing was conducted on May 21, 2026, at 10:00 a.m. The DON confirmed that there was no blood work done on April 1 and 14, 2026. The DON could not provide a reason why the ordered blood work was not done. The DON confirmed that the physicians were not notified of the missed laboratory orders. The facility failed to ensure that Resident 109's blood work for April 1, 2026, and April 14, 2026, was followed. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on observations, interview, and review of facility documentation, the facility failed to provide dentures to one out of seven residents reviewed (Resident 2).Findings include:Review of facility policy titled, Dental Services, revised in December 2026, revealed Routine and emergency detail services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Interview with Resident 2 on May 18, 2026 at approximately 2:05 p.m., revealed that he had been fitted for dentures in last year. Further, he revealed that he had yet to receive any dentures and no facility staff had followed up with him about the dentures. Further interview revealed that Resident 2 felt that without any teeth he talked funny and it was difficult to eat some foods.Review of Resident 2's care plan revealed Resident 2 was care planned for oral/dental health problems r/t (related to) possible broken/carious teeth.Review of Resident 2's physician orders reveal a therapeutic (prescribed for a particular health condition), regular texture diet with thin liquids.Review of Resident 2's weight chart revealed that Resident 2 weighed 192.3 pounds in December 2025, 196.4 pounds in January 2026, 199.2 pounds in February1 2026, 197.2 pounds in March 2026, 195.8 pounds in April 2026, and 193 pounds in May 2026, reflecting no significant weight loss.Review of Resident2's dental consult sheet dated November 17, 2025 revealed a dental a note that stated: Pt (patient) wants FU/FL (full upper and full lower dentures). Has had FMX (full mouth x-rays) done and lower impressions done.Review of Resident 2's clinical chart failed to reveal any documentation of the request for dentures or the dental services provided on November 17, 2025 in the progress notes.Review of Resident 2's dental consult sheet dated December 31, 2026 revealed a form with recommendations for full upper and full lower dentures circled and that a full mouth x-ray series was performed.A review of nursing progress notes dated December 31, 2026 at 8:43 a.m. revealed: Seen by Dental Services on 12/30/25. No new orders. Recommended for full upper and lower dentures.Interview with the Nursing Home Administrator (NHA) on May 20, 2026 at approximately 11:00 a.m. confirmed that Resident 2 was fitted for dentures and the dentures were made, but the company that made the dentures claimed there was a balance due and would not release the dentures to the resident. Subsequently the dentures were not delivered to Resident 2 because of the dispute that remains ongoing. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents when residents who smoke were permitted to keep smoking materials unsecured in their rooms and on their person. This failure resulted in an Immediate Jeopardy situation.Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states position purpose is to manage the Facility in accordance with current applicable federal, state, and local guidelines, and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.Review of the job description for the Director of Nursing (DON) states that the position is to: Plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that cover the facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times.The findings in this report identified the facility failed to maintain the safety of the residents from risk of fire by ensuring that there was a system in place to monitor and account for smoking materials for the residents who were assessed to be allowed to smoke during their leaves of absence.Refer to F689 28Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(b)(3) Management

Based on staff interview, observation, and clinical record review, it was determined that the facility failed to ensure an accurate clinical medical record for 1 of 1 resident reviewed (Resident 106). Findings include:A review of the facility policy titled Charting and Documentation, last revised July 2017, revealed the policy states, Documentation in the medical records will be objective, complete, and accurate.A review of Resident 106's diagnoses included Muscle Weakness (generalized weakness meaning overall reduced strength throughout the body).A review of Resident 106's physician order dated February 16, 2026, at 3:00 p.m., revealed an order for Weekly Skin Review on Mondays 3-11 shift. Complete Weekly Skin Review on the Tab FORMS. Document refusal every evening shift every Mon. and another physician order dated April 8, 2026, at 3:00 p.m., for Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to left buttocks topically every day and evening shift for Wound care.A review of Resident 106's April 2026 and May 2026 electronic Medication Administration Record (eMAR) revealed the Triad treatment was not administered on the following dates and shifts:April 12, 2026, day shift.April 14, 2026, evening shift.May 5, 2026, day shift.May 13, 2026, evening shift.A review of Resident 106's nursing progress notes failed to reveal any documentation explaining why the Triad was not administered on the dates listed above.A review of Resident 106's skin assessment dated [DATE], revealed no new areas of concern.A review of Resident 106's skin assessment dated [DATE], revealed, Resident seen by wound care nurse yesterday 4/07/2026, new orders for wound to left buttocks, cleanse wound with Normal saline apply Triad Hydrophilic Wound Dress External Paste to wound BID.A review of Resident 106's skin assessment dated [DATE], revealed no new areas of concern.A review of Resident 106's skin assessment dated [DATE], revealed no new areas of concern.A review of Resident 106's skin assessment dated [DATE], revealed Left buttock wound continues with treatment in place.A review of Resident 106's skin assessment dated [DATE], revealed no new areas of concern.An interview with the Nursing Home Administrator (NHA) conducted on May 20, 2026, at 12:36 p.m., confirmed the Triad treatment was incorrectly entered in Resident 106's clinical record, the skin assessment documentation present in Resident 106's clinical record belonged to a different resident, and Resident 106 does not currently have a wound.The facility failed to ensure that Resident 106's clinical medical records were complete and accurate.

Based on observation, clinical records review, and staff interviews, it was determined that the facility failed to provide behavioral services in a timely manner for one out of three residents reviewed (Resident 1).Findings: A review of the facility's policy titled Behavioral Health Services, undated, revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of Resident 1's diagnosis list revealed the following diagnoses: Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (A term used to describe a group of symptom affecting memory, thinking and social abilities severely enough to interfere with daily life), and Mood Disorder (A mental health condition that primarily affects your emotional state). Review of Resident 1's Annual Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 31, 2025, revealed the resident had severe cognitive impairment and was independent with transferring and walking. Review of Resident 1's Psychiatrists' consult, dated April 30, 2025, revealed the residents did not have mood or behavioral disturbances documented for the last 30 days. The same note revealed Sertraline (A medication used to treat depression) was discontinued in April 2025. Assessment and Plan include: No psychotropic medication (A prescription drugs that manage mental health conditions by altering brain chemicals to improve mood) recommended at this time; Recommend continued monitoring and documenting of mood and behavioral disturbances with description of behavior and if redirectable; and follow up as needed. Review of Resident 1's nursing progress note dated July 19, 2025, at 10:38 p.m., revealed Female resident made an allegation, stating that this resident pulled his pants down and showed her his penis. The same note revealed, This resident is now on 15 minutes check. Further review of Resident 1's nursing progress note dated September 7, 2025, at 9:13 p.m., revealed Inappropriate sexual gestures, spitting, yelling, cursing. Further review of Resident 1's nursing progress note dated September 28, 2025, at 9:57 p.m., revealed The resident has been acting inappropriately towards staff and other residents. He was found opening the doors of female residents, looking at them in bed. The same note revealed that the resident was difficult to redirect. Nursing progress note dated November 3, 2025, at 6:38 p.m., revealed Client observed rummaging through the roommate's personal items and personal food stash. Nursing progress note dated December 16, 2025, at 10:30 p.m., revealed Received verbal report that on dayshift, client was kissing another female resident. No behaviors involving other residents this shift. Nursing progress note dated December 30, 2025, at 2:19 p.m., revealed Resident found jerking himself off in the levator by staff, redirected to go to his room. Nursing progress note dated January 31, 2026, at 10:22 p.m., revealed Seen behind the door, kissing and attempting to pull his pants down. Redirected due to inappropriate behavior. A review of facility documents revealed an Event Report and investigation dated February 2, 2026, stating that at 2:15 p.m., on the same day, Resident 1 was found in a female resident's (Resident 2) room masturbating with one of his hands, with his other hand on Resident 2's side. The report indicated that Resident 2's gown was down to the knee, but the brief was intact and not open. Resident 1's hand was on Resident 2's side above the brief. Resident 1 was removed from Resident 2's room and was placed on 1:1. The physician and family were notified. The above behavioral notes dated September 7, 2025, September 28, 2025, November 3, 2025, December 16, 2025, December 30, 2025, and January 31, 2026, failed to reveal that the primary physician was notified of the resident's inappropriate/sexual behaviors. Further review of the nursing progress notes from July 19, 2025, until January 31, 2026, revealed that the facility did not provide Resident 1 with behavioral services despite multiple episodes of inappropriate/sexual behaviors until after February 2, 2026, the incident when the resident was found masturbating in another female resident's room. Review of Resident 1's psychiatry note dated February 9, 2026, revealed [resident] seen today for psychiatric follow-up per facility request due to recent increase in sexually inappropriate behaviors. The same note revealed: Plan and Assessment: Dementia with behavioral disturbances - ongoing, disease progressing as expected, consider Sertraline as recommended. The additional plan includes Recommend continuing 1:1 for safety related to sexually inappropriate behavior. An observation was conducted on February 10, 2026. at 10:00 a.m., and 1:00 p.m., revealed Resident 1 was lying in bed, with a 1:1 staff supervision. The resident was calm and quiet and refused to answer questions. The above findings were conveyed to the Nursing Home Administrator on February 10, 2026, at 2:00 p.m. The facility failed to ensure Resident 1 was provided with timely behavioral services for increasing inappropriate /sexual behaviors. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on policy review, interviews and records reviews it was determined that the facility failed to employ an Activity Director with the appropriate certification and/or qualifications for the position. Findings include:Review of facility policy titled Activities Staffing dated March 2015, revealed a statement noting the activity program is staffed with qualified personnel to meet the needs of residents. Per the policy the department is under the direction of a qualified Therapeutic Recreational Specialist (TRS) or an Activities Professional (AP) who is eligible or certified as a TRS or AP by a recognized accrediting body on or after October 1, 1990 or has two years of experience in a social or recreational program within the last five years, one of which was full-time in a resident activities program in a health care setting. Review of facility records revealed upon acceptance of the position on March 19, 2023, the Activity Director Employee E3 signed an agreement of understanding documenting E3 would be registering for classes to become a Certified Activity Director. E3's goal was to enroll in an Activity Certification program by May 15, 2023.Further review of the agreement documents the Occupational Therapist Employee E4 agreed to temporarily oversee the Activity Department. Per the agreement E4 would continue this oversight while E3 is enrolled in a certification program.E3 and E4 agreed to meet weekly to review activity calendars, one on one resident room visits, therapeutic recreation programming and schooling hours oversight, providing weekly updates to the Nursing Home Administrator.During interview with E3 on December 18, 2025, at 2:16 p.m., E3 confirmed that they were not certified, E3 stated they had taken a few random online classes and has received some credits but was not able to state exactly how many credits. E3 stated they intended to eventually take the state test but did not have a date when this would occur.E3 stated they still meet with E4 sporadically but not as often as initially. E3 stated there was no documentation for the meetings.During interview with E4 on December 18, 2025, at 2:05 p.m., E4 confirmed their agreement to oversee the Activity Department in 2023. E4 stated for at least the past year they had not met with E3 concerning activities. E4 denied knowledge that they were still supposed to be overseeing the activity department. Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 18, 2025, at 2:30 p.m., when the above information was presented, the NHA confirmed that Employee E3 was not currently certified but referred to the facility policy that noted the Activity Director needed to be certified or have two years of experience in a social or recreational program which the E3 now has since E3 has been in the position since 2023. 28 PA Code 201.29 (j) Resident Rights28 PA Code 211.5 (f) (h) Clinical Records28 PA Code 211.10 (d) Resident Care Policies

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the treating hospital received the medical records necessary to provide continuity of care and appropriate treatment for one of one resident reviewed (Resident R1).Findings include:A phone interview conducted with the complainant on November 12, 2025, at 9:18 a.m. revealed that the facility had not provided the hospital with the medical records required to initiate care for Resident R1.Review of Resident R1's clinical record did not contain documentation verifying that the facility faxed the medical records to the treating hospital.An interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on November 12, 2025, at 9:50 a.m. indicated that the Assistant Director of Nursing (ADON) faxed the necessary medical records to the hospital on November 6, 2025.Review of the facility's fax log revealed that the attempt to transmit the required medical records on November 6, 2025, was unsuccessful.A follow-up interview with the DON and NHA confirmed that the ADON did not wait for the fax confirmation sheet and that the facility did not contact the hospital to verify receipt of Resident R1's medical records.The facility failed to ensure Resident R1's medical records were successfully transmitted to the treating hospital, resulting in a delay of care.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documents and staff interview, it was determined that the facility failed refund to the resident or resident representative any and all refunds due to the resident within 30 days from the resident's date of discharge from the facility for one of three residents (Resident R1). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE] and ceased to breathe while in the facility on 5/28/25. Review of the record of Resident R1's payer source revealed that Resident R1 had privately paid for care. During an interview on 8/6/25, at 9:55 a.m., the Business Office Manager (BOM) confirmed that she had submitted a request for a refund of payment to Resident R1's Representative. The BOM provided evidence of a communication with the financial office, dated 6/11/25. The BOM was able to provide a request for an update Resident R1's Representative refund, dated 8/5/25. The BOM was able to provide evidence that the refund request was processed and provided to the Resident Representative on 8/6/25. During an interview on 8/6/25, at approximately 12:45 p.m., the Director of Nursing confirmed that the facility failed to refund the Resident or Resident Representative the refunds due to the Resident within 30 days from the Resident's date of discharge from the facility. 28 Pa. Code 201.24 (b) admission Policy.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a) Resident Rights.

Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, ( Employee E5,Employee E6,Employee E7,Employee E8 and Employee E9). Findings include: Review of staffing records and performance reviews revealed five staff members, E5, E6, E7, E8 and E9, did not have annual performance reviews performed within the last year. Interview with the Nursing Home Administrator on April 25, 2025, at 12:30 p.m. confirmed staff performance reviews were not completed. 28 Pa. Code 201.20(a)(c) Staff Development

Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were acted upon by a physician for five of five residents reviewed (Residents 37, 43, 59, 75, and 84). Findings include: Review of undated facility policy titled, Pharmacy Medication Regimen Review, indicated that the clinical pharmacist reviews condition concerns and reviews resident's medication regimen to identify any potential causes/concerns. The clinical pharmacist then faxes recommendations back to the facility. The clinical nurse then reviews recommendations and contacts physician for further orders. The physician signs Medication Regimen Review when reviewed. Review of Resident 37's clinical record revealed that medication regimen reviews were completed on January 15, 2025, February 12, 2025, March 13, 2025, and recommendations were made. Further review of Resident 37's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Review of Resident 43's clinical record revealed that medication regimen reviews were completed on January 15, 2025, March 13, 2025, and recommendations were made. Further review of Resident 37's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Review of Resident 59's clinical record revealed that medication regimen reviews were completed on July 16, 2024, August 14, 2024, and December 10, 2024, and recommendations were made. Further review of Resident 59's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Review of Resident 75's clinical record revealed that medication regimen reviews were completed on June 24, 2024, January 1, 2025, and February 25, 2025, and recommendations were made. Further review of Resident 75's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Review of Resident 84's clinical record revealed that medication regimen reviews were completed on July 16, 2024, and August 14, 2024, and recommendations were made. Further review of Resident 84's clinical record revealed no evidence of the reviews, recommendations, or evidence that the recommendations were addressed by the physician. Interview with the Nursing Home Administrator on April 25, 2025, at 12:00 p.m. confirmed that there was no evidence that the pharmacy recommendations were addressed by the physician. 28 Pa. Code 211.5(f) Clinical records Previously cited 8/12/24, 3/15/24 28 Pa. Code 211.10(c) Resident care policies Previously cited 3/15/24 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by five of five staff members reviewed (Employee E5, Employee E6, Employee E7, Employee E8 and Employee E9. Findings include: Review of Employees E5, E6, E7, E8, E9 training documentation regarding 12-hour annual training failed to reveal evidence that Employees E5, E6, E7, E8 andE9 completed the annual 12-hour training as required. Interview with the Nursing Home Administrator April 25, 2025, at 12:30 p.m. confirmed Employees E5, E6, E7, E8 and E9 did not complete the required 12-hour annual training. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on clinical record, facility documentation, and staff interviews, it was determined that the facility failed to ensure and implement a comprehensive care plan for residents CL1 and R4 with history of seeking and aggressive behaviors which resulted in Resident CL1 ingesting a sandwich subsequently choking and expiring. Resident R4 exhibited physical aggressive behaviors which resulted in an involuntary psychiatric hospitalization . This failure placed residents in Immediate Jeopardy for two of two residents identified as being at risk. Findings include: Review of the clinical record revealed Resident CL1 had diagnoses including but not limited to Dysphagia (inability/difficulty swallowing), Schizophrenia (mental illness characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution), Bipolar Disorder (mental illness characterized by extreme mood swings), Anxiety (intense, persistent, and excessive worry and fear about everyday situations), and Depression (loss of pleasure or interest in activities for long periods of time). Review of Resident CL1's quarterly comprehensive Minimum Data Set (MDS- assessment tool used to facilitate the management of resident care) dated August 23, 2023, revealed a BIMS of 09, indicating moderate cognitive impairment. Further review of Resident CL1's clinical record revealed in March of 2023, resident was noted to have seeking behaviors to include entering other resident rooms, taking personal items from tables, closets, bins. Additional review of Resident CL1's clinical record revealed a progress note dated April 26, 2023, when Resident CL1 was noted to make repeated requests for non-compliant food and was taking items (spoons, cups, etc) from nursing carts. The progress note continued that the behaviors are considered normal for resident. Interview conducted with non-licensed Employee E3, on November 15, 2023, at 7:24 p.m. revealed Resident CL1 was hungry all the time. [Resident] would tell us he/she was hungry right after he/she ate. [Resident] would regularly take items off the food cart, and we would take the food away from [resident]. Review of facility provided documentation including witness statements revealed, on October 25, 2023, approximately 1:22 p.m. Resident CL1 self- propelled to the end of the hallway where a nurse aide had placed discarded meal items. Resident CL1 was observed by another resident with a (peanut butter and jelly) sandwich and reminded Resident CL1 to not eat the sandwich then went to inform staff of concern. Further review of facility documentation revealed Resident CL1 was discovered by a nurse aide at 1:30 p.m. slumped over in wheelchair unresponsive. Nurse aide attempted to arouse Resident CL1 but was unsuccessful. Licensed nursing staff arrived and performed Heimlich maneuver. Emergency services (911) were contacted. No other interventions were noted to be used. Resident was pronounced dead at 1:41 p.m. with EMS present. Review of Resident CL1's behavior care plan revealed a history of rejecting care, and noncompliance related to Depression, Schizophrenia, Anxiety, ineffective coping skills, and poor impulse control. Review of Resident CL1's clinical record including care plans failed to reveal a care plan to address resident's inappropriate seeking behaviors. Review of Resident R4's clinical record revealed a Physician Order Sheet (POS) with diagnoses listed including but not limited to Post Traumatic Seizures and history of traumatic brain injury. Review of Resident R4's MDS assessments revealed admission/Medicare 5 day assessment dated [DATE] which indicated a BIMS (Brief Interview of Mental Score) score of 10 out of 15 (moderate cognitive impairment). Review of Resident R4's clinical record revealed progress note dated November 30, 2023 (1:15 a.m) Called to the unit by one of the CNA of the unit. Resident is noted to be screaming at staff stating I want to get out of here attempted to open the balcony door. 911 notified. Police officers arrived on scene stating they cannot take resident out of unit unless he was 302. On call doctor notified order obtained to send resident to [local hospital] ER for evaluation for combative and psychotic behavior. Further review of Resident R4's progress notes revealed note dated November 30, 2023 (1:25 a.m.) Resident came out to desk yelling and swinging at staff. He attempted to leave and swing at staff intermittently. Nurse Supervisor was called, [male nurse] came to assist. Police was called, and on their arrival resident stayed quite. They stated that they could not take resident unless staff from this facility initiated a 302 through Crisis Intervention. An order to transport resident for evaluation was taken from attending on call. Resident was transported out of here via litter with relevant transfer information. Police were on hand to ensure resident did not attack EMT while being taken out of facility. Review of Resident R4's clinical record revealed a nusing note dated November 26, 2023 (9:47 p.m.) [Hospital] Update: [Licensed staff, RN] - Resident taken off elopement precautions on 11/22. Barricaded himself in room and combative with staff on 11/23. Received IM medication. Appropriate conduct/elopement free expectations set with patient on 11/24. Resident remained calm/cooperative for almost 72 hrs.(hours) Seroquel and Zoloft added to medications. Pending discharge if continues to be stable. Further review of Resident R4's clinical record revealed a Nursing Note dated November 20, 2023 (10:21 a.m.), [Hospital personnel] a care coordinator for behavioral health called this am to staff and requested additional info (information) from staff regarding res (resident) history and behaviors. [Hospital staff] stating res (resident) conts (continues) restraints due to combative with hospital staff. Review of clinical record for Resident R4 revealed a progress note dated November 20, 2023 (3:30 a.m.) Physical Aggression initiated: Called into the 4th floor by the CNA of the unit. Upon arrival resident is noted to be very combative with staff. [Resident's] attempted to go through the balcony exit door (he/she) said (he/she) wants to jump. [Resident] knocked down the computer at the nursing station. [Resident] grabbed chairs to throw at the glass door. [Resident] grabbed a resident's walker from (him/her) as a result the resident sustain 2 skin tears on both of (his/her) wrists. One CNA (nursing assistant) jumped in front of the resident while the other Aid took the other resident to (his/her) room for safety. The Resident (aggressor) hit the aid with the walker on (his/her) back, pulled the CNA's hair and choking her. Unable to calm resident 911 is notified. 3:40 am: 1 officer arrived on scene. Officer called for back up a total of 8 officers plus 2 EMT personnels handcuffed resident and strapped (him/her) to the litter en route to LGH ER for evaluation. Review of Resident R4's clinical record including care plan goals and interventions failed to reveal a care plan to address R4's aggressive behaviors. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on November 30, 2023, at 12:58 p.m., and the IJ template was presented to the NHA, regarding care plans for Residents CL1 and R4. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure a comprehensive care plan for resident with history of seeking and/or aggressive behaviors and an immediate action plan was requested. The Nursing Home Administrator and facility's action plan included the following: 1). The facility is unable to correct deficient practice for CL1 and R4, both of whom are no longer in the facility. 2). DON (Director of Nursing) and designee will review all residents care plans to ensure care plans reflect specific aggressive behavior interventions are listed and have specific plans for follow up, if appropriate. To be completed by November 30, 2023. 3). DON and Designee will re-educate licensed staff to (A) Document aggressive behaviors, (B) Review resident care plans regarding specific behaviors, and (C) Update care plans to reflect new non listed behaviors and in using behavioral approaches. DON and designee will re-educate nursing staff to include, certified nursing assistants, to review Point of Care for their assigned residents in the resident Kardex and tasks and refer to licensed staff. The education will occur prior to current staff leaving scheduled shifts and upon arrival for next scheduled shift. DON and designee will re-educate nursing staff on behavior policies and procedures to ensure resident safety and supervision. Department heads will re-educate their staff on behavior policies and procedures to ensure resident safety and supervision. Re-education expected to be completed by November 30, 2023 and 4). DON and/or designee will review the 24 hour notes to ensure residents care plans are updated to reflect non listed behaviors three times per week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI for review and recommendations. The action plan was accepted on November 30, 2023 at 4:57 p.m. On December 1, 2023 a review of audits, documentation of completed employee education and interviews with eight licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on December 1, 2023 at 1:03 p.m. after confirmation that the action plan was implemented and the Nursing Home Administrator and Director of Nursing were informed the residents were no longer in Immediate Jeopardy. The facility failed to ensure and implement comprehensive care plans for Residents CL1 and R4 which resulted in CL1 fatally choking on a sandwich and R4's admission to hospital for physically aggressive behaviors toward staff and a resident. The Immediate Jeopardy was lifted at 1:03 p.m. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 PA Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 5/30/2023 28 Pa. Code 211.12(d)(1)(3) Nursing Services 28 Pa. Code 211.12(c) Nursing Services

Based on facility documentation, clinical record review and staff interviews it was determined the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent Resident CL1, with known seeking behaviors and receiving a specialty diet, from obtaining a sandwich from an unsupervised cart. Resident CL1 ingested the sandwich which caused resident to choke on the food and expire. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one resident identified as being at risk. This incident has been identified as past non-compliance. Findings Include: Review of the clinical record revealed Resident CL1 had diagnoses including but not limited to Dysphagia (inability/difficulty swallowing), Schizophrenia (mental illness characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution), Bipolar Disorder (mental illness characterized by extreme mood swings), Anxiety (intense, persistent, and excessive worry and fear about everyday situations), and Depression (loss of pleasure or interest in activities for long periods of time). Review of Resident CL1's quarterly comprehensive Minimum Data Set (MDS- assessment tool used to facilitate the management of resident care) dated August 23, 2023, revealed a BIMS of 09, indicating moderate cognitive impairment. Review of Resident CL1's clinical record revealed resident's diet recommendation was downgraded on April 11, 2023, to regular diet, pureed texture and thin consistency, due to an episode of swallowing difficulty with soft food (noodle). Review of Resident CL1's behavior care plan revealed a history of rejecting care, and noncompliance related to Depression, Schizophrenia, Anxiety, ineffective coping skills, and poor impulse control. Review of Resident CL1's clinical record revealed on September 20, 2022, Resident CL1 required a Heimlich maneuver to remove a glob of magic cup (pudding consistency). Further review of Resident CL1's clinical record revealed in March of 2023, resident was noted to have seeking behaviors to include entering residents' rooms, taking personal items from tables, closets, bins. Additional review of Resident CL1's clinical review revealed a progress note dated April 26, 2023, Resident CL1 was noted to make repeated requests for non-compliant food and was taking items (spoons, cups, etc) from nursing carts. The progress note continued that the behaviors are considered normal for resident. Interview conducted with non licensed Employee E3, on November 15, 2023, at 7:24 p.m. revealed Resident CL1 was hungry all the time. [Resident] would tell us [resident] was hungry right after[resident] ate. [resident] would regularly take items off the food cart, and we would take the food away from [resident]. Review of facility provided documentation including witness statements revealed, on October 25, 2023, approximately 1:22 p.m. the resident self- propelled to the end of the hallway where a nurse aide had placed discarded meal items. Resident CL1 was observed by another resident with a (peanut butter and jelly) sandwich and reminded Resident CL1 to not eat the sandwich then left to inform staff. Further review of facility documentation revealed Resident CL1 was discovered by a nurse aide at 1:30 p.m. slumped over in wheelchair unresponsive. Nurse aide attempted to arouse Resident CL1 but was unsuccessful. Licensed nursing staff arrived and performed Heimlich maneuver. No other interventions were noted to be used. Resident was pronounced dead at 1:41 p.m. with EMS present. Review of Resident CL1's clinical record revealed the coroner attested death certificate which indicated death was caused by aspiration of food bolus. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on November 15, 2023, at 6:37 p.m., and the IJ template was presented to the NHA, regarding supervision of Resident CL1. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure the implementation of supervision and safety measures to prevent Resident CL1 from obtaining inappropriate food items and supervision of the food carts which presented choking hazards and an immediate action plan was requested. The Nursing Home Administrator and facility's action plan which included the following: DON (Director of Nursing) performed an audit of all current residents identified on pureed diets and a history of impulsive behaviors. DON and designee provided education to nursing and dietary staff for juice and meal cart distributions, collections, and supervision. Revised policy and procedure began on October 25, 2023 and will continue with all new agency staff and new hires and will be reviewed during annual re-education. Policy and Procedures include appropriate supervision of residents during delivery and pick up of meal carts. All staff educated prior to leaving their current shift and prior to oncoming shift. DON and designee will audit weekly for four weeks, then monthly for two months. Dietary manager will audit weekly for four weeks then monthly for two months to ensure that dietary staff are not leaving (meal) carts on the (nursing) floors unattended. Audits started October 26, 2023 and will continue through December 2023. Results for audits will be presented to monthly QAPI for review and recommendations. The facility identified the jeopardy at the time of the incident, October 25, 2023. The facility conducted a full audit of current residents' pureed diets and impulsive behaviors. The audit was completed on October 25, 2023. The facility began education on October 25, 2023, of current dietary and nursing staff as well as nursing agency staff regarding newly implemented food service procedure which includes supervision of food delivery and disposal from each nursing unit. The education of the staff was completed on October 27, 2023. Daily audits were conducted of meal services and supervision of residents during the service and disposal of meal items. The facility continued with daily audits for four weeks and will continue weekly audits to ensure ongoing compliance as reviewed by facility Quality Assurance team. Facility staff was educated on the following: supervision of residents and food during meal services. The staff were also educated on the new procedure for distribution of meal services and retrieval of food trays/meal items at the end of the meal service. The staff were educated on residents who receive speciality diets and have seeking behaviors need supervision including meal service. The administration educated 67 facility staff and nine agency staff. The staff were educated before starting of the scheduled shift. Interviews conducted by surveyors on November 15 and November 16, 2023 of 15 staff including three Registered Nurses, nine nurse aides, one housekeeper, and one Licensed Practical Nurse. The interviews revealed the education provided to the staff at the time of incident included change in meal service and resident supervision. Assigned personnel monitor and supervise drink carts and discarded meal items during clean up. The Immediate Jeopardy was lifted on November 16, 2023, at 10:35 a.m., after confirmation that the action plan was implemented and completed. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 5/30/2023 28 Pa. Code 211.12(d)(1)(3) Nursing Services 28 Pa. Code 211.12(c) Nursing Services

Based on observations of resident care and services, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide an adaptive device to prevent accidental spilling of a beverage which resulted in a burn injury causing harm to one of 32 residents reviewed (Resident R59). Findings include: Review of the facility policy titled, Assistive Devices and Equipment, revised on July 2017, states, Staff and volunteers will be trained and will demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Review of the physician order sheet revealed an active order initiated on February 28, 2019, for Resident R59 that stated, Pureed texture, Nectar consistency, for dysphagia Sippy cup (a cup that has a top which prevents spills), at all meals, divided plate and maroon spoon (adaptive spoon) for all meals. The comprehensive Minimum Data Set assessment (MDS - an assessment of care needs) dated October 8, 2020, revealed that Resident R59 had severe cognitive impairment. The assessment indicated that Resident R59 required extensive assistance with eating (how a resident eats and drinks). The assessment also indicated that Resident R59 had a swallowing disorder, diminished ability to feed independently, and muscle weakness. A review of Resident R59's clinical documentation dated January 25, 2021, at 2:53 p.m. revealed a nursing note that stated, Called to assess resident after report of resident spilling hot coffee on self, area to mid chest with reddened, burned patch of skin 13x15cm with x 2 areas opened at 2x2cm each. Sippy cups to be provided, CRNP (Certified Registered Nurse Practitioner) notified and new order obtained for [MEDICATION NAME] cream BID. Further review of Resident R59's clinical documentation dated January 26, 2021, at 11:16 a.m. revealed a nursing note stating, Resident assessed as follow up to [MEDICAL CONDITION] spilling coffee on self-1/25/21. Circumoral (around the mouth) redness noted and extends to chin and lower lip. Resident reports chest area is painful. No discomfort or non-verbal pain cues expressed during assessment. Diffuse areas or redness noted to the chest with skin intact. Fluid filled blister at distal chest measures 1x2 cm, intact. Four areas of darkened skin noted, with skin intact. Wound bed cannot be visualized. No oozing or opened areas noted. Left lateral chest area measures 2x1 cm. Left medial chest area measures 1x3 cm. Right medial chest measures 4x2.5 cm. Right distal chest measures 2x1.5 cm. RN Supervisor notified of findings and will follow up on status of ordered treatment. Further review of Resident R59 clinical documentation dated January 26, 2021, at 4:49 p.m. revealed a nursing note related to the coffee spill and burn stating, pt did have open cup instead of sippy cup. A review of clinical documentation revealed on January 26, 2021, the facility completed a, Hot Liquid Safety Evaluation, for residents. A review of the facility-initiated investigation report completed on January 26, 2021, revealed a written statement by the nurse aide, that Resident R59 received a regular cup with thickened coffee. Interview with Employee E3, Director of Food Services, on March 3, 2021, at 12:45 p.m. revealed no changes have been made in the last six months to the, adaptive device list, and that Resident R59 has been listed as requiring adaptive devices. Observation on March 3, 2021, at 1:00 p.m. on the third floor revealed a hydration cart with a list of residents that require adaptive devices. Resident R59 was identified on the list. Interview with Nurse Aides, Employee E5 and Employee E6 on March 3, 2021, at 1:00 p.m. confirmed the list of residents requiring adaptive devices was accessible to all staff. Staff were aware of the location of the, adaptive devices list. Interview with the Nursing Home Administrator on March 3, 2021, revealed staff had education on the use of adaptive equipment prior to Resident R59 not receiving the correct cup. Documentation provided reveals staff were re-educated on the use of adaptive equipment and hot liquid safety on January 26, 2021. Interview with the Nursing Home Administrator on March 3, 2021, at 1:30 p.m. confirmed Resident R59 should have received a sippy cup with his meal. The facility failed to provide an adaptive device to prevent accidental spilling of a beverage as ordered by the physician which resulted in a burn injury causing harm to Resident R59. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident R1), creating a situation in which the resident was placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation. Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. The facility's policy regarding CPR, dated [DATE], stated that if a resident was found unresponsive and not breathing normally, CPR would be initiated unless there was a valid DNR order in place, or if there were signs of irreversible death (i.e., rigor mortis). The policy includes that if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated [DATE], indicated that Resident R1 had mild confusion (12 out of 15). The resident's care plan dated [DATE], revealed that the resident had an advance directive of FULL CODE: CPR will be performed as needed. There was no physician order stating the current code status of the resident and there was no evidence that the resident had an advanced directive. An interdisciplinary note written by the Nursing Home Administrator for Resident R1, dated [DATE], at 12:59 p.m. indicated that this writer was notified that the resident had ceased to breathe. Writer notified Coroner's office per protocol for a death of a resident that is currently positive for COVID-19. A nursing note written by the Registered Nurse, Employee E3, dated [DATE], at 7:58 a.m. indicated the resident expired at 1:00 p.m An order was received from the doctor to pronounce death, dispose of the medication and notify the family. There was no documented evidence that the resident was provided CPR in accordance with the care plan or with the facility policy that states if the resident DNR status is unclear, CPR will be initiated until there is a DNR order, or a physician's order not to administer CPR. Interview with Nursing Assistant (NA), Employee E6, on [DATE], at 11:57 a.m. revealed that Resident R1 was in the bed talking earlier in the day (on [DATE]). Lunch was about to be served and the drink and silverware was taken into the room. The resident appeared fine. Before lunch (the NA believes the time was 12:00 p.m.) the Licensed Practical Nurse (LPN), was seen going into the room to do a fingerstick (for blood sugar monitoring). The NA states that the LPN came out of the room and said the resident expired. The NA stated that CPR was not initiated. Interview with Licensed Practical Nurse (LPN), Employee E4, on [DATE], at 1:15 p.m. confirmed that Resident R1 was found in her bed cold, unresponsive and her face was yellow like they get when they die. The LPN then called the Supervisor (Registered Nurse) to report the death. CPR was not initiated. When asked why CPR was not performed it was stated that the resident was dead, it would not have mattered. The LPN would not state what the code status was of the resident. Interview with Registered Nurse, Employee E3, on [DATE], at 11:45 a.m. revealed that Resident R1 did not display any signs of rigor mortis when she was found with no pulse or respirations. The RN stated that she did not know the code status of the resident but thought that the LPN would have started CPR if the resident was a full code. An interview with the Medical Director on [DATE] at 4:00 p.m. revealed that if there is not a code status listed on a residents chart, the resident is a full code. An interview with Resident R1's guardian on [DATE] at 8:29 a.m. revealed that she is an appointed guardian by the court. If an individual is from Lancaster County, they are not allowed to make a resident a DNR until a judge determines it during a court proceeding. Resident R1 did not have a living will prior to the appointment and was a full code. An interview with the Director of Nursing on [DATE], at 10:15 a.m. revealed that she and Registered Nurse E3 realized the resident was a full code when they were reviewing the chart after the death. Education with the clinical staff began at that time ([DATE]). Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 10:22 a.m. revealed that they were aware that staff did not provide CPR to Resident R1 in accordance with the care plan, and CPR should have been provided in accordance with the facility's policy. On [DATE], at 4:56 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to the LPN failing to provide CPR in accordance with a resident's care plan and the facility policy. The facility submitted an acceptable immediate action plan on [DATE], at 9:14 p.m. that included the following actions: A facility wide sweep ensuring each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy and the signs of irreversible death, to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders. The plan also included to actively hold Code Blue drills (drills where staff respond to a resident experiencing [MEDICAL CONDITION]) with staff, and to complete ongoing audits. The Immediate Jeopardy was lifted on [DATE], at 12:17 p.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy, and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure the prevention of significant medication errors for 46 of 51 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, and Resident R46). This resulted in an Immediate Jeopardy situation when it was determined that Residents R1 through R46 missed a total of 473 doses of medications over the course of 20 days in May, June, July, and August, 2020. The frequency and number of missed medications and the lack of notification of their physicians had the potential to cause the residents discomfort or pain, to exacerbate medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety of 46 of 51 residents reviewed. Findings include: Review of the facility policy titled, Medication Administration- General Guidelines, without review date, revealed in Section C. Documentation number 1; The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At the end of each medication pass, the person administering the medications reviews the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In no case should the individual who administered the medications report off-duty without first recording the administration of medications. Review of documents provided by the Nursing Home Administrator on July 29, 2020, revealed six additional residents, not previously identified by the facility, with medication errors. An audit of the facility's current residents on August 6, 2020, revealed six additional residents identified as having medication errors in June, July, and August 1, 2020. Review of the MAR for the dates of May 6, May 14, May 16, May 18, May 19, May 20, May 21, May 22, May 24, June 4, June 7, June 22, June 24, June 27, June 28, June 22, July 11, July 15, July 16, and August 1, 2020, indicated that Residents R1 through R46 missed a total of 473 doses of medication over the course of these 20 days. The residents' physicians were notified of the May missed medications on June 8, 2020, and June 9, 2020, but for the missed medications in June, July, and August 2020, the physicians were notified on August 6, 2020. Review of medication error reports for Resident R1 through and including Resident R34 revealed in the incident description, failure of nurse to administer medication as directed and nursing failure to dispense those medications. Review of Resident R1's clinical record including the May 2020, MAR, revealed that on May 16, May 19, May 20, May 21, May 22, and May 24 the medications of [MEDICATION(S)] (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record failed to reveal documentation of a rationale for the missed dosages. Review of Resident R2's clinical record including the May 2020, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed the nurse did not indicate a reason for the missed dosages. Review of Resident R3's clinical record including the May 2020, MAR, revealed three doses of medication of [MEDICATION(S)] (antibiotic - prescribed to treat COVID 19 virus) were not administered on May 19, May 21, and May 22, 2020. Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R4's clinical record including the May 2020, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R5's clinical record including the May 2020, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R6's clinical record including the May and July 2020, MARs, revealed on May 16, May 19, May 21, May 22, and May 24, 2020, the medications [MEDICATION(S)] (used to improve blood sugar control), [MEDICATION(S)] (used to treat active [CONDITION(S)] ulcer) were not administered. Continued review of the record revealed the medication [MEDICATION(S)] (used to improve blood sugar control) was not administered on May 21, 2020. Further review of Resident R6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R6 was not given a total of ten doses of medication on the above dates. Further review of clinical record failed to reveal a rationale for the missed dosages. The physician was notified of the July 11th missed dose on August 6, 2020. Review of Resident R7's clinical record including the May 2020, MAR, revealed the medication [MEDICATION(S)] was not administered on May 19, 2020 and May 21, 2020, for a total of two doses. Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R8's clinical record including the May 2020, MAR, revealed that on May 19, May 20, May 21, and May 22, 2020, the medications [MEDICATION(S)] (used to treat fluid retention) and [MEDICATION(S)] were not administered for a total of eight doses. Further review of the clinical record failed to reveal the rationale for the missed dosages. Review of Resident R9's clinical record including the May 2020, MAR, revealed the medications Acetaminophen (used to treat pain), [MEDICATION(S)] (used to prevent seizures), [MEDICATION(S)] (anticonvulsant and/or used to treat moderate to severe pain), and [MEDICATION(S)] medications were not administered on May 18, 2020, for a total of four doses. Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R10's clinical record including the May 2020, MAR, revealed one dose of each medication [MEDICATION(S)] (used to treat depression) and [MEDICATION(S)] (used to treat disorders of the prostate) were not administered on May 6, 2020. Further review of the clinical record failed to reveal a rationale for the missed doses. Review of Resident R11's clinical record including the May 2020, MAR, revealed the medications Aspirin, [MEDICATION(S)] (used to treat fluid retention), [MEDICATION(S)] (used to treat underactive thyroid), Vitamin C (prescribed as treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record failed to reveal a rationale for the missed dosages. Review of Resident R12's clinical record including the May 2020, MAR, revealed the medications [MEDICATION(S)], [MEDICATION(S)] (used to treat high blood pressure and/or irregular heartbeat), [MEDICATION(S)] (used to prevent nausea and vomiting), and [MEDICATION(S)] were not administered on May 19, May 20, May 21, and May 22, 2020, totaling 20 doses. Further review of the clinical record failed to reveal documentation of a rationale for the missed dosages. Review of Resident R13's clinical record including the May 2020, MAR, revealed on May 6, 2020, the following medications of [MEDICATION(S)], [MEDICATION(S)] (oral medication used to manage blood sugar levels), [MEDICATION(S)] (anticoagulant), [MEDICATION(S)] (AKA [MEDICATION(S)] - used to treat high blood pressure and/or heart failure), [MEDICATION(S)], [MEDICATION(S)] (insulin used to treat diabetes), [MEDICATION(S)] (insulin used to treat diabetes), and [MEDICATION(S)] (AKA [MEDICATION(S)] - manages cholesterol levels in the blood stream) totaling eight doses were not administered. Further review of the clinical record failed to reveal documentation indicating a rationale for the missed dosages. Review of Resident R14's clinical record including the May 2020, MAR, revealed on May 6, 2020, the Medications [MEDICATION(S)] (used to reduce acid in the stomach) and [MEDICATION(S)] (used to treat fluid retention) were not administered for a total of two doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R15's clinical record including the May 2020, MAR, revealed that on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (laxative used to treat constipation) were not administered for a total of six doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R16's clinical record including the May 2020, MARs, revealed one dose of the medication [MEDICATION(S)] was not administered on May 16, 2020. Further review of the clinical record failed to reveal documentation of a rationale for the missed dose. Review of Resident R17's clinical record including the May 2020, MAR, revealed on the dates of May 16, 2020, May 19, and May 21, 2020, the medications [MEDICATION(S)] (AKA [MEDICATION(S)] - treats high blood pressure/Coronary Artery disease), [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were not administered for a total of 15 doses. Further review of the clinical record failed to reveal documentation of a rationale for the missed dosages. Review of Resident R18's clinical record including the May 2020, MAR, revealed one dose of the medication [MEDICATION(S)] (AKA [MEDICATION(S)] and used to manage cholesterol in the blood) was not administered on May 6, 2020. Further review of the clinical record failed to reveal documented rational for the missed dose. Review of Resident R19's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medications [MEDICATION(S)], [MEDICATION(S)] (antipsychotic medication), [MEDICATION(S)] (AKA [MEDICATION(S)]-used to treat pain and as an anticonvulsant) were not administered for a total three doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R20's clinical record including the May 2020, MAR, revealed on May 14, May 19, May 21, and May 22, 2020, medication doses for [MEDICATION(S)] (used to treat depression), [MEDICATION(S)] (AKA [MEDICATION(S)] - used to reduce amount of acid in the stomach), [MEDICATION(S)] (used to treat depression), Senna Tab (used to treat constipation), Vitamin B-12, and [MEDICATION(S)](used to treat anxiety) were not administered for a total of 18 doses. Further review of the clinical record failed to reveal documentation of rationale for the missed dosages. Review of Resident R21's clinical record including the May and June 2020, MARs, revealed on May 6, May 16, and June 22, 2020, the medications of Aspirin, [MEDICATION(S)] (AKA [MEDICATION(S)] - used to treat seasonal allergies), [MEDICATION(S)] (used to treat depression), [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (used to treat diabetes), [MEDICATION(S)], and [MEDICATION(S)] were not administered for a total of 17 doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R22's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medications [MEDICATION(S)] (anticonvulsant), [MEDICATION(S)], [MEDICATION(S)] (medication to lower lipid level), Iron, [MEDICATION(S)] (insulin used to control blood sugar levels), and [MEDICATION(S)] were not administered for a total of six doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R23's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medications [MEDICATION(S)] and Acetaminophen (Generic name for Tylenol) were not administered totaling two doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R24's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medications [MEDICATION(S)], Magnesium, [MEDICATION(S)] and [MEDICATION(S)] Cream were not administered totaling four doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R25's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)] (used to treat confusion related to Alzheimer's Dementia), Aspirin, [MEDICATION(S)] (treatment used to control amount of urine produced by kidneys), [MEDICATION(S)] (treatment used to increase the secretion of chloride), [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] (used to treat confusion related to Alzheimer's dementia), [MEDICATION(S)], [MEDICATION(S)] (anti-[CONDITION(S)] - used to prevent seizures), [MEDICATION(S)], and [MEDICATION(S)] were not administered for a total of 26 doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R26's clinical record including the May 2020, MAR, revealed that on May 6, 2020, the medication two doses of medication were not documented as administered for May 6, 2020. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R27's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)] Sulfate (AKA Iron), [MEDICATION(S)] (used to prevent seizures), [MEDICATION(S)], and [MEDICATION(S)] (used to treat depression) totaling seven doses of medication were not administered. Further review of the clinical record failed to document rationale for the missed dosages. Review of Resident R28's clinical record including the May 2020, MAR, revealed medications were not administered on May 16, 2020, totaling six doses. The medications not administered were [MEDICATION(S)]-[MEDICATION(S)] (used to treat [CONDITION(S)]), [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] (used to lower LCL cholesterol and elevate HDL cholesterol), [MEDICATION(S)] (used to treat depression), and [MEDICATION(S)]. Continued review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R29's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, medications were not administered totaling 14 doses. The medications included Aspirin, [MEDICATION(S)] (used to treat constipation), Fludrocortisone (used to treat low glucocorticoid levels caused by disease of the adrenal gland), [MEDICATION(S)], and [MEDICATION(S)] (AKA [MEDICATION(S)] - used to treat depression). Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R30's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)], [MEDICATION(S)] (reduces the amount of acid in the stomach), [MEDICATION(S)] (used to treat psychosis), [MEDICATION(S)] (used to treat high blood pressure), [MEDICATION(S)], Magnesium, Potassium, [MEDICATION(S)], [MEDICATION(S)] (used to treat diarrhea caused by Escherichia coli (E. coli), and [MEDICATION(S)] were not administered totaling 20 doses. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R31's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Vitamin C, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (used to prevent seizures) totaling 16 doses were not administered. Continued review of the clinical record failed to reveal documentation of rationale for the missed dosages. Review of Resident R32's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020, the medications [MEDICATION(S)], [MEDICATION(S)] (used to treat high blood pressure in the eye), [MEDICATION(S)], Senna-S, [MEDICATION(S)] (used to treat high blood pressure), [MEDICATION(S)], [MEDICATION(S)] sulfate, [MEDICATION(S)], [MEDICATION(S)] Insulin, [MEDICATION(S)], Vitamin C, [MEDICATION(S)], [MEDICATION(S)] (used to treat stomach ulcer), [MEDICATION(S)], Novolog, and [MEDICATION(S)] (used to prevent seizures) totaling 30 doses were not administered. Further review of the clinical record failed to reveal documented rationale for the missed dosages. Review of Resident R33's clinical record including the May 2020, MAR, revealed on May 6, 2020, medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were not administered totaling three doses. Further review of the clinical record failed to reveal any documented rationale for the missed dosages. Review of Resident R34's clinical record including the May 2020, MAR, revealed on May 6, 2020, and May 16, 2020 medications [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (used to prevent blood clots) were not administered totaling 18 doses. Further review of the clinical record failed to reveal any documented rationale for the missed dosages. Review of Resident R35's clinical record including the May, June and July 2020, MARs, revealed on May 6, May 16, June 4, June 28, and August 1, 2020, the medications [MEDICATION(S)] (used to treat Depression), Vitamin D (used to treat Vitamin D Deficiency), [MEDICATION(S)] (anti-[CONDITION(S)] used to prevent seizures), [MEDICATION(S)], Sodium chloride, [MEDICATION(S)] (AKA [MEDICATION(S)] - used to prevent seizures), and [MEDICATION(S)] (used to prevent seizures) totaling 39 doses. Continued review of the clinical record failed to reveal any documented rationale for the missed dosages. Review of Resident R36's clinical record including the May 2020, MAR, revealed that on May 16, 2020, the medication [MEDICATION(S)] was not administered for one dose. Further review of Resident R36's clinical record failed to reveal a rationale for the missed dose. Review of Resident R37's clinical record including the May 2020, MAR, revealed that on May 6, 2020, the medications Trazadone(used to treat insomnia), [MEDICATION(S)] (used to treat insomnia), [MEDICATION(S)] (used to treat [CONDITION(S)] Fibrillation), [MEDICATION(S)] (antibiotic used to treat COVID 19 virus), and [MEDICATION(S)] (used to treat constipation) totaling five doses were not administered. Continued review of the clinical record failed to reveal rationale for the missed dosages. Review of Resident R38's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medications of [MEDICATION(S)] (used to control blood sugar), [MEDICATION(S)] (used to treat high blood pressure), and [MEDICATION(S)] Syrup (used to treat dementia with behaviors) totaling three doses were not administered. Further review of the clinical record failed to reveal rationale for the missed dosages. Review of Resident R39's clinical record including the May 2020, MAR, revealed on May 6, 2020, the medication [MEDICATION(S)] (used to treat convulsions) was not administered. Continued review of the clinical record failed to reveal a rationale for the missed dose. Review of Resident R40's clinical record including the May 2020, MAR, revealed that on May 6, 2020, and May 16, 2020, the medications; [MEDICATION(S)] (used to treat dementia), [MEDICATION(S)] (AKA [MEDICATION(S)]-used to treat Depression), [MEDICATION(S)] (used to reduce acid produced by the stomach), [MEDICATION(S)] (AKA [MEDICATION(S)] -used to lower LDH and increase HDL cholesterol), [MEDICATION(S)] (used to treat high blood pressure in the eye due to glaucoma), and [MEDICATION(S)] (antipsychotic -used to treat conditions such as [CONDITION(S)] or [CONDITION(S)] disorder) totaling six doses were not administered. Continued review of Resident R40's clinical record failed to reveal rationale for the missed dosages. Review of Resident R41's clinical record including the June 2020, MAR, revealed that on June 7, 2020, the resident was not administered 2:00 p.m. dose of [MEDICATION(S)]. Continued review of the clinical record failed to reveal a rationale for the missed medication. The attending physician was notified on August 6, 2020. Review of Resident R42's clinical record including the June 2020, MAR, revealed that on June 7, 2020, the resident was not administered one dose of [MEDICATION(S)]. Further review of the clinical record failed to reveal rationale for the missed dose. Physician notification of the June missed administration on August 6, 2020. Review of Resident R43's clinical record including the June 2020, MAR, revealed that on June 7 and June 27, 2020, the resident missed Glucerna Enteral feeding 1.5 bolus (1 can) at 2 p.m. Continued review of the clinical record failed to reveal a rationale for the missed feedings. The attending physician was notified of the missed feeding on August 6, 2020. Review of Resident R44's clinical record including the July 2020, MAR, revealed that on July 15, 2020, the resident was not administered [MEDICATION(S)] Insulin-30 units (used to control high blood sugar levels), [MEDICATION(S)] (used to treat high blood pressure), Prevastatin, [MEDICATION(S)] (Antibiotic- used to treat infections), and Cefpodoxine Poxetil (Antibiotic -used to treat bacterial infections) totaling five doses. Review of Resident R45's clinical record including the June 2020, MAR, revealed that on June 24, 2020 the resident was not administered; [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (AKA: [MEDICATION(S)]) totaling four doses. Further review of the clinical record failed to reveal rationale for the missed dosages. The primary care physician was not notified until August 6, 2020. Review of Resident R46's clinical record including the July 2020, MAR, revealed one dose of [MEDICATION(S)] (medication used to treat pain) was not administered on July 17, 2020. The resident's primary care physician was not notified until August 6, 2020. Review of medication error reports for Residents R1 through and including R40 revealed medications including but not limited to following of [MEDICATION(S)] (treats underactive thyroid); [MEDICATION(S)](anti-[CONDITION(S)] medication); [MEDICATION(S)] (treats [CONDITION(S)]); [MEDICATION(S)]; [MEDICATION(S)] insulin; [MEDICATION(S)] insulin; Novolog insulin; [MEDICATION(S)] (treats high blood pressure); [MEDICATION(S)] (antiseizure); [MEDICATION(S)](antiseizure);[MEDICATION(S)] (reduce water weight for heart/kidney disease) [MEDICATION(S)] (anticonvulsant); [MEDICATION(S)]; [MEDICATION(S)] (treats high blood pressure and/or irregular heart beat); [MEDICATION(S)] (used to treat diabetes); [MEDICATION(S)] (anticoagulant); [MEDICATION(S)] (treats heart failure); [MEDICATION(S)] (antipsychotic); [MEDICATION(S)] (treats high blood pressure and coronary artery disease); [MEDICATION(S)] (used to treat Diabetes); [MEDICATION(S)](used to treat high blood pressure); [MEDICATION(S)] (anticonvulsant); [MEDICATION(S)] insulin; [MEDICATION(S)] (Moderate to severe pain); [MEDICATION(S)] (antipsychotic); [MEDICATION(S)] (used to prevent blood clots); [MEDICATION(S)]-[MEDICATION(S)](used to treat [CONDITION(S)]); [MEDICATION(S)] (used to treat high blood pressure); [MEDICATION(S)] (used to treat high blood pressure); and [MEDICATION(S)] (antiseizure medication) were identified as not being administered. Further review of medication error reports for Residents R1 through R34 revealed that the physician was notified of the May, 2020, missed medications on June 8, 2020, and June 9, 2020. The facility did not provide medication error reports for Residents R35 through Resident R46. The attending physicians were notified of the June and July medication errors on August 6, 2020. Interview occurred on July 17, 2020, at 2:10 p.m. and on August 5, 2020, at 3:10 p.m. with the Nursing Home Administrator (NHA), during which the above information was reviewed. The NHA confirmed that she believes the medications were not administered for the medication errors occurring in May, 2020. The Nursing Home Administrator indicated the nurse responsible for the significant medication errors in May, 2020, was terminated on June 3, 2020, due to performance issues. Interview on July 29, 2020 at 9:30 a.m. with licensed staff, Employee E21, who stated that if blanks are noted on the MARs (Medication Administration Record) then they would follow protocol. When asked to elaborate, Employee E21 stated, would follow our protocol. Employee E21 did not indicate what the protocol would be or how staff were expected to address the medication documentation issue. An interview was conducted on July 29, 2020, at 10:57 a.m., with licensed staff, Employee E20. Employee E20 revealed that on May 24, 2020, the facility contacted them at their residence and informed them that the DON, Employee E19, (now a former employee), showed up for a scheduled shift but then left the building. Employee E20 went to the facility and began to contact attending physicians due to residents that were noted to have medications not administered that morning, and to inform them that they would be given later than the specified time. Employee E20 noted that on a resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned, Employee E20 stated, don't believe the medications were given. When asked about the medication errors, Employee E20 responded, didn't know how many until Nursing Administrator asked to review the residents on 2nd and 3rd floors. That was early part of June 2020. Employee E20 was asked about the procedure if blanks on MARs were noted, and responded they were to alert the Director of Nursing (DON) and then perform an assessment of the resident. Interview on July 29, 2020, at 1:20 p.m., with the Nursing Home Administrator who revealed they first became aware of medication issue on May 24, 2020, when facility contacted her to report that (former) Director of Nursing (DON) left the building and one of the units was without a nurse to pass medications. The NHA indicated that she contacted Employee E20 to request she come into facility and assist with situation by administering medications and calling physicians to alert them to the situation of the day. The Nursing Home Administrator indicated that she made numerous attempts to contact Employee E19 on May 24, 2020, but was unsuccessful. The NHA spoke with the DON on May 25, 2020, when the DON indicated that she felt overwhelmed by job position and stated, I'm not a cart nurse. I don't like passing meds (medications). The Nursing Home Administrator reported that on May 31, 2020, the DON did not show up for her scheduled shift so a meeting was scheduled and held on June 3, 2020, when the DON was terminated. An interview on July 29, 2020, at 3:16 p.m. with Employee E16, the pharmacist revealed that the monthly medication reviews (MRRs), are being conducted offsite through review of electronic records. Employee E16 stated that prior to the pandemic reviews were being conducted onsite, with the DON, and any noted discrepancies were discussed. Employee E16 indicated that he was not made aware of a change in personnel; specifically the Director of Nursing position. Interview on July 29, 2020, at approximately 5:40 p.m., was conducted with the former Director of Nursing, Employee E19. Employee E19 indicated that she was hired in April, 2020, to be the Assistant Director of Nursing until prior DON abruptly quit the position and then needed to assume the responsibilities of the position. Employee E19 indicated that the facility had difficulty with staffing due to pandemic and COVID 19 illnesses. Employee E19 stated that the facility was able to staff a nurse on every floor. When asked about the medication errors, Employee E19 responded, I was never trained to do meds (medications). I came from hospital administration. I am not a cart nurse. When asked how the medications were handled, Employee E19 responded, I tried to give the meds but there were times when working overnight; I was informed that the nurse on the next shift would give the morning medications. Employee E19 was unable to identify which nurse was responsible for administering the medications in the morning. The frequency and number of missed medications and the lack of notification of their physicians had the potential to cause the residents discomfort or pain, to exacerbate medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures and jeopardized their health and safety. An Immediate Jeopardy situation was identified and the Nursing Home Administrator and the Director of Nursing were notified on August 6, 2020, at 10:40 a.m. for the facilities failure to ensure the prevention of significant medication errors which had the potential for harm to 46 of 51 residents reviewed. The facility submitted and completed an immediate action plan which included completing a medication audit for all current residents. Any newly identified resident were assessed and the primary physician notified. The facility staff were educated on proper medication pass administration, documentation, and policy on discovering medication omissions. Education and Competencies were given to nursing staff regarding medication administration prior to start of their work shift. The facility educated the pharmacy consultant on how to conduct an investigation of medication review errors. The Director of Nursing or designee will complete monthly audits of the pharmacy reviews for four months and report audit results to the QAPI team. Education was provided by the facility Regional Senior Administrator to the Administration regarding conducting a thorough investigation of medication administration omissions. The Administrator or designee will do audits every shift daily for four weeks to ensure medication doses are given according to physician orders. The action plan was accepted on August 6,

Based on clinical record review and staff interview, it was determined that the facility failed to provide a pain medication in a timely manner to adequately managed a resident (Resident CL9) pain level for one of three resident reviewed, which resulted in actual harm to Resident CL9. Findings include: Review of resident CL9 ' s clinical record revealed that the resident was admitted to the facility on [DATE] from home. The resident had a previous stay at the hospital on September 23, 2015 with the following (but not limited to) Diagnoses: [REDACTED]. Review of the hospital discharge notes revealed the following medications which included [MEDICATION NAME] (muscle relaxant medication) 5 milligrams by mouth three times a day as need for back spasms, [MEDICATION NAME] (pain medication) 30 milligrams by mouth every four hours as needed for severe pain (8 out of 10 on a pain scale) and [MEDICATION NAME] 15 milligrams by mouth every four hours for moderate pain (5-7 out of 10). Review of the Resident ' s CL9 nursing note dated November 11, 2015 stated that Resident CL9, arrived at the facility at 6:00 p.m. by way of family transportation and brought his medications from home. Review of nursing note dated November 12, 2015 at 12:05 a.m. revealed that the resident complaint of pain and the resident stated that he had pain of 10/10 all over his body. The resident requested [MEDICATION NAME] for pain The licensed nursing staff, phoned the physician to ask him to send a script to pharmacy due to the resident being in severe pain. The nursing note quoted the physician as stating Listen to the words coming out of my mouth. He will not get it until I see him in the morning. Further review of nursing notes dated November 12, 2015 at 1:17 a.m. noted that the resident received [MEDICATION NAME] 30 milligrams (given for inability to sleep) and at 1:18 a.m. Tylenol 650 mg (for pain) was adminstered. Further review of nursing notes date November 12, 2015 at 4:41 a.m. revealed that these medications were given with no effect on pain level or sleep and the resident has been crying in pain since the start of the shift. Review Resident CL9's November 2015 Medication Administration Record [REDACTED] An interview with the Nursing Home Administrator on January 10, 2016 at approximately at 12:30 p.m. revealed that the response of the physician was not acceptable and confirmed that the resident ' s pain management was not properly handled. The facility failed to ensure that Resident CL9 was admisntered a pain medication in a timely manner to adequately managed the resident pain level which resulted in actual harm to Resident CL9. 28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services Previously cited 12/15/2015, 07/02/2015, 02/8/2015 28 Pa 211.10(a) Resident care policies Previously cited 12/15/2015, 07/02/2015, 02/8/2015

Based on observations, facility policy reviews, clinical record reviews, staff interviews and resident interviews, it was determined that the facility failed to ensure the environment remained free of accident hazards and that there was adequate supervision related to resident smoking for 6 of 24 residents reviewed (Residents C7, J6, F7, J8, K9 and H4), thereby placing the health and safety of the residents in Immediate Jeopardy. The facility also failed to provide adequate supervision related to resident elopements for 5 of 24 residents reviewed (Resident J6, F7, J8, K9 and H4). Findings include: Review of the facility policy, "Smoking Policy", undated, revealed that smoking was only allowed in the designated smoking area, currently located in the gazebo adjacent to the side of the facility's primary parking lot. The policy indicated that all of the residents would be assessed, on an ongoing basis, for safety and supervision. The residents must be able to demonstrate the ability to smoke safely to maintain independent smoking privileges. All smoking materials, including cigarettes, matches and lighters, were to be secured at the nurses' station. Review of the facility policy, "Elopement Policy and Procedure," revised January 2011, indicated that elopement was related to those residents who left the facility without the knowledge of the staff, and therefore would be at risk for injury. The purpose of this policy was to identify those residents who are at risk for elopement; minimize episodes of elopement; protect residents; provide for equipment and techniques to minimize safety risks and educate staff. Documentation guidelines for actions taken to prevent or minimize an elopement included: the use of a Wander Alert bracelet (a device used to alert staff that a resident is leaving the unit) and visual checks and frequency of visual checks in accordance with the residents' needs. The prevention procedure indicated that the staff would observe that each resident's Wander Alert bracelet alarm/device was still in place each shift and that it was functioning. The prevention procedure revealed that the facility was to identify any external environmental hazards and was to implement additional interventions to minimize these potential risks and hazards for elopement. Review of Resident C7 nursing notes from November 16, 2013, revealed that the resident was educated about smoking and that smoking was only allowed in the designated area (the gazebo) due to safety. Review of the resident's care plan regarding at risk for smoking related injury, dated December 2, 2013, revealed interventions which included the storage of smoking materials per the facility policy. Review of Resident C7's signature and acknowledgement to the facility smoking policy, signed by the resident on February 25, 2014, indicated that the resident agreed to keep all smoking materials at the nurses' station. An interview with Resident C7 on February 27, 2014, at 11:30 a.m., confirmed that cigarettes and a fluid lighter are being stored in the resident's bedside table. An interview with Licensed Employee E6, on February 27, 2014, at 12:45 p.m., confirmed that Resident C7 is in possession of his smoking materials, and further revealed that other licensed or general nursing staff who are assigned to this First Floor Nursing Unit also know that the resident stores these smoking materials in his room. The facility failed to ensure that Resident C7, who was assessed and care planned for being at risk for smoking and storage of his smoking supplies had interventions in place to effectively maintain his safety and the safety of others. The facility failed to ensure that interventions were implemented and effective for the safe supervision of Resident C7. The facility also failed to follow the Smoking Policy, by allowing Resident C7 to be in possession of lighting materials and cigarettes in his room, therefore, placing the residents, the staff and visitors at risk for their health and safety. Observation of Resident J6 during the initial entrance into the facility on [DATE], at approximately 12:10 p.m., and on February 26, 2014, at approximately 9:10 a.m., revealed that the resident was in an electric wheelchair and smoking independently in the facility designated smoking area. Resident J6 was observed not to be wearing a smoking safety apron. There were no other residents or staff observed outside. Review of Resident J6's clinical record and quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated January 2, 2014, indicated that the resident was cognitively intact and used an electric wheelchair for mobility secondary to deficits in range of motion for bilateral amputation of the legs. The MDS further documented that Resident J6 was physically able to leave the facility. A current physician's order, dated March 14, 2013, also indicated that the resident may smoke unsupervised, but it's against medical advice. Review of Resident J6's current care plan for non-compliance behaviors, dated September 24, 2012, revealed that the resident was non-compliant with returning cigarette materials to the nurses' station when in the building and non-compliant with supervision by going to a corner store. Review of Resident J6's current Elopement Risk Assessment, dated September 25, 2012, documented that the resident was non-compliant with policies and had a past history of leaving the facility. The resident was described in this assessment as frequently wheeling himself to a corner store if he needed to make a purchase. (Personal items, food snacks, cigarettes or lighting materials as per resident interview). Review of the resident's quarterly Quarterly Interdisciplinary Resident Review (an assessment used periodically by the facility to evaluate the resident's needs), dated January 2, 2014, Section L: Risk for Elopement, documented that the resident had no history of wandering or elopement. Review of Resident J6's current care plan, effective date September 23, 2012, determined that the resident was at risk for elopement related to previous episodes of leaving without prior approval. There was no evidence that the facility had updated Resident J6's formal Elopement Risk Assessment since September 25, 2012. Review of Resident J6's Smoking Safety Assessment, dated March 18, 2013, documented that the resident had obtained lighter/matches from an outside source and had a history of [REDACTED]. A review of Resident J6's clinical record and quarterly MDS assessment, dated January 2, 2014, indicated the resident was able to smoke independently and acknowledged understanding of the policy and procedures related to storage of smoking materials. Resident J6's current care plan for being at risk for a smoking related injury as a result of smoking independently, dated December 6, 2011, directed the staff to: provide a smoking safety apron to the resident, not allow the resident to smoke in dangerous areas and to re-educate the resident on alternative smoking areas and on the fire hazards of smoking on the porch. Interview with Licensed Nurse, Employee E12, on February 27, 2014, at 12:00 p.m., in the presence of the facility's Medical Director, confirmed that Resident J6 stores the lighter and cigarettes in the bedside drawer. Employee E12, accompanied by a surveyor, interviewed Resident J6 on February 27, 2014, at 12:15 p.m., in the resident's room. Resident J6 confirmed that a smoking safety assessment had not been completed by the staff in a long time; and the resident stores the lighter and cigarette materials in the bedside table drawer, even though the resident previously acknowledged understanding of the policy and procedure related to storage of smoking materials. Resident J6 further confirmed that the cold weather is what currently interferes with the resident going to the neighborhood corner store. When the surveyor and Employee E12 both exited Resident J6's room, on February 27, 2014 at approximately 12:25 p.m., the surveyor observed that Employee E12 failed to follow the facility policy for safe storage of smoking materials, by not requesting these smoking materials from the resident and allowing the resident to remain in possession of these hazardous smoking materials. During an interview with Employee E12, on February 27, 2014, at 12:25 p.m., the employee did not confirm that residents on this nursing unit were being reminded or re-educated to sign out/sign in on a registry book. Additionally, there was no indication that residents were routinely telling staff that they were leaving the nursing unit. The facility was unable to provide the survey team with written protocol or procedure on the process related to the residents leaving their unit. An interview with the Medical Director on February 27, 2014, at 12:30 p.m., confirmed that the facility had a problem with residents who smoke and residents who travel independently to a neighborhood corner store for small purchases and smoking materials. Review of Resident F7's quarterly MDS assessment, dated January 22, 2014, revealed that the resident was cognitively intact. Review of the facility's Quarterly Interdisciplinary Resident Review (an assessment used periodically by staff to evaluate resident's needs), dated January 7, 2014, Section L: Risk for Elopement, documented that Resident F7 was physically able to leave the facility independently, but was also described with cognitive impairment, impairment with decision making skills and had a history of [REDACTED]. Review of Section N: Safe Smoking Evaluation of the Quarterly Interdisciplinary Resident Review, revealed that Resident F7 was described with cognitive impairments and physical limitations, which prevented the resident from safely containing the cigarette ashes and/or extinguishing cigarettes during smoking. The evaluation further documented that Resident F7 was not able to acknowledge understanding of the policy related to the storage of lighting and smoking materials. An informal note, handwritten at the bottom of this assessment, documented that Resident F7 often refused to return lighters and smoking materials to the nurse at the front desk for the safe storage of these materials and was described as becoming verbally aggressive. Review of Resident F7's physician's order, dated February 6, 2014, indicated the resident may smoke unsupervised, but it's against medical advice. Review of Resident F7's current plan of care, effective May 19, 2011, described the resident as being at risk for smoking related injury and that the resident was smoking against medical advice. This care plan for being at risk for a smoking related injury further documented that the resident becomes verbally aggressive when the staff request to secure the resident's smoking materials for safe storage and that the resident refuses to wear a smoking safety apron. Interventions to direct the staff to manage these non-compliant safe smoking behaviors documented that Resident F7 would be educated on the safety of applying a smoking safety apron and if the resident was not wearing the apron, the resident would be supervised by staff. The facility failed to provide any documented evidence that the plan of care to manage the incidents when Resident F7 was non-compliant with the smoking policy regarding the storage of smoking materials and the application of smoking safety apron, were not being implemented. An interview with Resident F7 on February 26, 2014, at 1:15 p.m., confirmed the resident goes outside, independent of staff, to smoke. Surveyor observations of the sign out book on February 28, 2013, at 11:30 a.m., revealed that only Resident F7's signature was being documented and there was no record of sign in or sign out times or destination. Interview with Licensed Employee E7 on February 28, 2014, at approximately 11:30 a.m., confirmed that Resident F7 independently smokes, is reminded to sign out in a book stored at the nurses' station, and does not wear a smoking safety apron. The interview further revealed that Employee E7 could not provide a system for how the staff monitors those residents who have signed out and were leaving the nursing unit. Interview with Director of Nursing (DON) on February 28, 2014 at approximately 12:00 p.m., confirmed that the facility had no policy and procedure to direct the staff for the safe monitoring and supervision of those independent residents who were known to independently leave the nursing unit or exit the facility. The DON further confirmed that it was known to the facility staff that Resident F7 was non-compliant with following the smoking policy, and there was no evidence that the facility re-evaluated the resident for safe smoking. Review of Resident J8's clinical record indicated that the resident was admitted to the facility on [DATE]. Resident J8's quarterly MDS assessment, dated December 18, 2013, assessed the resident as moderately independent with decision making and was her own responsible party. Review of Resident J8's care plan, for episodes of altered mood, dated January 18, 2013, indicated the resident would refuse the recommended placement of a medical device, a Wander Alert bracelet, in an effort to maintain safety. Resident J8 had a plan of care for being at risk for elopement. For monitoring the resident's whereabouts on the nursing unit, interventions were added to the elopement risk care plan, dated September 10, 2013 and September 12, 2013, for staff to check on the resident every fifteen minutes and for a Wander Alert bracelet to be stored in the resident's purse and for the staff to check the placement and the function of the Wander Alert bracelet. Review of Resident J8's Elopement Risk Assessment, dated September 12, 2013, documented that the resident was identified as an elopement risk on admission, had exhibited wandering behaviors in the past 90 days and would wander aimlessly about the facility. The Interdisciplinary composed of Licensed Nurses and members of the Social Service Department, were in agreement signing the document on September 12, 2013 and September 13, 2013, for the continued use of the Wander Alert bracelet. Review of Resident J8's Elopement Risk Assessment, dated November 25, 2013, documented that the resident's unsafe behaviors included: wandering behaviors in past 90 days, wanders aimlessly about the facility, verbalized wanting to go home or leave facility, experienced a recent move in facility or room and exhibited other behavior changes. The Interdisciplinary Team did not document for the continued monitoring of the resident or for the staff to discontinue the use of the Wander Alert bracelet. Review of Resident J8's nursing notes documented on November 17, 2013, that the resident does not allow the staff to look in the purse to check the placement and function of the Wander Alert bracelet every shift; did not locate the purse; would not allow the staff to look for the purse; and the purse was not with the resident at the time of a check. Review of a nursing note, dated November 17, 2013, documented that at 2:36 p.m., Resident J8 wanted to go outside and the staff were unable to take the resident outside, and educated the resident that she could not go outside without supervision. After the staff left the resident's sight, the resident was witnessed by another resident getting in the elevator independently. The resident was found outside on the porch and was requesting to go to the hospital with complaints of, "hearing voices in her head." A nursing note, dated November 17, 2013, at 10:23 p.m., documented that the resident was exit seeking after supper, was not having her purse with her and the Wander Alert bracelet was not on the resident. Nursing documentation, dated November 20, 2013, at 6:54 p.m., revealed that the resident was seen getting in the elevator several times. The resident then managed to go to the porch without supervision. Additionally, the resident was to have a Wander Alert bracelet but does not allow the staff to apply the Wander Alert bracelet, and for some time the Wander Alert bracelet was in the resident's purse but the resident refuses to allow the staff to look in the purse. Review of Resident J8's Treatment Administration Record, for November 2013, documented that the licensed staff were checking for the placement and function of the Wander Alert bracelet, every shift, for dates reviewed November 1, 2013 through November 22, 2013. Further review of the Treatment Administration Record, for dates November 22, 2013 through November 30, 2013, indicated that the licensed staff were no longer documenting the placement and function of the Wander Alert bracelet and the order was discontinued, as per the Treatment Administration Record, on November 22, 2013. Interview with Licensed Nurses, Employees E12 and E19, on February 26, 2014, at 12:00 p.m., confirmed routine assignments to the Fourth Floor Nursing Unit and that a physician's order was needed for the placement of a Wander Alert bracelet. Employees, E12 and E19, could not confirm if Resident J8 was to be monitored for the placement of a Wander Alert bracelet (which was to be stored in resident's purse) and/or for testing of the function of the Wander Alert bracelet every shift. Employees E12 and E19 further alleged that Resident J8 never went anywhere without the purse, however, Employee E19 was unaware if the resident was to have an alarming bracelet in the purse. The DON confirmed during an interview on February 27, 2014, at approximately 3:45 p.m., that there was no evidence that the facility completed a review into these incidents for dates, November 17, 2013 and November 20, 2013, regarding how Resident J8 was able to exit the nursing unit and exit the facility. The DON also confirmed there was no evidence of a physician's order for the parameters of use and placement of the Wander Alert bracelet and there was no evidence of an order to discontinue the Wander Alert bracelet on November 22, 2013. There was no evidence that the facility implemented alternate safeguards for Resident J8, who was assessed as having a history of a successful elopement from the facility, failed to be compliant with those ordered safety devices and continued to demonstrate exit seeking behaviors. Review of Resident K9's quarterly MDS assessment, dated December 5, 2013, indicated that the resident was cognitively intact and had a [DIAGNOSES REDACTED]. A review of Resident K9's care plan for being at risk for a smoking related injury, effective date May 24, 2013, indicated interventions to assist the resident to and from a designated smoking area, storage of smoking materials per facility policy, review of the smoking policy and routine Smoking Safety Assessments. There was no documented evidence of a completed Smoking Safety Assessment, indicating Resident K9's acknowledgement of understanding the smoking policy and the resident's agreement to cooperate with supervised smoking, prior to the development of the resident's current plan of care for smoking related injury, dated May 24, 2013. Review of a nursing note, late entry, December 24, 2013, at 3:20 p.m., documented that Resident K9 had some behaviors including: constantly requested to smoke; on some occasions would go into the elevator with no staff and refuses to come out; resident refuses to give up his cigarette pack and wants to keep it and he asked different staff and a visitor how to go to the store and buy a lighter. The resident was not satisfied with not being taken out to smoke and continued exit seeking. "Oncoming shift notified to approach the resident, when calm, for his pack of cigarettes." There were no further nursing notes documented on December 24, 2013, that the oncoming shift, as directed, was able to approach Resident K9 and retrieve the resident's cigarettes for safe storage, as per facility policy. Nursing documentation dated December 26, 2013, at 11:00 p.m., identified that at 2:45 p.m., Resident K9 was taken outside for supervised smoking and at 3:15 p.m., had demanded to go outside again. Resident K9 had become belligerent with the staff and attempted to go through the fire escape stairwell. The resident continued to threaten to hurt the staff. A nurses' note, dated December 27, 2013, at 9:58 a.m., documented that the resident started with behaviors right after breakfast and went into the elevator by himself and stated that he wanted to go smoke. The resident would not come out of the elevator until the staff took the resident outside to smoke. Nursing documentation further identified that the resident had his matches and cigarettes with him and was refusing to give them to the staff. Education was attempted but not successful and the resident was sitting at the nurse's station with a cigarette in his mouth. There was no further documentation to indicate how the facility was monitoring the environment to ensure the safety of all of the residents, when it was known to the staff that Resident K9 remained in possession of his matches and cigarettes as documented in the nurses' note, dated December 27, 2013, at 9:58 a.m. A nurses' note, dated December 27, 2013, at 1:54 p.m., documented by Employee E19, indicated at 12:20 p.m., Resident K9 was noted at the back elevator stating he was going to smoke. Employee E19 went to check on the resident in his room and noted the resident was smoking and refused to put the cigarette away. A social service note, documented by Social Service Employee E20, dated December 27, 2013, at 1:06 p.m., revealed that Employee E20 was called to assist the staff on the Fourth Floor Nursing Unit to address behavior problems with Resident K9. Employee E20 documented that the resident was observed in his room with a lit cigarette in his hand and he had smoked more than half of his cigarettes. Employee E20 further documented that Resident K9 was then accompanied into the hallway by the DON, the nursing supervisor and Employee E20, and the resident handed his pack of cigarettes to the DON and was taken outside to smoke and the resident no longer had the pack of cigarettes. Interview with the DON on February 26, 2014, at approximately 10:00 a.m., confirmed that the general staff and the licensed staff were afraid of Resident K9's behaviors and were afraid that the resident would hit them if they tried to secure the resident's lighter and cigarettes. The DON provided evidence of a psychiatric consultation, dated January 9, 2014, related to Resident K9's oppositional and defiant behaviors surrounding smoking in the building, however, no other changes were noted except the recommendations for laboratory work to be checked. Review of Resident H4's current care plan revealed that on March 28, 2013, the resident was at risk for smoking related to limited mobility, fine motor coordination, and that smoking was against medical advice. Review of Resident H4's Quarterly Interdisciplinary Resident Review (an assessment used periodically by staff to evaluate resident's needs) dated January 23, 2014, revealed a current [DIAGNOSES REDACTED]. There was no documented evidence of a Smoking Safety Assessment, as per facility policy, indicating that the resident had been determined to be safe to smoke independent of staff supervision. Interview with the Nursing Home Administrator (NHA), DON, Medical Director and licensed Employee E10, on February 27, 2014, at 4:20 p.m., confirmed that the Safety Committee assessment and assurance meetings are scheduled monthly. Employee E10 confirmed the Safety Committee had previously identified that the facility had a smoking problem for a long time; but also confirmed with the survey team that there was a potential problem for those residents who have a smoking order allowing the resident to smoke; or an order for [REDACTED]. Employee E10 further confirmed that both of these current physician orders, were not congruent, when the written order also included that the order was being written against medical advice. Surveyor review of the Safety Committee agenda and minutes, November 2013 to February 12, 2014, revealed no information of concern regarding the Wander Alert devices and the expectation to check for placement and function, as related to the licensed staff role and function, when there was an elopement concern. Surveyor review of the January 16, 2014, Safety Committee action plan documented indicated that the facility would be working on a resident smoking policy. There was no information regarding any Safety Committee action plans for the facility as related to residents that are allowed a leave of absence from the facility to go to the corner store and/or residents that smoke. The survey team informed the facility on February 27, 2014, at 4:20 p.m., that Immediate Jeopardy had been identified. The NHA, the DON, the Medical Director and Licensed Employee E10, who described self as the corporation's field representative for this region, were asked for an action plan. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 2/07/12, 7/06/12, 1/23/13, 5/29/13, 8/23/13. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 2/07/12, 1/23/13, 5/29/13, 9/17/13. 28 Pa. Code 201.18(b)(1) Management Previously cited 2/07/12, 6/07/12, 3/05/13, 5/29/13, 8/23/13, 9/17/13. 28 Pa. Code 201.18(e)(1) Management Previously cited 2/07/12, 1/23/13, 3/05/13, 5/29/13, 9/17/13. 28 Pa. code 201.18(b)(3) Management. Previously cited 6/07/12, 1/23/13, 3/05/13, 5/29/13, 8/23/13, 9/17/13. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 2/07/12, 6/07/12, 1/23/13, 3/05/13, 9/17/13. 28 Pa. Code: 211.2(c)(d)(1)(2) Physician services. 28 Pa. Code 211.5(f) Clinical records Previously cited 2/07/12, 6/15/12, 3/05/13, 7/26/13, 8/23/13, 9/17/13, 10/28/13, 2/08/14. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 3/05/13, 5/29/13, 7/26/13, 10/28/13. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 2/07/12, 7/06/12, 1/23/13, 3/05/13, 5/29/13, 7/26/13, 9/17/13, 10/28/13. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(c) Nursing services. Previously cited 2/07/2012, 3/05/13, 5/29/13, 7/26/13, 10/28/13. 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 2/07/12, 7/06/12, 1/23/13, 3/05/13, 5/29/13, 8/23/13. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/07/12, 6/15/12, 7/06/12, 1/23/13, 3/05/13, 5/29/13, 7/26/13, 8/23/13, 9/17/13, 10/28/13, 2/08/14.

Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to timely identify, assess and evaluate treatment for [REDACTED]. Findings include: Review of the current facility policy titled, "Skin Integrity Guidelines", revised on 2013 (no month or day defined), indicated that the facility routinely reviews residents with wounds or at risk of developing wounds, on a weekly basis and that the results of the reviews i.e. condition/status, would be documented on the wound sheets. The Director of Nursing or designee is responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. Review of the September 2013 physician's orders [REDACTED]. Review of the Braden Scale (a tool used to evaluate risk for skin breakdown) dated January 9, 2013, revealed a score of 12 which placed the resident at high risk of developing pressure ulcers (localized injury to the skin and or underlying tissue that usually occurs over a bony prominence.) Review of the resident's quarterly assessment (assessment of resident status and needs) dated June 17, 2013, identified the resident with short term and long term memory impairments. The resident required total dependence of two people for transferring and had no ambulation capabilities. Review of the weekly wound evaluation flow sheets, revealed that on March 30, 2013, the resident was identified with an open area on the coccyx (tail bone) measuring 1.5 centimeters (cm) x 0.8 cm x 0.3 cm with irregular wound margins and the surrounding tissue was identified as red in color. The open area was described as incontinent [MEDICAL CONDITION] (a rash resulting from frequent skin exposure to urine or feces). A physician's orders [REDACTED]. Further review of the weekly wound evaluation flow sheets, revealed that on June 3, 2013, incontinent [MEDICAL CONDITION] was still identified on the coccyx. On June 17, 2013, the area was assessed as an open area Stage III coccyx wound (full thickness skin loss involving the epidermis) measuring 1.2 cm x 0.8 cm x 0.1 cm Review of the nursing documentation dated June 27, 2013, (10 days later) noted that the resident had incontinent [MEDICAL CONDITION] to the buttocks and an open area to the coccyx site that was a Stage III pressure ulcer (ulcer involving full thickness skin loss exposing tissue) with moderate amount of sanguineous drainage (blood-tinged fluid), even margins and surrounding tissue pink and excoriated (surface of the skin that experiences abrasion or trauma as a result of frequent rubbing or scratching). The treatment of [REDACTED]. There was no documented evidence that the facility identified this pressure ulcer at an earlier stage. Further review of weekly wound evaluation flow sheets from June 27, 2013 through September 10, 2013, confirmed that there was no change of the pressure ulcer treatment or further consideration to change the treatment after the Stage III pressure ulcer was identified on the resident's coccyx. An interview conducted with licensed nursing Employee E10 on September 17, 2013 at 1:30 p.m., confirmed that a Stage III pressure ulcer was documented on June 17, 2013, and the previous week on June 3, 2013, the resident was assessed with [REDACTED]. Review of Resident J4's weekly coccyx wound documentation flow sheets dated September 4, September 10 and September 16, 2013, failed to document the wound stage when listing the wound measurements, color and exudate (drainage). Observation of a treatment to the Resident J4's pressure ulcer on September 19, 2013 at 11:10 a.m., in the presence of licensed nurses, Employees E6 and E7, confirmed a Stage III pressure area to the coccyx. The facility failed to timely identify, evaluate treatment and consistently describe Resident J4's pressure ulcer to ensure adequate wound healing. 28 Pa. Code 211.5(f) Clinical records. Previously cited 2/7/2012, 6/15/2012, 3/5/2013, 7/26/2013, 8/23/2013 28 Pa. Code 211.10 (c) Resident care policies. Previously cited 2/7/2012, 6/15/2012, 7/6/2012, 5/29/2013, 7/26/2013 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/7/2012, 6/15/2012, 7/6/2012, 1/23/2013, 3/5/2013, 5/29/2013, 7/26/2013, 8/23/2013

Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to ensure adequate supervision and monitoring for one of seven residents reviewed, who was at high risk for choking, resulting in actual harm to the resident. (Resident CL1).. Findings include: A review of Resident CL1 physician orders [REDACTED]. Review of speech therapy plan of care, dated [DATE] revealed a [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the safe feeding instructions in the clinical record listed for Resident CL1 to be fed by staff; to have all food in bite sized pieces and immediately mashed by staff in not received in bite size pieces. Staff is to use sauces and condiments to moisten foods. Food should be scooped by staff and fed to resident 2 bites at a time and then 2 small sips of liquid. Bites and sips should be alternated. Review of Resident CL1's dietary progress note, dated [DATE] revealed that the resident received a regular mechanical diet (a diet developed for people who have difficulty chewing or swallowing food), with no salad, bread or toast and should be fed by staff in the dining room. Review of the facility reported event dated [DATE] related that Resident CL1 receives a mechanical soft diet but the special instructions were not followed. On [DATE] at approximately 6:30 p.m., the resident was observed coughing and shaking her head while walking to her bathroom. The resident continued to cough in the bathroom and her face got pale. The Heimlich maneuver was begun. The resident had been coughing strongly but now ceased to cough and became unresponsive. Abdominal thrusts were begun and finger sweep completed. Small amounts of food were removed. 911 EMS arrived and took over. Resident remained unresponsive. Resident ceased to breathe. Review of nursing Employee E11 ' s statement of the incident revealed that Resident CL1 was seated in the dining room for the evening meal on [DATE]. The resident was served a grilled cheese sandwich (not allowed per physician's order [REDACTED]. Nursing Employee E11 placed the sandwich on the table in front of the resident and proceeded to help set up other residents in the dining room with their meals. Employee E11 observed resident CL1 leave the dining room and noted that the resident had eaten the sandwich. Employee E11 followed the resident to her room as did nursing Employee E12. Employee E11 stated that Employee E12 initiated the Heimlich maneuver (an emergency method for treating choking that uses an upward thrust immediately below the breastbone to expel food or another blockage from the windpipe). Review of licensed nursing Employee E13's progress noted indicated that the resident remained unresponsive and that EMS (Emergency medical services) was contacted and took over when they arrived. Resident remained unresponsive, no palpable pulse, no respirations. EMS notified the physician and was instructed to cease interventions. The resident was pronounced deceased by EMS. Review of menu dated [DATE] revealed that a grilled cheese sandwich on rye bread was offered on the mechanical soft diet. Interview with the dietary employee E10 on [DATE] at 2:50 p.m., revealed that whole wheat bread was listed for the Mechanical Soft diet and that the resident would have received a grilled cheese sandwich on wheat bread. Review of Resident CL1's individual meal ticket (lists diet order and special instructions) revealed that the resident was on a mechanical soft diet and was to have no salad and no bread or toast. The diet meal ticket was not followed. Interview with the nursing home administrator on [DATE] at 2:00 p.m., revealed that the resident should have been supervised and fed. Further interview with the administrator at 4:20 p.m., revealed that there was no evidence to show the resident's diet was upgraded to feed self with supervision from the previous requirement to be fed by facility staff. The facility failed to follow physician orders [REDACTED]. The resident should have been fed small bites of soft moistened foods (not bread/toast), by a staff member and observed at all times. The physician's orders [REDACTED]. The resident was given a grilled cheese sandwich and was not monitored or fed by a staff member. The resident ate the sandwich and choked. Staff was unable to dislodge the sandwich from the resident ' s windpipe and the resident died as a result. 28 PA Code: 201.14(a) Responsibility of licensee 28 PA Coed: 201.18(b)(1)(3)(e)(1) Management Previously cited [DATE] 28 PA Code: 211.10 (a)(d) Resident care policies Previously cited [DATE] 28 PA Code: 211.10 (c) Resident care policies 28 PA Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE]

Based on review of facility policy, clinical records review and staff interview, it was determined that the facility failed to assure that less restrictive interventions were attempted prior to the administration of an anti-psychotic medication by injection to four out of 24 residents reviewed (Residents: G13, G2, C6, and C23), resulting in actual harm to resident C6. Findings include: Review of the facility policy for Behavior Management Guidelines revealed that prior to the initiation of an antipsychotic medication a physician order is obtain to include the [DIAGNOSES REDACTED]. Antipsychotics will not be used if the only indication is one or more of the following: restlessness, anxiety and agitated behaviors that do not represent danger to the resident or others. Review of Resident C6's current undated physician orders indicated that the resident had [DIAGNOSES REDACTED]. Review of physician orders also included an order for [REDACTED]. Review of nurse's note dated November 3, 2011 at 5:44 a.m. revealed that the resident was becoming increasingly agitated and combative throughout the shift and struck a licensed staff,. tried to throw water on staff members, was yelling out loudly, cursing staff, calling for people not present, and pulling at intravenous site. The note further indicated that the physician was notified of behaviors and ordered intramuscular [MEDICATION NAME] (anti-psychotic injection) 5 milligrams every eight hours PRN for agitation and combative behavior. Another nurse's note on November 3, 2011 at 7:02 a.m. indicated that the resident was given two doses of [MEDICATION NAME] gel plus an injection of [MEDICATION NAME] 5 milligrams and continued to hit kick curse, try to climb out of chair and yelled throughout the shift and that the medications had no effect on the resident. Review of November 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at 12:00 a.m., 5 milligrams of [MEDICATION NAME] IM at 05:30 a.m. and half hour later at 6:00 a.m. 0.25 milligrams of [MEDICATION NAME] gel. Further review of nursing documentation revealed that 11:24 a.m. the resident was found to be very catatonic, rigid, with his neck tight and upper extremities tight and contracted; requiring an assessment by the licensed nurse on the unit. Furthermore, the facility could not provide documented evidence that interventions were attempted before the 5:30 a.m. dose of [MEDICATION NAME] injection or before the 6:00 a.m. dose of [MEDICATION NAME]. On November 9, 2012 at 11:00 a.m. and on November 15, 2012 at 9:45 p.m. the resident again received an injection of 5 mg [MEDICATION NAME]. There was also no evidence that the facility attempted to identify any triggering events for the resident's continued agitated behavior. The facility failed to administered the least restrictive anti-anxiety medication before the IM dose of the antipsychotic medication, failed to allowed sufficient time to assess the effects of the IM [MEDICATION NAME] medication before administering an antianxiety medication half hour later resulting in actual harm to Resident C6, who was later assessed by the licensed staff in a catonic state. Review of Residents G13's December, 2011 physician's orders revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A physician's order was obtained December 21, 2011 for the antipsychotic medication [MEDICATION NAME] 1 milligram, intramuscular (IM), twice a day, as needed for extreme agitation. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of Resident G13's nursing documentation and behavior monitoring records for the above aforementioned dates revealed that the resident showed combativeness, restlessness and agitation. There was no documented evidence of the actual type of behaviors were severe enough for the resident to required the administration of a chemical restraint by injection A review of Resident G2 February 2012 physician's orders revealed a [DIAGNOSES REDACTED]. A review of nursing documentation dated February 6 2012 at 11:53p.m. indicated that resident G2 was crawling around on the floor, sitting on buttocks on the floor and scooting herself out into the hallway, she believed her sister was there and they were hiding her, and resident G2 would not allow staff to assist her into a chair. A nursing note dated on February 7, 2012 indicated that the physician was notified and ordered the antipsychotic medication [MEDICATION NAME] 1 milligram intramuscularly (IM) every six hours when needed for agitation and the antianxiety medication [MEDICATION NAME] 0.5 milligrams orally (PO) every six hours. The physician's order did not indicate which medication to administer first or an indication of the severity of agitation needed for the administration of the [MEDICATION NAME] IM (intramuscular medication). A note written on February 7, 2012 indicated that the [MEDICATION NAME] 1 milligram was given without effect. The licensed nursing staff attempted to give [MEDICATION NAME] 0.5 milligrams orally but the resident spit it out. There was no documented evidence that the least restrictive antianxiety was attempted prior to the intra muscular medication and there was no evidence to indicate that the resident behaviors were so severe that warranted the use of an IM antipsychotic medication. Review of Resident C23's physician's orders dated January 11, 2012 indicated that the resident had [DIAGNOSES REDACTED]. The orders also indicated that the resident had an order for [REDACTED].[REDACTED]. Review of nurse's notes dated January 7, 2012 at 6:22 p.m. revealed that behaviors had escalated to where resident was placing self on floor after loudly voicing requests or demands. The note further indicated that the resident was normally able to be redirected. The note also revealed that behaviors were noted on the day shift with resident being quiet for the evening of January 7, 2012. However, the facility could provide no evidence of aggressive or agitated behavior or interventions prior to administration of the injections of [MEDICATION NAME]. 28 Pa. Code: 211.12(d)(3)(5) Nursing services Previously cited 11/17/2011, 7/27/2011; 3/07/2011 28 Pa Code: 211.18(b)(1) Management Previously cited 11/17/2011 28 Pa Code: 201.29(j) Resident rights Previously 11/17/2011, 4/5/2011, 3/7/2011 28 Pa Code: 211.10(d) Resident care policies Previously cited 3/7/2011 28 Pa Code: 211.12(c)(d)(1)(5) Nursing services Previously cited 11/7/2011, 7/27/2011, 3/7/2011