Every finding on record at Rosemont Center

Based on review of employee personnel records and staff interview it was determined that the facility failed to complete annual performance review at least once every twelve months for three out of three nurse aides reviewed (Employee E13, Employee E14, and Employee E15). Findings Included: Review of facility documentation and employee personnel files revealed the following nurse aides did not have (a completed) an up-to-date annual performance review: Employee E13, Employee E14, and Employee E15. Interview on July 30, 2026, at 2:30 p.m. with Nursing Home Administrator, Employee E1, confirmed the facility failed to complete annual performance reviews for the following employees Employee 13, Employee 14, and Employee 15. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.19 (2) Personnel records.

Based on interviews with staff, it was determined that the facility did not ensure that a complete policy for staff exposure to MDROs was developed in accordance with requirements in 2007 PA Act 52.Review of 2007 PA Act 52, Reduction And Prevention of Health Care-Associated Infection and Long-Term Care Nursing Facilities, revealed that facilities in Pennsylvania are required to develop procedures and protocols for staff who may have had potential staff exposure to a resident known to be colonized or infected with MRSA or MDRO, including cultures and screenings, prophylaxis (prevention) and follow-up care. MDRO stands for MultiDrug-Resistant Organism and is a type of bacteria or microbe resistant to multiple antibiotics, making infections difficult to treat. MRSA stands for Methicillin-Resistant Staphylococcus Aureus and is a specific type of MDRO.In an interview with employees E1, and nursing Home Administrator, E3, the corporate support RN, on July 31, 2026, at 12:30 p.m., the surveyor requested the facility policy or policies which addressed the required components outlined in Act 52. In a follow-up interview at 1:00 p.m., employees E1 and E3 stated that the facility was unable to provide a policy which met all of the requirements.28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges for two out of two medication rooms observed (First and Second Floor Medication Rooms) and the facility failed to ensure that drugs and biologicals were appropriately labeled on two out of two medication carts observed. Findings Include: Observation of medication administration was conducted on July 28, 2026, on the first-floor nursing unit with Licensed Nurse Employee E20, and Licensed Nurse, Employee E21 (each employee assigned to their own medication carts). Observations during medication administration revealed Licensed Nurse, Employee E20, and Licensed Nurse, Employee E21, both had open vials of ophthalmic eye drop medications on their carts that were not labeled with the dates they were opened. Interview on July 28, 2026, with Licensed Nurse, Employee E20, and Licensed Nurse, Employee E21, confirmed the ophthalmic medications did not have open dates. Without the date open, staff cannot determine whether the medication remains within the manufacturer's recommended beyond use. Review of facility documentation Medication Room Refrigerator Temperature Log indicates that refrigerator temperatures are to remain between 36 to 46 degrees Fahrenheit (F). Review of facility documentation Medication Room Temperature Log indicates the room temperatures are to remain between 59 to 86 degrees Fahrenheit. Review of facility documentation Medication Room Humidity Temperature Log indicates humidity levels are to remain between 30 to 60 percent. Review of facility documentation revealed inconsistent and incomplete documentation for monitoring of the medication room refrigerator temperatures, medication room air temperatures, and medication room humidity on the first and second floor nursing unit to ensure medications are stored at safe and proper temperatures. Review of facility documentation and interview on July 30, 2026, at 10:00 a.m. with Nursing Supervisor, Employee E7, confirmed staff failed to document refrigerator temperatures, room air temperatures, and humidity percentages for the second-floor nursing unit medication room on the following days: 7/3, 7/4, 7/5, 7/11, 7/12, 7/13, 7/22, 7/23, 7/27/2026. Review of facility documentation and interview on July 30, 2026, at 11:00 a.m. with the Director of Nursing, Employee E2, confirmed staff failed to document refrigerator temperatures, room air temperatures, and humidity percentages for the first-floor nursing unit medication room on the following days: 7/1, 7/2, 7/3, 7/4, 7/5, 7/12, 7/13, and 7/14/2026. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on facility record review and interviews with staff, it was determined that the facility failed to maintain up-to-date records of staff education and ensure current vaccination status were maintained related to the COVID-19 vaccination.In an interview with employees E1, and nursing Home Administrator, E3, the corporate support RN, on July 31, 2026, at 12:30 p.m., the surveyor requested documented evidence that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; that they were offered the vaccine or information on how to obtain the vaccine; COVID-19 vaccination status of staff. Employees E1 and E3 stated that they did not have a current list of that information, as they were unaware that it was still required. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement, monitor, and modify interventions (as appropriate), consistent with the resident's assessed nutrition needs for one of one resident reviewed for significant weight loss (Resident R26). Findings Include: Review the facilities policy titled Weight Assessment and intervention revised April 2026, revealed the interdisciplinary team, including the physician, nursing staff, and dietitian, was responsible for preventing, monitoring, evaluating, and intervening for residents with undesirable weight loss. The policy required residents to be weighed on admission, weekly for 4 weeks, and monthly thereafter unless weight concerns warranted more frequent monitoring. Any weight change of 5% or greater since the previous assessment was to be re-weight for confirmation. Once verified nursing was required to notify the dietitian, who was to respond within 72 hours. The policy further required the interdisciplinary team to evaluate significant weight loss trends, identify contributing medical, functional medication related and nutritional factors, develop individualized interventions, and revised the residence care plan to address the identified causes of weight loss, established measurable goals, and include ongoing monitoring and reassessment. Review of Resident R26's MDS dated [DATE], revealed the resident has a diagnosis of cerebrovascular accident (damage to the brain from interruption of its blood supply), hypertension (high blood pressure), diabetes mellitus (chronic condition affecting the body's ability to regulate blood sugar levels), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety (characterized by persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and Tourette's syndrome (a neurological disorder characterized by involuntary motor and or vocal tick). Further review of the MDs revealed Resident R1 receives a mechanically altered diet and weighs 122 pounds. Review of Resident R26's clinical record revealed the following documented weights within the vital sign documentation: May 3, 2026 - 148.7 pounds (lbs) May 4, 2026 - 148.5 lbs. June 1, 2026 - 122.4 lbs. (represents a weight loss of 26.1 lbs. (17.6%) in one month) June 2, 2026 - 122.4 lbs. (confirms significant weight loss) July 4, 2026 - 122.2 lbs. Review Resident R26's comprehensive care plan revealed the resident is identified as being at risk for altered nutritional status related to diagnosis including hypertension, diabetes, depression, dementia, dysphasia, obesity, need for staff assistance with meals, therapeutic diet restrictions, mechanically altered diet, variable oral intake and a need for oral nutritional supplements. Review of Resident R26's nutrition progress dated June 3, 2026, by the Registered Dietitian, revealed Resident R26 was assessed with a weight of 122.4 pounds, representing an 18.1% weight loss since May 13, 2026. The nutrition progress note recommended weekly weights to monitor the resident's nutrition status and also recommended obtaining laboratory studies if not completed recently. Further, the nutrition progress note documented nursing would notify Resident R26's physician and the resident's representative regarding the weight loss. Further review of the clinical record revealed no documented evidence that weekly the weights were implemented and no documented evidence that the laboratory studies were obtained, as recommended. Interview on June 30, 2026, with the Registered Dietitian, Employee E22, confirmed the recommended weekly weights were not implemented, and labs were not ordered and completed. Further the surveyor requested review of Resident R26's meal intake average for the month of May 2026 (leading up to the documented weight loss). Registered Dietitian, Employee E22, was unable to provide request explaining that the dietary system only retained intake documentation for the previous 30 days. 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical record, and staff interviews it was determined that the facility failed to develop a comprehensive, person-centered care plan for three of thirty-seven residents reviewed (Resident R50, R3, and R7). Findings include: Review of the facility policy, Care Plans, Comprehensive Person Centered, last revised in March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Review of clinical records for Resident R3 and Resident R7 revealed each resident was prescribed anticoagulant medication (prevent blood clots by interfering with the blood coagulation process) for treatment of atrial fibrillation (irregular heartbeat). Review of Resident R3 and Resident R7's comprehensive care plan revealed no documented evidence a comprehensive, person-centered care plan was developed to address the use of an anticoagulant medication and subsequent treatment of atrial fibrillation. Interview on July 30, 2026, at 12:00 p.m. with Licensed Practical Nurse. Employee E8, confirmed no comprehensive care plan was developed for Resident R3 and Resident R7 related to use of anticoagulant medication and treatment of atrial fibrillation. Review of the Resident R50's clinical record revealed the resident was admitted to the facility on [DATE]th, 2025, with diagnosis of cerebrovascular accident (CVA, commonly known as a stroke), hemiplegia (paralysis or significant weakness affecting one side of the body), seizure disorder, and colostomy. Review of Resident R50's clinical record revealed a court order dated January 5th, 2026, revealed that the resident was authorized to be transferred to the nursing facility to receive long-term care. The court order further stated that Resident R50 was to remain subject to electronic monitoring by the Pennsylvania Department of Corrections throughout the placement. The order required the facility to notify the resident's attorneys, the Pennsylvania Department of Corrections, and the Court of any material changes in the resident's health status or any plans to change the resident's location. Continued review of resident R50's clinical record nursing note dated February 27, 2026, revealed state parole officer called and stressed the importance of changing the ankle monitor every other day. Review of resident R50's clinical record revealed no documented evidence a comprehensive care plan was developed related to the resident's supervision needs, potential risk, use of an ankle monitor, or coordination with Correctional Authorities. Interview on July 30, 2026, with Social Worker, Employee E16, confirmed Resident R50's specific safety, supervision, and legal considerations were not incorporated into Resident R50's comprehensive care plan. 28 Pa. Code 211.10 (c) Resident care policies.

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to complete and document assessments for the ongoing care and monitoring of dialysis sites for one of X residents reviewed (Resident R46). Findings Included: Review of facility policy End-Stage Renal Disease, Care of a Resident revealed residents with end-stage renal disease (ESRD - (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) will be cared for according to currently recognized standards of care. Education and training of staff include, specifically: signs and symptoms of worsening condition and/or complications of ESRD, and the care of grafts and fistulas. Review of Resident R46's clinical record revealed the resident has an arteriovenous (A/V) fistula (surgically created in the arm to provide a durable access point for hemodialysis, allowing higher blood flow and easier needle insertion) used for hemodialysis (a medical treatment that filters waste and excess fluids from the blood when the kidneys can no longer perform this function effectively). Continued review of Resident R46's clinical record revealed a physician order for monitoring of the A/V fistula which included assessment and documentation of the vascular access site, including evaluation for the presence of a bruit and thrill, and monitoring for signs and symptoms of complications such as infection, bleeding, swelling, redness, pain, or other abnormalities Continued review of Resident R46's medication administration record revealed no documented evidence evaluation for the presence of bruit and thrill were completed on July 11, 2026, and July 17, 2026. Interview on July 31, 2026, at 12:30 p.m. with Nursing Supervisor, Employee E7, and Licensed Nurse, Employee E8, confirmed the assessments for Resident R46's AV fistula was not completed and documented on July 11, 2026, and July 17, 2026. Nursing Supervisor, Employee E7, and Licensed Nurse, Employee E8, confirmed Resident R46's clinical record lacked consistent documentation of assessment of the vascular access site, including evaluation for the presence of a bruit and thrill and monitoring for signs and symptoms of complications such as infection, bleeding, swelling, redness, pain, or other abnormalities. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of policy, review of clinical record and review of facility provided documentation, it was determined facility did not ensure to provide adequate supervision to prevent elopement for one of three residents reviewed (Resident R1)Findings include: Review of facility policy 'Wandering, Unsafe Resident,' revised August 2014, indicated its purpose is to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Review of Resident R1's clinical record revealed a medical diagnosis of dementia with mood disturbance and agitation, depression, cognitive communication deficit, adjustment disorder with anxiety, conduct disorder. Review of elopement assessment completed on December 31, 2025, at 3:15 pm, revealed Resident R1 was at high risk for elopement. Review of facility provided investigation report, completed on February 13, 2026, revealed that on February 12, 2026, at 9:00 am, R1 was residing on second floor unit and managed to escape by taking stairs after pressing of fire doors for more than 15 seconds (which activated alarm). Further review of investigation report revealed that Resident R1 also managed to walk through emergency fire doors on first floor which is right next to entrance doors and is located across from receptionist's desk area. Review of Resident R1's care plan revealed that the facility did not develop a care plan to prevent elopement until February 12, 2026; after the elopement incident. 28 Pa Code 201.18(b.1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to ensure kitchen equipment was maintained in safe and operating condition (Main Kitchen). Findings Include:Review of undated facility policy Pot and Pan Washing revealed proper pot and pan washing procedures reduce the possibility of food contamination. Review of facility policy revealed pots and pants will be washed in the first sink, rinsed in the second sink, and sanitized in the third sink. Pots and pans are sanitized using warm water and bleach or sanitizer to provide no less than 50 PPM chlorine in solution for one minute. An initial tour of the main kitchen was conducted on September 2, 2025, at 9:00 a.m. with Food Service Director, Employee E6. During a tour of the kitchen, a dietary aide was observed to be utilizing the 3-compartment sink to wash pots and pants. The third compartment of the 3-compartment sink was identified as the sanitizing sink.The Food Service Director, Employee E6, used a chlorine test strip to monitor the sanitizing solution of the water. The test strip resulted < 50 ppm chlorine, indicating that there was not a sufficient amount chlorine solution to properly sanitize.Observations during testing of the sanitizing sink revealed the faucet had a constant stream of water pouring into the sanitizing sink. Interview with the Food Service Director, Employee E6, revealed that the faucet was broken and could not be turned off causing the sanitizing solution to be diluted.Interview on September 2, 2025, at 2:37 p.m. with Food Service Director, Employee E6, revealed the sink faucet has been broken since end of last month and that staff need to frequently check the level of sanitizing solution while using the 3-compartment sink and add extra sanitizer as needed to compensate for the broken faucet diluting the solution.28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on staff interviews and review of clinical records, it was determined that the facility failed to conduct a complete and thorough investigation to rule out abuse/neglect for 4 of 17 residents reviewed (Resident R1, R2, R23 and R51). Findings Include: Review of facility policy Abuse Prevention Program reviewed November 30, 2022, revealed all reports of resident abuse, neglect, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. The individual conducting the investigation will include, but not be limited to, interview any witnesses to the incident and interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. The facility administration will protect our residents from abusee by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members. The facility will investigate and report any allegations of abuse within timeframes as required by federal and state requirements; protect residents during abuse investigations. Continued review of the policy indicated that for resident-resident altercations all altercations including those that represent resident-to-resident abuse shall be investigated and reported to the nursing supervisor, the director of nursing, the administrator and applicable regulatory agencies. Review of Resident R2's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 19, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of neurogenic bladder (a condition when neurological conditions causes one to lose bladder control), lack of coordination, and stage 2 pressure ulcer (characterized by partial-thickness skin loss, presenting as a shallow, open wound or blister) of the right buttock. Review of Resident R2's comprehensive care plan dated January 30, 2025, revealed the resident was at risk for skin breakdown related to decreased mobility, fragile skin, refusal of showers, and bowel/bladder incontinence. Review of Resident R2's wound consultation dated March 24, 2025, revealed the resident was seen for an initial consultation for wound services. Continued review of the wound consultation dated March 24, 2025, revealed Resident R2 was evaluated and treated for a stage II pressure ulcer on the left buttock. Review of Resident R2's wound consultation dated April 1, 2025, revealed upon examination the stage II (ulcer involving loss of the top layers of the skin) pressure ulcer of the left buttock showed complete epithelization (formation of a new layer of skin over the wound) with no signs of infection or inflammation. The wound report indicated that the wound healing was complete, and the wound was fully closed. Review of Resident R2's clinical record revealed Licensed Nurse, Employee E7, documented an existing skin issue on a skin check assessment dated [DATE]. Further review of the skin check assessment dated [DATE], revealed location and description of the skin issue was left blank. Continued review of Resident R2's clinical record revealed a nursing note dated April 7, 2025, that revealed during Resident R2's weekly shower a skin issue was identified on the resident's sacrum. The area was described as having sanguineous drainage (leakage of fresh blood from a wound). Review of Resident R2's clinical record revealed a wound consultation dated April 8, 2025, that the resident was seen for a re-consultation visit for wound care services. Continued review of the wound consultation dated April 8, 2025, revealed Resident R2 was evaluated and treated for an unstageable pressure ulcer on the left buttock. Interview on September 4, 2025, at 12:50 p.m. with Director of Nursing, Employee E2, revealed no investigation or incident report was available for the new wound identified on April 7, 2025. Continued interview with the Director of Nursing, Employee E2, revealed no statement was available from Licensed Nurse, Employee E7, regarding the documentation on the skin check assessment dated [DATE]. Review of the August 2025 physician orders for Resident R51 revealed the diagnoses of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as see things and hearing voices and believing things that are not real or true, and mood disorder symptoms; anxiety (intense, excessive and persistent worry and fear about everyday situations); adjustment disorder (a mental health condition characterized by an excessive emotional or behavioral response to a significant life stressor, leading to distress and functional impairment); hypertension (high blood pressure); muscle weakness, and hyperlipidemia (high cholesterol).Review of the resident's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2025 indicated that the resident cognitive intact.Review of the September 2025 physician orders for Resident R23 revealed the diagnoses of psychosis; bipolar; schizophrenia; dementia; unspecific pain; cataracts; cognitive communication deficit and anxiety. Continued review of the September 2025 physician orders indicated that Resident 23 had a physician's order dated March 27, 2025 and monthly thereafter for the resident to wear a wanderguard (a system used to prevent residents with a tendency to wander from leaving monitored areas) to his left ankle.Review of the resident's person-centered plan of care included a plan of care dated July 7, 2022 for the behavior of wandering the halls and going into other resident rooms. Interventions included re-directing the resident as needed for behavioral episodes.Review of the resident's quarterly MDS dated [DATE] indicated that the resident was cognitively impaired.Review of a nursing note dated May 22, 2025 at 2:53 a.m. documented that Employee E10 (licensed nurse) Resident R23 had very aggressive and had to be redirected by staff. The note also documented that the resident was seen going to room [ROOM NUMBER]A multiple times and that Resident R51 got upset and threw a trashcan at Resident R23, directing him to get out of her room. Resident with very aggressive behavior hard to redirect by staff. Resident going to room [ROOM NUMBER]A multiple times. Resident in room [ROOM NUMBER]A was upset throw the trash can to him screaming Get out of my room and c/o (complaint) about [Name of Resident] going to her room. Resident also noted going to the elevator. Resident with wanderguard in placed. Will give report to incoming Nurse. Resident refused to go to his room. Resident is sitting at the nurses station for close monitoring. Will continue to monitor. Snack was given to resident.Review of a nursing note dated May 22, 2025 at 2:00 p.m. documented that Employee E13 (licensed nurse) observed Resident R51 hitting Resident R23 with a trash can. Resident R23 reported to the nurse that he did not know why Resident R51 hit him with the trash can. this nurse was exiting room [ROOM NUMBER] when i observed the other resident hitting this resident with a trash can at the back of his head. this resident stated he is unsure of why other resident hit him with the trash can. This nurse removed resident from hallway into the lounge area. nurse did a skin check to head, no skin issues present. pain assessed as well, no pain. md (physician) . notified upon arrival facility. nurse tried to contact the contacts on file for resident, no answer. nursing sup (supervisor)/adon (assistant director of nursing) notified.Review of the clinical record did not show evidence of a complete and through investigation that was conducted to prevent further incidents from occurring between the residents during the investigation.During an interview with the Director of Nursing (DON) on September 8, 2025 at 11:21 a.m. the DON reported that she was aware of the above referenced incident and confirmed during the interview that the facility did not complete an investigation for the above two referenced incidents related to allegations of resident-to-resident abuse.Review of the September 2025 physician orders for Resident R1 revealed diagnosis that included anxiety (intense, excessive and persistent worry and fear about everyday situations); depression (a mood disorder that may be described as feelings of sadness, loss, or anger that interfere with a person's everyday activities); cerebral vascular disease (a group of disorders that affect blood flow to the brain, leading to conditions such as stroke, aneurysms, and vascular malformations); dysphagia (difficulty swallowing)d and unspecified pain.Review of a quarterly Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated December 13, 2024, indicated that the resident was awake, alert and oriented.Review of a nursing note for Resident R51 dated December 10, 2024 at 11:28 a.m. indicated that Employee E7 (licensed nurse) reported that on December 9, 2025, the facility's occupational therapist reported to the charge nurse that Resident R1 was self medicating himself in Resident R51's room, and that upon entering the room the charge nurse (Employee E7) found a pill on Resident R51's end table but Resident R51 reported that she did not know where it came from. Licensed nurse also documented that on December 10, 2024 Resident R51 told the facility's activity staff that she gave Resident R1 medication for a head ache. OT overserved the resident's roommate [NAME OF RESIDENT] attempting to self-medicate himself she then notifies the charge nurse upon entering the room the charge nurse found a pill on the resident end table when question by the charge nurse the resident stated that she doesn't know where it came from. 12/10/24 the resident told activities that she gave it to the resident for a headache the charge nurse then educated the resident that she cannot self-medicate herself nor another resident and that if she has any more medication, she should turn them over to the nurse. Resident stated that she understands and that she did not give any medication to the resident.Review of the clinical record did not show evidence of a complete and through investigation that was conducted to prevent further ingestions of unknown substances from occurring during the investigation, and to ensure that appropriate corrective actions were taken.During an interview with the Director of Nursing (DON) on September 8, 2025 at 11:22 a.m. the DON reported that she was aware of the above referenced incident and confirmed during the interview that the facility did not complete an investigation for the above referenced incident of allegations on unknown substances in Resident R1 and Resident R51 possession that may have been ingested. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.29 (a) Resident rights

Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement an effective infection control program related to medication administration and the use of personal protective equipment (PPE) in enhanced barrier precautions 4 of 17 residents reviewed (Resident R27, R47, R14, R59). Findings Include:Review of facility policy on Enhanced Barrier Precaution (EBP) dated April 1, 2024, revealed that it is the policy of the facility to follow state and federal guidelines to minimize the spread of Multidrug Resistant Organism (MDRO's) by implementing effective personal protective equipment (PPE) usage. The policy is intended to provide guidance for PPE use as well as room restriction for preventing transmission of MDRO's. Under section Key Points #2. EBP is indicated for residents with the following: wounds or indwelling medical devises, regardless of MDRO colonization status; infections or colonization with an MDRO when contact precaution do not otherwise apply. Observation of the first-floor unit conducted September 2, 2025, at 10:56AM revealed that an Enhanced barrier Precaution Signage was posted outside Resident R3's door to his bedroom.Observation of Resident R3 revealed that Nurse's Aide Employee E4 was providing care to Resident R3.Further observation revealed that Employee E4 was wearing gloves but not wearing a gown while providing care to Resident R3.Interview with DON (Director of Nursing) Employee E2 conducted at the time of the observation confirmed that Resident R3 was on EBP. Further, DON Employee E2 revealed that staff were required to wear gown and gloves when caring for Resident R3 Further DON Employee E2 confirmed that Nurse's Aide Employee E4 was not wearing gown while providing ADL care to Resident R3. Observation of the first-floor unit conducted September 2, 2025, at 12:24PM revealed that an Enhanced barrier Precaution Signage was posted outside Resident R46's door to her bedroom. Further observation revealed that nurse aide, Employee E4, was wearing gloves but was not wearing a gown. Interview with the DON, Employee E2, conducted at the time of the observation confirmed that Resident R46 was on enhanced barrier precautions and that gown and gloves was required when providing care. Director of Nursing, Employee E2, confirmed that nurse aide, Employee E4, was not wearing gown. Medication administration observation was conducted on September 3, 2025, at 10:01 AM with licensed nurse, Employee E5. Medication observation was observed for Residents R27, R47, R14, and R59. Licensed nurse, Employee E5, administered eye drops for Resident R27 without sanitizing hands before putting on and after taking off his/her gloves. Further, licensed nurse, did not sanitize hands between medication administrations for the identified residents. Review of Resident R27's comprehensive care plan dated August 6, 2024, revealed the resident was on enhanced barrier precautions related to indwelling medical devices (suprapubic catheter - medical device used to drain urine from the bladder through a small incision in the abdomen). Interventions dated August 6, 2024, instructed staff to wear gloves and gowns for high contact resident care.Observations on September 4, 2025, at 1:20 p.m. revealed nurse aide, Employee E8, was emptying Resident R27's catheter bag at bedside and was not wearing a gown.Medication administration observation on Resident R27 conducted on September 3, 2025, at 10:01 AM with Employee E5 revealed that Employee E5 did not sanitize her hands before and after preparing Resident R27's medications.Further observation revealed that Employee E5 did not sanitize her hands before and after administering Resident R27's medications via feeding tube.Further observation revealed that before administering artificial tears to Resident R27's left eye. Further, Employee E5 did not sanitize her hands after administering eye drops on resident R27's left eye, did not sanitize her hands before administering artificial tears to Resident R27's right eye and Employee E5 did not sanitize her hand after administering artificial tears to resident R26's right eye.Interview with Employee E5 conducted at the time of the observation confirmed that she did not sanitize or wash her hands during the medication administration for Resident R27. 28 Pa Code 211.12 (d)(1)(5) Nursing services28 Pa. Code 211.12 (d)(1)28 Pa. Code 211.12 (d)(5)

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to store and prepare food in accordance with standards of food service safety (Main Kitchen). Findings Include:Review of undated facility policy Food Storage revealed leftover food is stored in covered containers or wrapped carefully and securely.Observations during an initial tour of the main kitchen on September 2, 2025, at 9:00 a.m. with Food Service Director, Employee E6, revealed the following:Observations of the walk-in refrigerator revealed deli meats in open plastic bags, not sealed. Further observations revealed opened containers of chicken and beef broth base, with no open date.Observations in the walk-in freezer revealed a box of cauliflower open to air, not sealed. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of facility documentation, review of personnel files, review of clinical records, observations, and staff interviews it was determined that the facility failed to assure that nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet the residents' needs for two of five nursing staff reviewed (Employee E5 and E9).Findings Include:Review of facility policy Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to promote optimal safety and independence.Review of facility's job description for nurse aides revealed that nurse aide staff are responsible for reviewing care plans and daily assignments and perform nursing care as outlined.Review of facility's job description for licensed practical nurse (LPN) revealed that LPN staff are responsible for rendering professional nursing care to residents, follow facility policies and procedures to implement treatment orders and to maintain residents' medical records.Review of Resident R12's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was cognitively intact and had diagnoses of hemiplegia (affecting left non-dominant side), muscle weakness, and need for assistance with personal care.Further review of Resident R12's MDS dated [DATE], revealed the resident had impairment of functional limitation in range of motion on one side to the upper and lower extremities.Review of Resident R12's occupational therapy Discharge summary dated [DATE], by Occupational Therapist, Employee E11, revealed a splint was recommended to maintain level of performance and in order to prevent decline.Review of Resident R12's comprehensive care plan dated November 14, 2024, revealed Resident R1 should wear left resting hand splint after morning care and taken off prior to bedtime care, as tolerated. The goal was to maintain the left hand and arm range of motion and prevent contractures.Review of Resident R12's nursing kardex (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) task dated August 3, 2025, revealed the assigned nurse aide should apply the left resident hand splint after morning care and taken off prior to nighttime care. Review of facility documentation revealed Nurse aide, Employee E9, was assigned to provide care for Resident R12 on September 3, 2025, during the 7:00 a.m. to 3:00 p.m. shift.Observation on September 3, 2025, at 1:29 p.m. revealed Resident R12 was not wearing the left-hand splint. Resident R12 reported staff does not apply the splint daily. Interview on September 3, 2025, at 1:38 p.m. with Licensed Nurse, Employee E5, reported he/she was unaware of a splint for Resident R12.Interview on September 3, 2025, at 1:39 p.m. with Nurse Aide, Employee E9, revealed he/she was unaware of a splint for Resident R12. When asked about the splint, Nurse aide Employee E9, stated I don't know I'm agency staff. Review of Employees E5and E9's personnel files revealed no evidence that the employees received any skills competency evaluations to ensure competency of hands-on skills and techniques necessary to care for residents' needs.28 Pa. Code 201.19(7) Personnel policies and procedures28 Pa. Code 201.20(b) Staff development

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the failed to provide treatment/services to maintain or improve range of motion/mobility for one of four residents reviewed for limited range of motion (Resident R12).Findings Include:Review of facility policy Restorative Nursing Services revised July 2017 revealed residents will receive restorative nursing care as needed to promote optimal safety and independence. Review of Resident R12's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was cognitively intact and had diagnoses of hemiplegia (affecting left non-dominant side), muscle weakness, and need for assistance with personal care. Further review of Resident R12's MDS dated [DATE], revealed the resident had impairment of functional limitation in range of motion on one side to the upper and lower extremities.Review of Resident R12's occupational therapy Discharge summary dated [DATE], by Occupational Therapist, Employee E11, revealed a splint was recommended to maintain level of performance and in order to prevent decline. Review of Resident R12's comprehensive care plan dated November 14, 2024, revealed Resident R1 should wear left resting hand splint after morning care and taken off prior to bedtime care, as tolerated. The goal was to maintain the left hand and arm range of motion and prevent contractures.Observation on September 3, 2025, at 1:29 p.m. revealed Resident R12 was not wearing the left-hand splint. Resident R12 reported staff does not apply the splint daily. Interview on September 3, 2025, at 1:38 p.m. with Licensed Nurse, Employee E5, reported he/she was unaware of a splint for Resident R12.Interview on September 3, 2025, at 1:39 p.m. with Nurse Aide, Employee E9, revealed he/she was unaware of a splint for Resident R12.Interview on September 4, 2025, at 9:15 a.m. with the Director of Rehab, Employee E10, confirmed Resident R12 should have the splint applied every morning and removed every night.Observations on September 4, 2025, at 9:45 a.m. revealed Resident R12 was again not wearing the left-hand splint. Resident R12 reported someone from therapy attempted to apply the splint but could not get it on.Interview on September 4, 2025, at 9:48 a.m. with the Director of Rehab, Employee E10, revealed he/she tried to apply Resident R12's left hand splint but had trouble getting it on. Director of Rehab, Employee E10, reported that occupational therapy is going to reassess the resident.Interview on September 4, 2025, at 1:40 p.m. with Occupational Therapist, Employee E11, confirmed he/she recommended a left-hand splint for Resident R12 in July 2025.Continued interview on September 4, 2025, at 1:40 p.m. Occupational therapist, Employee E11, reported that upon reassessment [on September 4, 2025] Resident R12 was no longer able to tolerate the hand splint due to worsening contracture. Occupational therapist, Employee E11, explained that the splint required Resident R12 to be able to lay his/her fingers flat, which Resident R12 was no longer able to do. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(3) Nursing services

Based on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that proper feeding tube placement was established prior to administering medication through a feeding tube for one of two residents observed (Resident RF27).Findings include:Review of facility Policy on Administering mediations through an Enteral Tube revised in March 2015, revealed that under section Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. To assess for tolerance of enteral feeding. Under section Equipment and supplies: 12: Stethoscope. Undersection Steps in the Procedure: 18. Conform placement of feeding tube. #20. Check gastric residual volume to assess tolerance of enteral feeding. #21 when correct tube placement and acceptable gastric residual volume have been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount).Review of Resident R27's clinical record revealed that Resident R27 was admitted to the facility on [DATE], with diagnoses of but not limited to: Chronic Obstructive Pulmonary Disease.Review of Resident R27's MAR ( medication administration Record) for September 2025 revealed the following medications: Fludrocortisone Acetate Oral Tablet 0.1 MG (Fludrocortisone Acetate) Give 1 tablet via PEG-Tube (Percutaneous Endoscopic Gastrostomy- a tube that is connected to the stomach used to provide feeding and administering medications ) one time a day, Multivitamin Oral Liquid (Multiple Vitamins w/ Minerals) Give 5 ml via PEG-Tube one time a day, Sertraline HCl Oral Tablet 25 MG, Give 25 mg via PEG-Tube one time a day, Apixaban Oral Tablet 5 MG Give 5 mg via PEG-Tube two times a day, Docusate Sodium Oral Liquid 50 MG/5ML, Give 10 ml via PEG-Tube two times a day.Review of Resident R27's MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated June 24, 2025, section K0520. Nutritional Approaches, B. Feeding tube (e.g., nasogastric or abdominal (PEG) revealed that resident was on tube feeding.Medication administration observation on Resident R27 conducted on September 3, 2025, at 10:01 AM with Licensed nurse, Employee E5 revealed that Employee E5 crushed all of Resident R27's medications and mixed it with water. Further, Employee E 5 then proceeded to administer Resident R27's medication via tube feeding without checking for placement.Interview with Licensed nurse, Employee E5 conducted at the time of the observation confirmed that she did not check Resident R27's PEG) tube for placement.Interview with DON (Director of Nursing) conducted on September 3, 2025, at 12:05PM revealed that placement of feeding tubes must be checked and confirmed prior to administering medications. 28 Pa. Code 204.14(a) Responsibility of licensee28 Pa. Code 201.18 (e)(1) Management28 Pa. Code 211.12 (d) (1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to revise a care plan related to aggressive behaviors for one of 17 residents reviewed. (Resident R51) Findings include:Review of the August 2025 physician orders for Resident R51 revealed the diagnoses of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as see things and hearing voices and believing things that are not real or true, and mood disorder symptoms; anxiety (intense, excessive and persistent worry and fear about everyday situations); adjustment disorder (a mental health condition characterized by an excessive emotional or behavioral response to a significant life stressor, leading to distress and functional impairment); hypertension (high blood pressure); muscle weakness, and hyperlipidemia (high cholesterol).Review of the resident's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2025 indicated that the resident cognitive intact.Review of the September 2025 physician orders for Resident R23 revealed the diagnoses of psychosis; bipolar; schizophrenia; dementia; unspecific pain; cataracts; cognitive communication deficit and anxiety. CReview of the resident's person-centered plan of care included a plan of care dated July 7, 2022 for the behavior of wandering the halls and going into other resident rooms. Interventions included re-directing the resident as needed for behavioral episodes.Review of Resident R23's quarterly MDS dated [DATE] indicated that the resident was cognitively impaired.Review of Resident R23's nursing note dated May 22, 2025 at 2:53 a.m. revealed that resident was very aggressive and had to be redirected by staff. The note also documented that the resident was seen going to room [XXX] multiple times and that Resident R51 got upset and threw a trashcan at Resident R23, directing the resident to get out of her room. Resident with very aggressive behavior hard to redirect by staff. Resident going to room [ROOM NUMBER]A multiple times. Resident in room [ROOM NUMBER]A was upset throw the trash can to (him/her) screaming Get out of my room and c/o (complaint) about [Name of Resident] going to her room. Resident also noted going to the elevator. Resident with wanderguard in placed. Will give report to incoming Nurse. Resident refused to go to his room. Resident is sitting at the nurses station for close monitoring. Will continue to monitor. Snack was given to resident.Review of a nursing note dated May 22, 2025 at 2:00 p.m. documented that Employee E13 (licensed nurse) observed Resident R51 hitting Resident R23 with a trash can. Resident R23 reported to the nurse that he did not know why Resident R51 hit him with the trash can. this nurse was exiting room [XXX] when i observed the other resident hitting this resident with a trash can at the back of (his/her) head. this resident stated (he/she) is unsure of why other resident hit (him/her) with the trash can. This nurse removed resident from hallway into the lounge area. nurse did a skin check to head, no skin issues present. pain assessed as well, no pain. md (physician) . notified upon arrival facility. nurse tried to contact the contacts on file for resident, no answer. nursing sup (supervisor)/adon (assistant director of nursing) notified. Review of Resident R51's care plan revealed that a care plan was developed on March 20, 2024 related to the resident exhibiting an increase of agitation. A focus area was added on May 22, 2025 I threw a garbage can at a resident when (he/she) entered my room. The interventions included encourage medication compliance and notify the police of physical aggression towards others. Continued review of the resident's care plan revealed that on June 10, 2025 a care pan was developed with a focus area I am known not to use the STOP sign at my door. The only intervention listed was magnetic stop sign is placed across my door. Interview conducted on September 5, 2205 at 12:27 p.m. with the Director of Nursing confirmed that Resident R51 refused to keep stop sign in front of her door and kept removing it.There was no documented evidence that the resident's care plan was revised to include interventions to assist Resident R51 in decreasing aggressive behaviors towards residents who may wander into (his/her) room since the resident was not compliant with a STOP sign at the room door. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211/12(d)(1) Nursing services

Based on staff interviews, and review of clinical records, it was determined that that facility failed to ensure that prompt efforts were made to resolve a resident's grievance regarding a room change request for 1 out of 17 residents reviewed (Resident R51). Findings include:Review of Resident R51's August 2025 physician orders revealed the diagnoses of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as see things and hearing voices and believing things that are not real or true, anxiety (intense, excessive and persistent worry and fear about everyday situations); adjustment disorder (a mental health condition characterized by an excessive emotional or behavioral response to a significant life stressor, leading to distress and functional impairment); hypertension (high blood pressure); muscle weakness, and hyperlipidemia (high cholesterol).Review of the facility's undated policy, Grievances/Complaints, Filing, indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The policy also indicated that actions on such issues will be responded to in writing, including a rationale for the response. Continued review of the policy indicated that grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously.Review of a nursing note written by the Director of Nursing (DON) dated April 18, 2025 at 2: 33 p.m. indicated that the DON received a call from the resident concerning another resident on the 2nd floor nursing unit where the resident resided, and as result, the resident contacted the DON requesting to move to the 1st floor. Call received from [Name of Resident]. She has non-emergent concern regarding another resident on the unit and is requesting move to the 1st floor. [Name of Resident] continues to be a risk to a resident's safety on the 1st floor. Notified the primary nurse of [Name of Resident] concern and monitoring for the concern is initiated. Attempt to notify [Resident's Guardian] is unsuccessful. Message is left with receptionist for return call on Monday, 4/21/25.Continued review of the clinical record and facility documentation did not show evidence that the facility made prompt efforts to resolve the resident's grievance regarding a request for a room change. During an interview with the Director of Nursing on September 5, 2025 at 12:50 p.m. no documentation could be produced by the DON to show evidence that prompt efforts were made by the facility to address the resident's grievance requesting a room change. 28 Pa. Code 201.18 (b)(1)(3) Management28 Pa. Code 201.18 (d.1)(4) Management28 Pa. Code 201.29 (a) Resident Rights

Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide personal privacy during care for two of 17 residents reviewed (Resident R3, and R46). Findings Include: Observation of the first-floor unit conducted September 2, 2025, at 10:56AM revealed that Nurse Aide, Employee E4, was providing care for Resident R3. Further observation revealed that Resident R3's roommate was in Bed-B, next to the window. Further, the privacy curtain for Resident R3 was drawn only partially at foot of the bed, exposing Resident R3 to his/her roommate. Interview with the Director of Nursing (DON), Employee E2, conducted at the time of the observation confirmed that Nurse Aide, Employee E4, did not fully draw the curtain to provide Resident R3 with full privacy during care. Further observation of the first-floor unit conducted September 2, 2025, at 12:24PM revealed that Nurse Aide, Employee E4, was providing care for Resident R46. Further observation revealed that Resident R46's roommate was in Bed-B next to the window. Further, the privacy curtain for Resident R46 was drawn only partially at foot of the bed, exposing Resident R46 to his/her roommate. Interview with the DON, Employee E2, conducted at the time of the observation confirmed that Nurse Aide, Employee E4, did not fully draw the curtain to provide Resident R46 with full privacy during care. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that written notification was received prior to a resident's room change for 1 out of 17 residents reviewed (Resident R1). Review of Resident R1's September 2025 physician orders revealed the diagnoses of anxiety (intense, excessive and persistent worry and fear about everyday situations); depression (a mood disorder that may be described as feelings of sadness, loss, or anger that interfere with a person's everyday activities); cerebral vascular disease (a group of disorders that affect blood flow to the brain, leading to conditions such as stroke, aneurysms, and vascular malformations); dysphagia (difficulty swallowing) and unspecified pain. Review of a Quarterly Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated December 13, 2024 indicated that the resident was cognitive intact.Review of the facility policy, Room Change/Roommate Assignment, revised September 2017, indicted that the facility reserves the right to make resident room changes or roommate assignments when the facility deems it necessary or when the resident requests the change. The policy also indicated that prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives (sponsors) will be given a _____ ( no specific time indicated in the policy) hour/day advance notice of such change, and that advance notice of a roommate change will include why the change is being made, in addition to any information that will assist the roommate in becoming acquainted with his or her new roommate. Continued review of the policy indicated that unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room change and that such notice will include the reason(s) why the move is recommended.Review of a nursing note dated December 9, 2025 at 11:26 p.m. indicated that that resident's room was changed. Day 1/3: Resident transferred from 2nd floor to RM [ROOM NUMBER]C with schedule medications and belongings. Alert and oriented. No s/s of distress. Tolerated all Po (by mouth) meds. Staff assisted with adls (activities of daily living). Adjusting to new room and roommate. Safety precautions in place. Bed in lowest position with call bell within reach.Continued review of the facility's room change notification(an in house form used to document the date of the room change, person notified, and the reason for the room change) dated December 9, 2025 indicated that that the room change was due to safety reasons and that the resident's room change occurred on December 9, 2025 and that written notification of the room change was provided to the resident's responsible party. Continued review of the clinical record also did not show evidence of any written notification to the resident and/or responsible party prior to the move, including an explanation as to why the move was needed. During a discussion with the Director of Nursing (DON) September 5, 2025 at 12:27 p.m. it was discussed that there was no evidence that the resident/responsible party was received written notice, including the reason for the change, prior the resident's room /roommate in the facility was changed.28 Pa. Code 201.29(c) Resident Rights28 Pa. Code 201.29(c.3)(1) Resident Rights28 Pa. Code 211.12(c)Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 18 resident records reviewed (Residents R17, R41, R44, R48, R49, and R59). Findings include: Review of Resident R17's clinical record revealed the resident was initially admitted to the facility on [DATE], diagnosed with Acute and Chronic Respiratory Failure With Hypoxia (a condition that occurs when the body doesn't have enough oxygen in its tissues); and was ordered, dated August 6, 2024, with oxygen at 2L/Min, via nasal cannula continuously, every shift, related to acute and chronic respiratory failure with hypoxia (low lwvels of oxygen) On October 10, 2024, at 1:13 p.m., Resident R17 was observed that R17 receiving oxygen via nasal canula. which was confirmed with Licensed Nurse, Employee E5. Further review of Resident R17's clinical record revealed no evidence of a plan of care developed for Resident R17's oxygen administration. On October 10, 2024, at 1:15 p.m., interview with Licensed Nurse, Employee E5, confirmed that the facility failed to develop a care plan for Resident R17's oxygen administration in a timely manner. Review of Resident R41's clinical record revealed the resident was initially admitted to the facility on [DATE], diagnosed with epilepsy (a chronic brain disorder that causes seizures, which are episodes of involuntary brain activity that can affect the body) and given 500 mg of Keppra two times a day to prevent seizures. Nursing progress note, dated March 27, 2024, noted Resident R41 with seizure activity. The physician was notified and orders for blood work to verify the Keppra levels were at therapeutic levels. Further review of Resident R41's clinical record revealed no evidence a plan of care was developed for Resident R41's diagnosis of epilepsy. On October 11, 2024 at 10:00 a.m. interview with the Director of Nursing, Employee E2 confirmed the facility failed to develop a care plan for Resident R41's diagnosis of Epilepsy. Review of Resident R44's clinical record revealed the resident was initially admitted to the facility on [DATE], diagnosed with Rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage); and was ordered on September 20, 2024, to change urinary indwelling foley catheter (16 F with 10ml balloon), (Foley catheter is a flexible tube that drains urine from the bladder into a collection bag), change as needed, based on clinical indications such as infection, obstruction, or when the closed system is compromised. On October 10, 2024, at 12:19 p.m. Resident R44 was observed with a urinary catheter in place. Further review of Resident R44's clinical record revealed no evidence of a plan of care was developed for Resident R44's indewelling urinary foley catheter administration, in a timely manner. On October 10, 2024, at 12:22 p.m., interview with Licensed staff, Employee E4, confirmed that the facility failed to develop a care plan for Resident R44's foley catheter. Review of Resident R48's clinical record revealed that Resident R48 was initially admitted to the facility on [DATE], with a most recent readmission of September 28, 2024. Further review of Resident R48's clinical record revealed that Resident R48 had the following diagnoses of Urinary Tract Infection, Hemiplegia/Hemiparesis, Benign Prostatic Hyperplasia with lower Urinary Tract Symptoms, Presence of Urogenital Implant, Retention of Urine. Review of Resident R48's clinical record revealed a physician's order dated September 28, 2024, to: Change Foley Catheter: Size: 16fr- change prn based on clinical indications such as infection, obstruction, or when the closed system is compromised as needed and every day shift starting on the 8th and ending on the 8th every month for catheter change. Further a physician's order dated September 28, 2024, was obtained for Foley Catheter Care every shift. Observation conducted during tour of the facility on October 8, 2024, from 7:23 a.m. to 10:45 a.m. revealed that Resident R48 had a urinary catheter in place connected to a urine bag. Further Review of Resident R48's clinical record revealed that there was comprehensive person-centered care plan for urinary catheter in place for Resident R48. Interview with DON (Director of Nursing) Employee E2 conducted on October 10, 2024, at 9:50 a.m. confirmed that there was no comprehensive patient-centered care plan for catheter use in place for Resident R48. Review of Resident R49's clinical record revealed that Resident R49 was admitted to the facility on [DATE], with diagnoses of Quadriplegia, S/P Fusion of the spine (Cervical Region), Renaud's Syndrome, Muscle Weakness. Review of Resident R49's Occupational Therapy (OT) discharge summary dated August 8, 2024, revealed a discharge recommendation for splint/brace and AROM (Active Range of Motion) and PROM (Passive Range of Motion) for transfers and grooming Review of Resident R49's physician's order revealed an order SPLINT: RUE (right upper extremity) resting hand splint, on after lunch meal daily and worn per tolerance; patient may remove independently, March 14, 2024 Further review of Resident R49's clinical record revealed that there was no person-centered comprehensive care plan related to splinting and for active range of motion. Interview with DON Employee E2 conducted on October 10, 2024, at 12:28 pm confirmed that there was no person-centered comprehensive care plan for splinting in place for Resident R49. Review of Resident R59's clinical record revealed that Resident R59 was initially admitted to the facility on [DATE], with a most recent readmission of September 15, 2024. Further review of Resident R59's clinical record revealed that Resident R59 had the following diagnoses Acute Osteomyelitis of the right ankle and foot dated July 20, 2024, Type two Diabetes Miletus dated July 20, 2024, and Acquired Absence of Right Leg Below the Knee dated September 16, 2024. Review of Resident R59's clinical record revealed a progress note dated September 15, 2024, indicating that Resident R59 arrived at facility from local hospital via stretcher accompanied by 2 transporters. readmitted with a diagnosis of RBKA (Right Below the Knee Amputation) related to Osteomyelitis to right foot. Further review of Resident R59's clinical record revealed that there was no person-centered comprehensive care plan related to Resident R59's below the knee amputation. Interview with DON Employee E2 conducted on October 10, 2024, at 12:28 pm confirmed that there was no person-centered comprehensive care plan for below the knee amputation for Resident R59. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on staff interviews, review of clinical records, and facility documentation, it was determined that the facility failed to provide adequate supervision in the form of one to one as order by the physician and as indicated in the resident's plan of care for Resident R39. This failure resulted in actual harm to Resident R39 who sustained a fall, a laceration to the forehead, requiring transfer to the hospital and sutures for one of 20 residents reviewed. (Resident R39). Findings include: Review of the May 2023 physician orders for Resident R39 included the diagnoses of colon cancer; cerebral infarction (a stroke); schizophrenia (a mental disorder characterized by having false beliefs about people, places and things, seeing, hearing, feeling and smelling something that does not does not exit, disorganized thoughts, speech and behavior), and anxiety (a feeling of fear or apprehension about what's to come). Review of the resident's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 5, 2023, indicated that the resident was cognitively impaired. Review of the resident's fall assessment dated [DATE], indicated that the resident was at risk for falls. Review of nursing notes dated May 18, 2023, at 7:00 a.m. documented that staff heard Resident R39 yelling in his room and found him lying on his back on the floor next to his bed. The resident told staff that he was looking for his brother who was supposed to visit him. Review of Resident R39's May 2023 physician orders dated May 18, 2023, revealed a physician order for the resident to have a one-on-one supervision from nursing staff. Review of the resident's person-center plan of care plan revealed a plan of care dated May 18, 2023, for the resident to have one-on-one supervision from nursing staff. Review of a nursing note written by the Nursing Supervisor, Employee E8 dated May 19, 2023, at 4:41 p.m. revealed that Resident R39 was sitting in his broda chair at the nursing station when staff heard a loud noise. The note stated that Resident R39 was found laying face down on the floor by nursing staff. Resident R39 was assessed by nursing staff to have a laceration to his right forehead and was transferred to the hospital at approximately 4:00 p.m. Review of the resident's hospital records indicated that the resident had a laceration to his forehead that was 3 centimeters in length and 2 millimeters in depth. The hospital documentation stated that the resident's forehead wound was treated with five sutures (stitches) to close the wound. Review of the nursing notes and facility investigation did not indicate that the resident was receiving one-on-one supervision by any assigned staff member as indicated in the physician's order, and the resident's person-centered plan of care, to ensure continued safety of a resident who was identified as a fall risk resident safety. During an interview with the Director of Nursing (DON) on May 24, 2023, at 3:20 p.m. it was confirmed that the one-on-one supervision was initiated on the 11:00 p.m. through the 7:00 a.m. shift on May 18, 2023, after the resident had a fall on that date. During an interview with Licensed nurse, Employee E4 (the charge nurse during the 7:00 a.m. through 3:00 p.m. shift), revealed that the fall happened during the change of shift (3:00 p.m. through 11: 00 p.m.). Employee E4 reported that nursing staff was coming in to start their 3:00 p.m. through 11:00 p.m. shift while the 7:00 a.m. through the 3:00 p.m. nursing staff was ending their shift. Employee E4 reported that the nursing assistant who was assigned to the resident during the 7-3 p.m. shift left after her shift was done, and upon nursing assistant, Employee E6 and nursing assistant, Employee E7 starting their shift, Employee E4 reported that she told both nursing assistants at the nursing station that the nursing assistant assigned to Resident R39 for the 3-11 shift was not there yet, and that they had to decide amongst themselves which one of them was going to provide one-on-one supervision for Resident R39. Employee E4 reported that she then went over to give the nursing report to Licensed nurse, Employee E5 and that both she and Employee E5 were standing at the medication cart near room [ROOM NUMBER]. Employee E4 stated that she heard a sound, turned around and saw Resident R39 on the floor. During an interview with nursing assistant, Employee E6 on May 24, 2023, at 3:14 p.m. it was confirmed that she was not assigned to provide one-one-one supervision to the resident and denied the claims that Licensed nurse, Employee E4 stated that she told both Employee E6 and E7 that they had to decide amongst themselves who would provide one-on-one supervision to Resident R39 for the 3:00 p.m. through the 11:00 p.m. nursing shift. Employee E6 reported that she heard Licensed nurse, Employee E4 tell Employee E7 that a nursing assistant will be coming in on the 11:00 p.m.-7:00 a.m. shift to provide one-on-one supervision for the resident. Employee E6 stated that she heard Employee E7 state to Employee E4 that she will provide one-on-one supervision for Resident R39 for the the 11-7 p.m. shift. Employee E6 stated that Employee E4 told her again that the shift for the resident's one-one-one supervision was already covered for the 11:00 p.m. through the 7:00 a.m. shift (starting on May 19, 2023 and ending May 20, 2023 at 7:00 a.m.). Nursing assistant, Employee E6 stated that nursing assistant, Employee E7 then went to call the nursing scheduler about what Licensed nurse, Employee E4 stated, and that this is when the fall happened. During the interview with Employee E6 on the above date and time, it was discussed with Employee E6 and the Nursing Home Administrator (NHA) that there was no written statement from Employee E6. Review of the interview from nursing assistant, Employee E7 revealed that the employee reports that the resident was at the nursing station and the resident fell face forward while trying to get out of his chair. Review of the investigation included an interview from Licensed nurse, Employee E5, she stated that as she started to count medications with Licensed nurse, Employee E4 around 3 p.m. Employee E5 reported that as they both started counting medications, she heard a loud sound, turned around and saw the resident on the floor. Employee E5 stated that the resident was sitting in the nurse's station in his chair prior to the fall. Review of the investigation and nursing notes did not produce evidence that Resident R39 with history of falls, and with a physician's order and a person-centered plan of care intervention for one-on-one supervision, was being properly supervised by staff on the date and time of his fall with an injury on May 19, 2023, during the 3:00 p.m. through the 11:00 p.m. nursing shift. During an interview with the Nursing Home Administrator (NHA) on May 24, 2023, at 11:00 a.m. the name of the staff responsible for the resident during the resident's fall with an injury could not be provided by the Nursing Home Administrator when asked. The facility failed to ensure that Resident R39 was provided adequate supervision in the form of one to one as ordered by the physician and as indicated in the resident's plan of care. This failure resulted in actual harm to Resident R39 who sustained a fall, with a laceration to his right forehead, requiring transferred to the hospital and five sutures to close the wound. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide assistive devices necessary to prevent a fall incident for one of 17 residents reviewed. This failure resulted in actual harm to Resident R32 who sustained a fall in the bathroom, requiring transfer to the hospital and diagnosed with a left femur fracture. (Resident R32) Findings include: Review of facility policy Restorative Nursing Services revealed restorative goals and objectives are individualized and resident -centered, and are outlined in the resident's plan of care. Review of Resident R32's quarterly Minimum Data Set (MDS - resident assessment and care screening) dated September 14, 2022, revealed the resident was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (deteriorating disease of the joints that can cause pain and stiffness), lack of coordination, muscle weakness, and polymyalgia rheumatica (inflammatory disease that results in muscle aches and stiffness in different parts of the body). Review of Section G title Functional Status of the MDS indicated Resident R32 was not steady with walking, required 1-person physical assistance for transfers and walking in the room and corridor, and used a wheelchair for assistance. Review of Resident R32's care plan dated December 3, 2021, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to musculoskeletal (includes your bones, muscles, tendons, ligaments, and soft tissues) impairment. Continued review of Resident R32's care plan revealed the resident was at risk for falls related to encephalopathy (disease that affects the brain and causes altered mental state and confusion), poor safety awareness, and history of falls. The care plan indicated the resident had falls on the following dates: 9/13/2022, 9/20/2022, 9/28/2022, and a fall on 10/6/2022 that subsequently resulted in a left hip fracture. Review of nursing note dated October 6, 2022 by licensed nurse, Employee E4, revealed this charge nurse was alerted to Resident R32's room by nursing assistant, Employee E3. Licensed nurse, Employee E4 revealed on arrival to the room, Resident R32 was laying on the bathroom floor in a left, lateral fetal position. Nursing assistant, Employee E3 informed licensed nurse, Employee E4 that the aide attempted to assist Resident R32 with transfer back from the bathroom, when the resident could no longer walk and was lowered to the floor. The physician ordered an x-ray of the left hip due to complaints of pain. Continued review of nursing notes, dated October 7, 2022, by Employee E4, revealed an x-ray was still pending for Resident R32 and the resident was also observed with change in condition related to chest pain, fever, and hypoxia (low oxygen levels). Resident R32 was subsequently transferred to the hospital. Further review of nursing note dated October 7, 2022, revealed the resident was admitted to the hospital with admitting diagnosis of left hip fracture and anemia (lack of red blood cells). Review of hospital records dated October 7, 2022, confirmed x-ray findings of a closed left hip fracture. Review of facility investigation summary related to the fall on October 6, 2022, revealed Resident R32 was being assisted with toileting around 8:00 p.m. by nursing assistant, Employee E3. During the transfer off the toilet Resident R32 stated he could not walk and the nursing assistant lowered the resident to the ground. Review of the statement by nursing assistant, Employee E3, dated October 11, 2022, revealed the nursing assistant ambulated Resident R32 to the bathroom. When Resident R32 was finished in the bathroom, Employee E3 provided hand-held assistance off the commode and the resident reported he could not walk and was lowered to the ground. Interview on December 7, 2022, at 9:50 a.m. with licensed nurse, Employee E4, revealed Resident R32 was not steady on his feet prior to the fall and that the aide should not have ambulated the resident to the bathroom. Employee E4 reportedly educated the nursing assistant, Employee E3, after the fall, that the resident was not safe for ambulation. Interview, via telephone, on December 7, 2022, at 12:20 p.m. with nursing assistant, Employee E3, revealed she ambulated Resident R32 to the bathroom. Once Resident R32 was finished, Employee E3 got Resident R32 to stand up off the commode, he took a step or two, then was lowered to the floor. Employee E3 confirmed there was no assistive device or a wheelchair used. After the fall the charge nurse, Employee E4, made her aware that that Resident R32 is not steady on his feet and should not be ambulated. Employee E3 reported they did not usually work with Resident R32 and was unaware of his new functional baseline. Review of Resident R32's clinical record revealed the resident started physical therapy on September 21, 2022, and was referred for therapy due to exacerbation of decrease in strength, decrease in functional ability, decrease in transfers, reduced functional activity tolerance, reduced static and dynamic balance, increased need for assistance from others, and reduced ADL participation placing Resident R32 at risk for falls. It was noted that Resident R32 had a fall on September 20, 2022, attempting to self-transfer to the bathroom. Review of Resident R32's physical therapy discharge summary dated October 6, 2022, revealed the resident required 24-hr supervision secondary to a decline in functional mobility along with cognition. Restorative nursing program was recommended for transfers into wheelchair as ambulation was inconsistent and unsafe. Interview on December 6, 2022, at 3:00 p.m. with the Director of Therapy, Employee E5, revealed Resident R32 was not safe for ambulation at the time of the fall on October 6, 2022. Employee E5 reported the resident was referred for physical therapy September 21, 2022, because the resident sustained a drastic decline in functional status and ambulation. Review of email communication for restorative nursing recommendations, dated October 5, 2022, revealed the Director of Therapy, Employee E5, made the Director of Nursing, Employee E2, aware that Resident R32 should just be transferred into a wheelchair. Employee E5 reported that Resident R32 was unable to walk consistently and safely. Recommendations should read transfer out of bed into a wheelchair with 1-person assist at least daily. Review of Resident R32's entire clinical record revealed no documented evidence the resident's plan of care was updated to alert nursing staff that the resident was not safe for ambulation and required the use of a wheelchair. Interview on December 6, 2022, at 3:05 p.m. with the Director of Nursing, Employee E2, revealed the nursing assistant was going based off the latest MDS Kardex (a system of communication and organization used in nursing that helps long term care facilities document patient and resident care summaries) that indicated the resident was able to walk in room/corridor with one-person physical assistance, not the latest physical therapy recommendation. The facility failed to ensure that the necessary assistive device was used while assisting Resident R32 in the bathroom which resulted in actual harm to Resident R32, who sustained a fall, required transfer to the hospital and was diagnosed with a left femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(c) Resident rights

Based on observations, review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of six residents reviewed (Resident R1). This deficiency was identified as an Immediate Jeopardy of past non-compliance for Resident R1 who was struck by a nurse aide. Findings include: Review of facility policy, Abuse Prevention Program dated revised December 2016, revealed that, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. Review of Resident R1's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 25, 2022, revealed that the resident was admitted to the facility April 19, 2022, with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), hemiplegia (paralysis) and schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 11, which indicated that the resident was moderately cognitively impaired. Review of Resident R1's care plan, dated initiated April 29, 2022, revealed that the resident had behavioral problems such as yelling and screaming at staff. The care plan was updated July 22, 2022, to reflect that Resident R1 had a resident-to-resident altercation where she tipped a table towards another resident. Interventions included monitoring behavior episodes, encouraging the resident to express her feelings appropriately, approaching the resident in a calm manner, diverting her attention, removing her from situations and taking her to an alternate location as needed. Review of facility documentation submitted to the Department of Health on July 22, 2022, at 4:34 p.m. revealed that upon investigating a resident-to-resident altercation, it was alleged that a Nurse Aide, Employee E5, hit Resident R1. Review of facility documentation revealed a written statement from Resident R1, dated July 22, 2022, at 1:15 p.m. in which the resident stated that she was hit by Nurse Aide, Employee E5 in the second-floor dining room. Continued review of facility documentation revealed a written statement from Nurse Aide, Employee E5, dated July 22, 2022, at 1:42 p.m. which indicated that Resident R1 lifted her walker and was standing to hit me I then push her hands. Review of the facility's investigation summary related to the event that occurred on July 22, 2022, revealed that review of camera footage revealed that nurse aide, Employee E5 appeared to strike Resident R1. The facility determined that based on camera footage and interview with Resident R1, the allegation of physical abuse by Nurse Aide, Employee E5 was validated. Observation of camera footage on September 1, 2022, at 9:30 a.m. with the Nursing Home Administrator (NHA) revealed that Resident R1 lifted her walker up in front of nurse aide, Employee E5, appearing to try to hit or push the employee with her walker. Nurse aide, Employee E5 responded by striking the resident with an open hand. The NHA confirmed that in the camera footage, it appeared that Nurse Aide, Employee E5 struck Resident R1. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the components of immediate jeopardy) was provided to the Nursing Home Administrator, on September 1, 2022, at 7:46 p.m. On July 22, 2022, the facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 1. Facility staff in-servicing was initiated and over 93% of current staff have been educated, date of compliance August 11, 2022. All staff that have not completed in-servicing have been removed from the schedule and will not be allowed to work until in-service is completed. 2. Facility has been auditing all incidents to rule out abuse since June 5, 2022. No other occurrences of abuse have been identified. 3. Upon identifying perpetrator, the nurse aide was removed from patient care area, a statement was obtained, and the nurse aide was escorted from the facility. Residents on the nurse aide assignment were interviewed to rule out any additional abuse and all residents reported no abuse. 4. During the QAPI meeting of August 15, 2022, the facility reviewed abuse reporting, prevention, training and identification. The event of July 22, 2022, was reviewed as well. Abuse requirements will continue to be reviewed in the next QAPI meeting, which is scheduled for September 19, 2022. Review of facility documentation revealed that the corrective action plan was immediately initiated on July 22, 2022. Residents were interviewed to rule out abuse. Staff education related to abuse was implemented. Audits were in place to review all incidents for the potential of abuse. Abuse reporting and education requirements were reviewed during QAPI meetings as well as the event that occurred on July 22, 2022. Interviews with residents conducted on September 1, 2022, between 9:00 a.m. to 9:30 a.m. revealed that residents reported feeling safe at the facility and had no abuse concerns. Interviews were conducted with staff from various departments on September 1, 2022, between 12:03 p.m. to 12:30 p.m. All staff reported that they received in-service training regarding abuse, that they were able to recognize signs of abuse and that they were knowledgeable on reporting abuse as well as their role in the abuse investigation process. The facility's action plan was accepted on September 1, 2022, at 8:50 p.m. and identified as past non-compliance. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(c) Resident rights 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety on one of two nursing units (Second Floor Nursing Unit) during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020. Residents on the Second Floor Nursing Unit did not receive medications and treatments; the security of a medication cart was compromised; and non-licensed nursing staff were not appropriately supervised and monitored by a licensed nurse. This failure placed all 27 residents who resided on the Second Floor of the facility in an Immediate Jeopardy situation. Findings include: Review of facility nursing schedules from December 25, 2020, to December 31, 2020, revealed that there was no licensed nurse scheduled to work the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020, on the Second Floor Nursing Unit. The resident census on the Second Floor Nursing Unit was 27 residents on December 25, 2020. Continued review of the nursing schedules for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, revealed that there was no Registered Nurse (RN) on duty in the building. The facility's total census was 62 residents on December 25, 2020, with 27 residents residing on the Second Floor Nursing Unit. Interview on June 24, 2021, at 11:07 a.m. with staffing scheduler, Employee E26 confirmed that she was the person responsible for scheduling nursing staff during December 2020. Employee E26 stated that she began working on the holiday season nursing schedule in October 2020 and made attempts to find staff to work during the Christmas holidays. Employee E26 stated that during morning meetings that included the Nursing Home Administrator (NHA) and the Director of Nursing (DON) that occurred on December 21, 22, and 23, 2020, she informed the NHA and the DON that there was an unfilled shift for the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020. Employee E26 stated that she specifically reviewed the unfilled shift on the schedule during the morning meetings and that the NHA and the DON were fully aware that the shift for the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020, was unfilled. Continued interview with Employee E26 revealed that she reached out to four nursing agencies and offered extra pay and bonuses in attempts to find staff. Employee E26 stated that she spoke with Employee E8, who was the Registered Nurse (RN) Supervisor on duty on December 25, 2020, at approximately 8:00 a.m. that day to inform him that she was still unable to find any nurses to work for that night. Employee E33, Licensed Practical Nurse (LPN), was scheduled to work the 3:00 p.m. to 11:00 p.m. tour of duty on December 25, 2020, and Employee E26 stated that she informed Employee E8 that he may have to mandate Employee E33, LPN, to stay and work the 11:00 p.m. to 7:00 a.m. shift. Employee E26 stated that she attempted to inform the DON of the above and left a voicemail for her. During further interview Employee E26 stated that she assumed Employee E33 had stayed and worked the shift. Employee E26 stated that she was not aware that there was no nurse on duty for the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020, on the Second Floor Nursing Unit until December 28, 2020. Interview on June 24, 2021, at 10:12 a.m. with Employee E8, Registered Nurse (RN) Supervisor, confirmed that he had worked both the day (7:00 a.m. to 3:00 p.m.) and evening (3:00 p.m. to 11:00 p.m.) shifts on December 25, 2020. Employee E8 stated that he noticed on December 24, 2020, that there was no nurse scheduled for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, and that he spoke to the scheduler, Employee E26, about it. Employee E8 continued that upon completion of his shift at 11:00 p.m. on December 25, 2020, when no relief arrived, he reached out to co-workers and nursing agencies in an attempt to find a replacement nurse for the shift. Employee E8 stated that he then notified the NHA who instructed him to leave since he had already worked for more than 16 hours. Employee E8 stated that he stopped working at 11:30 p.m. on December 25, 2020, and reported off to Employee E31, Licensed Practical Nurse (LPN) the only other licensed nurse in the building at that time. Review of Employee E8's time-card revealed that he clocked in for duty on December 25, 2020, at 7:00 a.m. and clocked out on December 26, 2020, at 12:30 a.m. Interview on June 25, 2021, at 12:22 a.m. Employee E31, LPN, confirmed that she was the only licensed nurse on duty in the facility during the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020. Employee E31 stated that when she arrived for duty, she was not aware that there was no nurse scheduled to work on the Second Floor Nursing Unit that shift. Employee E31 stated that at approximately 11:30 p.m. Employee E8 came to the First Floor Nursing Unit to inform her that no relief had arrived and that he was leaving. Employee E31 informed Employee E8 that she refused to cover both nursing units. Employee E31 stated that she attempted to call and text the DON but did not receive any response. Employee E31 stated that she then spoke with the NHA and informed the NHA that she did not feel it was safe as an LPN being responsible for both nursing units, that she refused to accept the keys to the Second Floor Nursing Unit medication cart, and that she would only work and provide nursing care on the First Floor Nursing Unit. Employee E31 stated that when Employee E8 left he placed the keys to the Second Floor Nursing Unit medication cart on the desk of the First Floor Nurses ' Station and that she did not count narcotics or review the mediation cart with him. Employee E31 stated that at the end of her shift she reported to the oncoming dayshift supervisor, Employee E23, that there was no nurse on duty for the second floor for the 11:00 p.m. the 7:00 a.m. shift, that the keys to the medication cart for the Second Floor Nursing Unit were on the desk at the nurses ' station and that no medications were administered to any of the residents on the second floor. Interview on June 24, 2021, at 9:34 a.m. with RN Supervisor, Employee E23, confirmed that she was the RN Supervisor on duty on December 26, 2020, for the 7:00 a.m. to 3:00 p.m. shift. Employee E23 stated that she was informed by Employee E31, LPN that there had been no nurse on duty on the Second Floor Nursing Unit for the 11:00 p.m. to 7:00 a.m. shift and that Employee E31 did not give any medications, treatments or care to any of the second floor residents. Employee E23 stated that she verified with Employee E31 that the DON and the NHA were notified and aware of what occurred. Employee E23 stated that she provided an update during her shift on December 26, 2020, to the DON regarding the residents on the Second Floor Nursing Unit. Continued review of facility nursing schedules revealed that Employee E27, LPN, worked on the 7:00 a.m. to 3:00 p.m. shift on December 26, 2020, on the Second Floor Nursing Unit. Employee E27 provided a written statement, dated January 15, 2021, which indicated that she noticed that the medication cart was unlocked and the keys were at the nurses' station. Employee E27 indicated that she notified the Supervisor, Employee E23 and the DON. Employee E27 wrote that she was instructed by the nursing supervisor to start her morning med pass, that she noticed that there was a lot of missing documentation and was informed by the supervisor that there was not a nurse at the facility on the Second Floor Nursing unit. Interview with the NHA on June 16, 2021, at 6:30 p.m. confirmed that 27 residents resided on the Second Floor Nursing Unit on December 25, 2020. The NHA also confirmed that if any of the 27 residents on the Second Floor Nursing Unit had medications and treatments scheduled on December 25, 2021, during the 11:00 p.m. and 7:00 a.m. shift, they did not received them due to not having a nurse on duty during that shift. The NHA reported that the facility initiated a performance improvement plan and implemented corrective actions. Review of facility documentation, Performance Improvement Plan undated, revealed that under section title Problem, it was identified that a licensed nurse was not scheduled for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020; that the DON and the NHA were not made aware that there was an open shift; that the RN Supervisor had already worked for greater than 16 hours; that medications were not passed for this shift to the residents on the second floor; that information was not shared shift to shift; and that there was a lack of communication from floor staff to the DON/NHA when no nurse reported for duty. Continued review of facility documentation, Performance Improvement Plan, revealed that under the section titled, Steps to be taken, included statements and education to all nurses involved; educate nursing staff as part of their report/hand-off to review actual MAR (medication administration record) and TAR (treatment administration record) to ensure all tasks had been completed; and educate supervisors how to mandate when absolutely necessary. The document noted that the NHA and the DON were responsible for the Performance Improvement Plan. Documentation provided by the facility at the time of the survey related to the implementation of their self-imposed, Performance Improvement Plan, was reviewed with the NHA and the DON on June 24, 2021, at 2:20 p.m. The facility was not able to provide written statements from Employee E8, the RN supervisor who stopped working at 11:30 p.m. on December 25, 2020, Employee E33, the LPN who left after completing the 3:00 p.m. to 11:00 p.m. shift on December 25, 2020, or Employees E34, E35, E36 and E37 who were the nurse aides on duty during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020. Continued review of facility documentation revealed that the NHA confirmed that the facility had a total of ten licensed nurses on staff directly employed by the facility in December 2020, and that only six of those nurses received education. Three of those six nurses refused to sign the education record. Further review of facility documentation revealed that the DON indicated that the facility had three RN Supervisors on staff in December 2020, and confirmed that only one supervisor received education. The NHA confirmed that no agency staff received any education. Follow-up interview on June 24, 2021, at 2:45 p.m. the above missing documentation related to the facility's self-imposed, Performance Improvement Plan, was requested. The NHA replied, You already have everything Based on the above findings Immediate Jeopardy to the health and safety of the residents was identified to the NHA and the DON on June 24, 2021, at 4:10 p.m. for failing to ensure sufficient licensed nursing staff were available to provide nursing services, including medications and treatments. This failure resulted in 27 residents not receiving medications and treatments as prescribed by the physician and the security of a medication cart was compromised. Non-licensed staff were not appropriately supervised and monitored by a licensed staff. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested On June 26, 2021, at 1:37 p.m. the facility provided the following corrective action plan: 1. The facility self-identified this deficiency 12/27/20, started reviewing the schedule daily as an audit on 12/28/20, educated the staff and initiated a QAPI (Quality Insurance Improvement Plan) by 1/13/21. The facility placed the scheduler on a performance improvement plan and ultimately replaced the scheduler. 2. The NHA, DON & Nursing staff will be immediately educated to ensure that sufficient licensed nursing staff are available 24 hours a day to provide nursing care. The NHA, DON & Nursing staff will be immediately educated that at no time are residents or non-licensed nursing staff to be left unsupervised by licensed personnel. The nursing staff will be immediately educated of their responsibility at the end of the shift to ensure there is sufficient nursing staff in the facility. In the event there is not sufficient staff the Nursing Supervisor will contact the DON and/or NHA to call staff. Nursing Supervisor will initiate calls to staff members. If no one responds to the request for staff, current staff will be mandated to stay. The DON and/or NHA will reach out to sister facilities and staffing agencies and assist with calling staff members. Contact information is available in the supervisor's binder. As the staff including agency staff comes into work, they will immediately be educated on the facilities policy prior to taking their assignment. The facility will educate 80% of the nursing staff within 24 hours and 100% within 48 hours. 3. The licensed nursing staff will be educated to keep the med cart secure and to give the keys only to another nurse at the end of the shift. 4. An audit log will be immediately created to ensure that at the end of each shift there is sufficient licensed nursing staff in the facility to meet the needs of the residents as per the MD's orders with a minimum of one nurse on each floor. In alignment with both CMS regulations and Pennsylvania state regulations, there will be a minimum of 1 RN and 1 LPN 7:00 a.m.-3:00 p.m. shift; 1 RN and 1 LPN 3:00 p.m.-11:00 p.m. shift; and 1 RN and 1 LPN for 11:00 p.m. to 7:00 a.m. This staffing pattern will be maintained, reviewed daily, for a period of 12 months. The audit will ensure that no residents or non-licensed nursing staff are left unsupervised by licensed personnel. The audit will ensure that the med cart was kept secure and the keys were handed to another nurse. 5. The NHA or designee will audit the logs twice a day for 2 weeks then twice a day 3x times a week for 2 weeks. Then twice a day 2x a week for 3 months. Findings will be presented at our QAPI meetings to make recommendations. The implementation of the immediate action plan was verified on June 25 and 26, 2021 Interviews conducted with licensed nursing staff on June 25, 2021 at 1:17 p.m. through 1:53 p.m., confirmed that they were in-serviced on ensuring that there were sufficient nursing staff present prior to leaving their shift. If no nursing staff were available to relieve them from their shift the NHA and DON were to be notified. Further licensed nursing staff interviewed communicated that they were not to leave the assigned nursing unit until relief arrived. Further, during interview licensed nursing staff confirmed that they were responsible for ensuring that all medications and treatments were administered to the residents on their assigned unit as ordered by the physician. If they were not able to administer medications and treatments as prescribed by the physician the NHA, DON, physician, resident and resident's responsible party are to be notified. Licensed nursing staff interviewed were able to verbalize that they were instructed on the security of the medication carts and that medication carts' keys are to be handed to the next nurse who is scheduled to work. The Immediate Jeopardy was lifted on June 26, 2021, at 4:31 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that adequate nursing staffing was maintained resulting in the neglect of six of 27 residents as evidenced by nursing care, medications and treatments not being administered to Residents R1, R4, R11, R38, R56 and R65. This failure placed all 27 residents on the Second Floor Nursing Unit in an Immediate Jeopardy situation during one of three nursing shifts (11:00 p.m.- 7:00 a.m.) on December 25, 2020. Findings include: Review of facility policy, Abuse Prevention, dated revised March 2020, revealed, The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility policy defines neglect as, failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further review of the policy revealed that the facility will, identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes .sufficient staffing on each shift to meet the needs of the residents. Clinical record review for Resident R1 revealed a nursing note, dated December 21, 2020, at 3:58 p.m. which indicated that the resident was a new admission to the facility and was seen for a psychiatry evaluation by a nurse practitioner who noted that the resident was confused, oriented to self only, forgetful and required 24 hour supervision to ensure safety. Continued record review for Resident R1 revealed a nursing note, dated January 8, 2021, at 5:16 p.m. signed by the Director of Nursing (DON) which stated, Nursing has identified that on 12/25/20, resident did not receive his meds and or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . No adverse effects noted at this time. Review of Resident R1's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for December 2020, revealed that the resident did not receive the following medications and treatments during the 11:00 p.m.- 7:00 a.m. shift on December 25, 2021: blood sugar monitoring due at 6:30 a.m. on December 26, 2020; Behavior monitoring for the night shift of December 25, 2020; Acetaminophen 500 milligrams (mg) every six hours for pain that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020; pain monitoring for the night shift of December 25, 2020; Skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to both heels for the night shift of December 25, 2020; [MEDICATION(S)] for incontinent care for the night shift of December 25, 2020. Review Resident R4's MARs and TARs for December 2020, revealed that the resident did not receive the following medications and treatments during the 11:00 p.m.- 7:00 a.m. shift on December 25, 2020: blood sugar monitoring that was part of the resident's diabetic insulin regimen due at 6:30 a.m. on December 26, 2020; Insulin [MEDICATION(S)] (rapid acting insulin used to treat diabetes) 2 units that was due at 6:30 a.m. on December 26, 2020; Insulin [MEDICATION(S)] sliding scale dosage that was due at 6:30 a.m. on December 26, 2020; [MEDICATION(S)] (medication used to treat reflux) delayed release 40 mg that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] solution (used to treat abnormal [MEDICATION(S)] levels) 20 grams every eight hours that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (used to treat muscle spasticity) 20 mg every six hours that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (used to treat nerve pain) 600 mg every six hours that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020; Icy Hot 5% patch (for pain relief) apply to both knees that was due at 6:00 a.m. on December 26, 2020; Foley catheter care and monitoring for the night shift of December 25, 2020; Pain monitoring for the night shift of December 25, 2020; [CONDITION(S)] care and monitoring for the night shift of December 25, 2020; Protective heel boots for the night shift of December 25, 2020; Barrier cream to sacrum for rash for the night shift of December 25, 2020; Air mattress monitoring for the night shift of December 25, 2020;Skin prep to heels for the night shift of December 25, 2020; Turn and reposition every two to three hours for the night shift of December 25, 2020. Review of Resident R11's MARs and TARs for December 2020, for Resident R11 revealed that the resident did not receive the following medications and treatments: [MEDICATION(S)] (an antipsychotic used to treat mental disorders) 1mg that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (medication used to treat reflux) delayed release 40 mg that was due at 6:00 a.m. on December 26, 2020; Pain monitoring for the night shift of December 25, 2020. Review of Resident R38's MARs and TARs for December 2020, revealed that the resident did not receive the following medications and treatments: [MEDICATION(S)] (medication used to treat reflux) 30 mg that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] patch 4% (for pain relief) to lower back that was due at 6:00 a.m. on December 26, 2020; Behavior monitoring for the night shift of December 25, 2020; Pain monitoring for the night shift of December 25, 2020; Enteral feeding via peg tube (a tube inserted through a surgical opening into the stomach to allow for food, fluids and medication administration) bolus feeding 240 milliliters (ml, 240 ml is equivalent to 8 ounces or 1 cup) High Cal supplement that was due for the night shift of December 25, 2020; Hydration flush via peg tube of 250 ml of water that was due for the night shift of December 25, 2020; [MEDICATION(S)] 250 mg per 5 ml, give 2 ml three times per day that was due at 6:00 a.m. on December 26, 2020; Peg tube site care and monitoring for the night shift of December 25, 2020; Pain monitoring for the night shift of December 25, 2020; Foley catheter care and monitoring for the night shift of December 25, 2020; Skin prep to both heels for the night shift of December 25, 2020. Review of Resident R56's MARs and TARs for December 2020, revealed that the resident did not receive the following medication and treatments: Blood sugar monitoring that was part of the resident' s diabetic insulin regime that was due at 6:30 a.m. on December 26, 2020; Insulin [MEDICATION(S)] sliding scale dosage that was due at 6:30 a.m. on December 26, 2020; [MEDICATION(S)] delayed release 40 mg that was due at 6:00 a.m. on December 26, 2020; Aspiration Precautions monitoring for the night shift of December 25, 2020; Behavior monitoring for the night shift of December 25, 2020; Pain monitoring for the night shift of December 25, 2020. Review of Resident R65's MARs and TARs for December 2020, for Resident R65 revealed that the resident did not receive the following medications and treatments: Blood sugar monitoring that was part of the resident's diabetic insulin regime that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020; Insulin [MEDICATION(S)] 3 units every six hours that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (used to treat high blood pressure) 0.3 mg every eight hours that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (used to treat high blood pressure) 100 mg every eight hours that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] (used to treat high blood pressure) 1 tablet every eight hours that was due at 6:00 a.m. on December 26, 2020; Nicardipine (used to treat high blood pressure) 40 mg every eight hours that was due at 6:00 a.m. on December 26, 2020; [MEDICATION(S)] solution (for prevention of blood clots) 5000 units subcutaneously every eight hours that was due at 6:00 a.m. on December 26, 2020; Enteral feeding via peg tube (continuous feeding) 60 ml Glucerna 1.2 every hour that was due at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m., and 6:00 a.m. on December 26, 2020; Hydration flush via peg tube of 100 ml of water that was due at 12:00 a.m. midnight and 6:00 a.m. on December 26, 2020. Aspiration Precautions monitoring for the night shift of December 25, 2020; Peg tube site care and monitoring for the night shift of December 25, 2020; Head of bed elevated monitoring for the night shift of December 25, 2020; Pain monitoring for the night shift of December 25, 2020 Skin prep to both heels for the night shift of December 25, 2020; [MEDICATION(S)] for incontinent care for the night shift of December 25, 2020. Review of facility documentation revealed that Residents R1, R4, R11, R38, R56 and R65 resided on the Second floor of the facility. Additional review of the, Daily Census 12/25/20, confirmed that a total of 27 residents resided on the Second Floor Nursing Unit on December 25, 2020. Interview on June 16, 2021, at 6:30 p.m. with the Nursing Home Administrator (NHA) confirmed that 27 residents resided on the Second Floor Nursing Unit on December 25, 2020. The NHA also confirmed that none of those 27 residents received any of their medications or treatments during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, due to not having a nurse on duty during that shift on that unit. The NHA reported that the facility initiated a performance improvement plan and implemented corrective actions. Review of facility documentation, Performance Improvement Plan, undated, revealed that under section title Problem, it was identified that a licensed nurse was not scheduled for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020; that the Director of Nursing (DON) and the NHA were not made aware that there was an open shift; that the RN Supervisor had already worked for greater than 16 hours; that medications were not passed for this shift to the residents on the second floor; that information was not shared shift to shift; and that there was a lack of communication from floor staff to the DON/NHA when no nurse reported for duty. Interview on June 24, 2021, at 11:07 a.m. with Employee E26 revealed that she was the person responsible for scheduling nursing staff during December 2020. Employee E26 stated that she began working on the holiday season nursing schedule in October 2020, and made attempts to find staff to work during the Christmas holidays. Employee E26 stated that during morning meetings that included the NHA and the Director of Nursing (DON) that occurred on December 21, 22, and 23, 2020, she informed the NHA and DON that there was an unfilled shift for the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020. Employee E26 stated that she specifically reviewed the unfilled shift on the schedule during the morning meetings and that the NHA and DON were fully aware that the shift for the 11:00 p.m. to 7:00 a.m. tour of duty on December 25, 2020, was unfilled. During a follow-up interview on June 24, 2021, at 9:06 a.m. the NHA and DON were asked what actions were taken immediately following the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, to ensure the residents' safety and well-being. The DON did not provide an answer and the NHA stated that she was unable to answer the question at the time of the interview. An interview on June 24, 2021, at 10:12 a.m. with Employee E8, RN Supervisor, confirmed that he had worked both the day (7:00 a.m. to 3:00 p.m.) and evening (3:00 p.m. to 11:00 p.m.) shifts on December 25, 2020. Employee E8 stated that he noticed on December 24, 2020, that there was no nurse scheduled for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, and that he spoke to the scheduler, Employee E26, about it. Employee E8 continued that upon completion of his shift at 11:00 p.m. on December 25, 2020, when no relief arrived he reached out to co-workers and nursing agencies in an attempt to find a replacement nurse for the shift. Employee E8 stated that he then notified the NHA who instructed him to leave since he had already worked for more than 16 hours. Employee E8 stated that he stopped working at 11:30 p.m. on December 25, 2020, and reported off to Employee E31, a Licensed Practical Nurse, the only other licensed nurse in the building at that time. Employee E8 confirmed that he did not administer any medications after 11:30 p.m. to residents on the Second Floor Nursing Unit and that if a medication was not signed on the MAR or TAR then it was not administered by him. Review of Employee E8 's time-card revealed that he clocked in for duty on December 25, 2020, at 7:00 a.m. and clocked out on December 26, 2020, at 12:30 a.m. Interview on June 25, 2021, at 12:22 a.m. with Employee E31, Licensed Practical Nurse, confirmed that she was the only licensed nurse on duty in the facility during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020. Employee E31 stated that when she arrived for duty she was not aware that there was no nurse scheduled to work on the Second Floor Nursing Unit that shift. Employee E31 stated that at approximately 11:30 p.m. Employee E8 came to the First Floor Nursing Unit to inform her that no relief had arrived and that he was leaving. Employee E31 informed Employee E8 that she refused to cover both nursing units. Employee E31 stated that she attempted to call and text the DON but did not receive any response. Employee E31 stated that she then spoke with the NHA and informed the NHA that she did not feel it was safe as an Licensed Practical Nurse and not a Registered Nurse to be responsible for both nursing units, that she refused to accept the keys to the Second Floor Nursing Unit medication cart, and that she would only work and provide nursing care on the First Floor Nursing unit. Employee E31 stated that when Employee E8 left he placed the keys to the Second Floor Nursing Unit medication cart on the desk of the First Floor Nurses Station and that she did not count narcotics or review the mediation cart with him. Employee E31 stated that she only went up on the Second Floor Nursing Unit once during the entire shift to inform the nurse aides that there was no licensed nurse on duty for the Second Floor Nursing Unit. Employee E31 stated that she did not give any medications, treatments or nursing care to any of the residents on the Second Floor Nursing Unit. Employee E31 stated that she did not touch the Second Floor Nursing Unit medication cart at any time during the shift and that she did not round on any of the residents on the second floor at any time during the shift. Employee E31 stated that at the end of her shift she reported to the oncoming dayshift supervisor, Employee E23, that there was no nurse on duty for the second floor for the 11:00 p.m. the 7:00 a.m. shift, that the keys to the medication cart for the Second Floor Nursing unit were on the desk at the nurses station and that no medications were administered to any of the residents on the second floor. Interview on June 24, 2021, at 9:34 a.m. with Employee E23, Registered Nurse (RN) Supervisor, confirmed that she was the RN Supervisor on duty on December 26, 2020, for the 7:00 a.m. to 3:00 p.m. shift. Employee E23 stated that she was informed by Employee E31 that there had been no nurse on duty on the Second Floor Nursing Unit for the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020, and that Employee E31 did not give any medications, treatments or care to any of the second floor residents. Employee E23 stated that she verified with Employee E31 that the DON and NHA were notified and aware of what occurred. Employee E23 stated that she provided an update during her shift on December 26, 2020, to the DON regarding the residents on the second floor. Employee E23 stated that she did not receive any direction from Administration regarding how to proceed and that resident care and medications were given as per their usual routine on December 26, 2020, for the 7:00 a.m. to 3:00 p.m. shift. Employee E23 stated that no medications or treatments that were due on December 25, 2020 during the 11:00 p.m. to 7:00 a.m. shift were administered by day shift staff. Continued review of facility documentation, Performance Improvement Plan, revealed that under the section titled, Steps to be taken included statements and education to all nurses involved; educate nursing staff as part of their report/hand-off to review actual MAR and TAR to ensure all tasks have been completed; and educate supervisors how to mandate when absolutely necessary. The document noted that the NHA and the DON were responsible for the Performance Improvement Plan. Documentation provided by the facility at the time of the survey related to the implementation of it's self-imposed, Performance Improvement Plan, was reviewed with the NHA and DON on June 24, 2021, at 2:20 p.m. The facility was not able to provide written statements from Employee E8, the Registered Nurse supervisor who stopped working at 11:30 p.m. on December 25, 2020, Employee E33, the Licensed Practical Nurse who left after completing the 3:00 p.m. to 11:00 p.m. on December 25, 2020, or Employees E34, E35, E36 and E37 who were the nurse aides on duty during the 11:00 p.m. to 7:00 a.m. shift on December 25, 2020. Continued review of facility documentation revealed that the NHA confirmed that the facility had a total of ten licensed nurses on staff directly employed by the facility in December 2020, and that only six of those nurses received education. Three of those six nurses refused to sign the education record. Further review of facility documentation revealed that the DON indicated that the facility had three RN Supervisors on staff in December 2020, and confirmed that only one supervisor received education. The NHA confirmed that no agency staff received any education. Follow-up interview on June 24, 2021, at 2:45 p.m. the above missing documentation related to the facility's self-imposed, Performance Improvement Plan, was requested. The NHA replied, You already have everything. Based on the above findings Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator and the Director of Nursing on June 24, 2021, at 4:10 p.m. for failing to ensure that prescribed medications, treatments and nursing care were administered along with supervision and monitoring to the 27 residents residing on the Second Floor Nursing Unit. The Nursing Home Administrator was provided with the Immediate Jeopardy template and an immediate action plan was requested. On June 24, 2021, at 10:44 p.m. the facility provided the following corrective action plan: 1. The facility was under the assumption that the single licensed nurse in the facility passed the medications to all residents in the facility. The facility discovered, on January 8, 2021, that medications were not passed to the residents on the second floor. At that time, education and audits were expanded to include the resident missing doses of medications. 2. The nursing staff will be immediately educated to ensure that all residents receive their medications, treatments and nursing care at their prescribed time including diabetic medications and monitoring, blood pressure medications, pain medications, enteral feeding, anticoagulant medications, antipsychotic medications, gastrostomy care, [CONDITION(S)] care, and Foley catheter care. As the staff come into work, they will immediately be educated on the facility's policy prior to taking their assignment. The facility will educate 80% of the nursing staff within 24 hours and 100% within 48 hours. 3. The Licensed nursing staff will be immediately educated on whom to notify in the event residents' medications and treatments were not able to be administered. The nursing staff will notify the Supervisor, DON, MD (physician), Resident & Resident Representative. The Supervisor or DON will monitor the resident as per the MD's direction. As the staff come into work, they will immediately be educated on the facilities policy prior to taking their assignment. The facility will educate 80% of the nursing staff within 24 hours and 100% within 48 hours. 4. The Licensed Nursing staff currently in the facility, upon approval of this plan, will be educated to ensure that non licensed nursing staff are adequately supervised and monitored using the facility's monitoring tool. As staff come into work, they will immediately be educated on the facilities policy prior to taking their assignment. The facility will educate 80% of the nursing staff within 24 hours and 100% within 48 hours. 5. Facility will use the missed medication report in PointClickCare (electronic documentation system) to monitor medication administration. The DON or the NHA will run this report daily, and audit to ensure notifications were made in the event of a missed medication. An audit log will immediately be created to ensure that the physician is notified for any residents that did not receive their medications or treatments every shift. An audit log will be immediately created to ensure that all non-licensed nursing staff are adequately supervised and monitored every shift. 6. The NHA or designee will audit the logs twice a day for 2 weeks then twice a day 3x times a week for 2 weeks. Then twice a day 2x a week for 3 months. Findings will be presented at our QAPI meetings to make recommendations. The implementation of the immediate action plan was verified on June 25 and 26, 2021. Interviews conducted with licensed nursing staff confirmed that they were in-serviced on ensuring that there were sufficient nursing staff present prior to leaving their shift. If no nursing staff was available to relieve them from their shift the NHA and the DON were to be notified. Further licensed nursing staff interviewed communicated that there were not to leave the assigned nursing unit until relief arrived. they were responsible for ensuring that all medications and treatments were administered to the residents on their assigned unit. If they were not able to administer medications and treatments as prescribed by the physician the NHA, DON, physician, resident and resident's responsible party were to be notified. The Immediate Jeopardy was lifted on June 26, 2021, at 4:31 p.m. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(d)Management 28 Pa. Code 201.18(e)Management 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(a) Nursing services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 28 Pa Code 211.12(e) Nursing services

Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for two of 2 nursing units observed (First Floor and Second Floor Nursing Units). This failure placed residents on the First and Second Floor Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy title, Safety of Water Temperatures, dated November 14, 2020, revealed that, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Continued review revealed that, Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit, or the maximum allowable temperature per state regulation. Further review revealed that, Direct-care staff shall be informed to feel the water to make sure it is comfortable and to report to the Supervisor if it feels too warm or too cold. Observation conducted on June 13, 2021, at 10:30 a.m. of the resident bathroom hand sink in room 211 revealed that the hot water felt uncomfortably too hot to the touch. Continued observation on June 13, 2021, at 10:33 a.m. in the presence of licensed nursing staff, Employee E8, revealed that the only thermometer available on the Second Floor Nursing Unit to check water temperatures, could only go up to 120 degrees Fahrenheit. Licensed nursing staff, Employee E8 tested the hot water temperature in the resident's bathroom hand sink in Room 211 and confirmed that the thermometer read a hot water temperature of 120 degrees Fahrenheit and that the actual water temperature was unable to be determined using the available thermometer. The hot water in the bathroom's hand sink of Room 211 was tested on [DATE], at 10:39 a.m. with the Director of Maintenance, Employee E12. The water temperature in the bathroom's hand sink of resident room 211 tested 123 degrees Fahrenheit which was above the 110 degrees Fahrenheit indicated in the facility's policy. During an interview at the time of the observation, the Director of Maintenance, Employee E12 stated that he was unsure what the proper water temperature was supposed to be. Employee E12 further stated that he noticed on Friday, June 11, 2021, that the water temperature in another hand sink of a resident ' s room was higher than usual and that he scheduled a vendor to come to address the issue for June 14, 2021. Hot water temperatures on the First and Second Floor Nursing units were tested with the Director of Maintenance, Employee E12 on June 13, 2021, between 10:44 a.m. and 10:55 a.m. The following hot water temperatures were above 110 degrees Fahrenheit at the resident's hand sink: Resident room 212 water temperature was 118 degrees Fahrenheit; resident room 200 water temperature was 120 degrees Fahrenheit; resident room 102 water temperature was 115 degrees Fahrenheit; resident room 108 water temperature was 111 degrees Fahrenheit; resident room 109 water temperature was 118 degrees Fahrenheit. Review of maintenance logs titled, Record Hot Water Temperature in Resident Use Areas revealed that on June 11, 2021, the water temperature in resident room 201 was 117 degrees Fahrenheit. Interview on June 14, 2021, at 1:20 p.m. with the Nursing Home Administrator revealed that water temperatures were not checked on June 12, 2021, because the Director of Maintenance was off from work that day. The Nursing Home Administrator stated that nursing staff were notified via the, 24 Hour Report, to check water temperatures prior to showers beginning on June 11, 2021. The Nursing Home Administrator also confirmed that the resident in room 201 was not notified regarding the water temperature at the hand sink on June 11, 2021, after it was discovered by the facility that the water was too hot at the hand sink. Interview conducted on June 14, 2021, at 1:25 p.m. with nursing assistant, Employee E13, stated that she was not aware of any concerns with the hot water temperatures, that no thermometer was available for nursing staff to check the temperature of the hot water and that she would check water temperatures by using her hand. Interview conducted on June 14, 2021, at 1:26 p.m. with licensed nursing staff, Employee E11, revealed that she was not aware of any issues with water temperatures. Interview conducted on June 14, 2021, at 1:27 p.m. with licensed nursing staff, Employee E8, stated that no hot water temperature issues were reported by any nurse aides and that he was not aware of any hot water temperature problems at the facility over the weekend. Interview conducted on June 14, 2021, at 1:28 p.m. with Employee E14, nursing assistant, stated that she was not aware of any issues related to water temperatures and that she has been giving baths and showers as per her usual routine. Employee E14 stated that she would check water temperatures by using her hand to feel the water. Interview conducted on June 14, 2021, at 3:00 p.m. with nursing assistant, Employee E16, revealed that she was not aware of any hot water temperatures and that she checks water temperatures by feeling the water with her hand. Employee E16 was unable to state what the proper water temperature should be if she were to use a thermometer to check water temperatures. Interview conducted on June 14, 2021, at 3:00 p.m. with licensed nursing staff, Employee E8 revealed that the residents in rooms 200A, 200B, 201A and 212B were capable of independently turning on the water at the hand sink in their bathrooms without assistance from staff. Interview conducted on June 14, 2021, at 3:04 p.m. with licensed nursing staff, Employee E11 revealed that the residents in rooms 108A, 109B and 109C were capable of independently turning on the water at the hand sick in their bathrooms without assistance from staff. Continued observation of resident room water temperatures with the Director of Maintenance, Employee E12 on June 14, 2021, at 4:00 p.m. revealed the following hot water temperatures above 110 degrees Fahrenheit: Resident room 200 water temperature was 116 degrees Fahrenheit Resident room 102 water temperature was 114 degrees Fahrenheit Interview conducted with the Nursing Home Administrator on June 14, 2021, at 4:30 p.m. revealed the facility's policy on safe water temperatures was, probably not adequate and that appropriateness of water temperatures should be based on resident comfort rather than a number on a thermometer. The Nursing Home Administrator was unable to explain how a resident who cannot speak for themselves would be able to communicate what a safe or comfortable water temperature would be. Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator and the Director of Nursing (DON) on June 14, 2021, at 6:30 p.m. for failure to ensure that safe hot water temperatures were maintained on the First and Second Floor Nursing units. The Nursing Home Administrator was provided with the Immediate Jeopardy template and an immediate action plan was requested. On June 14, 2021, at 9:26 p.m. the facility provided the following corrective action plan: 1. The facility's water safety policy was immediately updated to include the appropriate hot water temperature of no more than 110 degrees Fahrenheit. In the event the temperature is too hot the staff is to notify the Nursing Home Administrator and Maintenance to take appropriate measures to bring water temperatures below 110 degrees Fahrenheit. The staff will have a second employee take a second temperature to verify if the hot water temperature exceeds 110 degrees Fahrenheit. Until the Maintenance staff can address the issue all use of hot water will immediately halt. The facility will use the overhead system to let the staff know to stop hot water usage. The staff will immediately be educated on the facility's new policy. As the staff come into work, they will immediately be educated on the facility's policy prior to taking their assignment. Staff will be educated to return demonstrate thermometer usage and temperature reading. The staff will be educated to use a thermometer prior to any resident using the shower or being given a bed bath to ensure it is at a safe and comfortable temperature. A temperature log will be created and placed in the shower book. The facility will educate 80% of the staff within 24 hours and 100% of staff within 48 hours. 2. Maintenance adjusted the boiler at 5:00 p.m. and took a temperature in each resident room. All rooms had a temperature below 110 degrees Fahrenheit. The kitchen will use the three-compartment sink to clean all utensils and will serve on plastic until the repair is made. Laundry will use bleach to ensure that all the laundry is sanitized until the repair is made. Maintenance staff will audit all resident rooms twice a day to ensure water temperature is at an appropriate level until the repair is made. The supervisor will audit two rooms per unit every shift to ensure we are at an appropriate temperature until the repair is made. In the event one of the temperatures exceeds 110 degrees Fahrenheit the supervisor will audit five rooms on each unit. 3. The Nursing Home Administrator or designee will audit Maintenance Log and the Supervisor's log twice a day to ensure the temperatures are below 110 degrees Fahrenheit until the repair is made. The Nursing Home Administrator or designee will audit the kitchen and laundry twice per day to ensure the utensils and laundry are being sanitized until the repair is made. 4. Once the repair is made maintenance staff or designee will audit all resident rooms twice a day for two weeks, then twice a day three times a week for two weeks. Then twice a day two times a week for three months. Findings will be presented at our QAPI meetings to make recommendations. Review of the facility's updated policy, Safety of Water Temperatures, dated June 14, 2021, revealed that, Direct-care staff will be educated on the maximum allowable temperature of 110 degrees Fahrenheit. Continued review revealed, Direct-care staff shall use a thermometer prior to a resident taking a shower or going into the tub to make sure it is an appropriate temperature and to report to the Supervisor if the water is above 110 degrees Fahrenheit, and the resident is not to be placed in the shower until the temperature below 110 degrees Fahrenheit. Observation conducted with nursing assistant, Employee E14 on June 15, 2021, at 9:47 a.m. revealed that Employee E14 was unable to read a thermometer. Agency licensed nursing staff, Employee E21, proceeded to described to Employee E14 how to read the thermometer. Interview at the time of the observation with Employee E14 confirmed that she received an in-service but was unable to recall what was taught in the in-service. Employee E14 also stated that no one showed her how to use a thermometer or asked her to complete a return demonstration. Interview on June 15, 2021, at 9:50 a.m. Employee E22, nursing assistant, revealed that she did not have a working thermometer available and was therefore unable to check water temperatures. Interview on June 15, 2021, at 10:07 a.m. with the Nursing Home Administrator revealed that Employee E14 did not complete her in-servicing exam related to the facility's Immediate Action Plan prior to beginning her shift. Observation on June 15, 2021, at 10:23 a.m. revealed that Employee E15, nursing assistant , only had one thermometer available on the nursing unit for checking water temperatures and that the thermometer was attached to the shower and unable to be removed. Employee E15 stated that she was unsure how to obtain an accurate temperature reading using the thermometer. Interview on June 15, 2021, at 10:27 a.m. Employee E13, nursing assistant , stated that no thermometers were provided to staff and that she would have to use her hand to check water temperatures. Employee E13 further stated that she was about to start giving baths/showers to her residents. Interview on June 15, 2021, at 10:34 a.m. with Employee E20, Regional Director of Operations, revealed that the facility purchased new thermometers and that the facility was going to initiate new in-services for staff regarding their usage. Interviews were conducted on June16, 2021, between 9:15 and 9:40 a.m., with nursing staff to verify the implementation of the immediate action plan. Nursing staff were able to verbalize to facility's updated policy, including that water temperatures should not exceed 110 degrees Fahrenheit, what to do if water temperatures were found to be too hot, and how often to check water temperatures. Nursing staff were able to demonstrate proper use of a thermometer for checking water temperatures and that they had sufficient thermometers available for use. Maintenance and Supervisory staff were observed checking water temperatures and completing audit logs. The hot water at residents' hand sinks were tested and verified that they did not exceed 110 degrees Fahrenheit. Water temperature logs were reviewed and revealed appropriate water temperatures. Staff education documentation was reviewed and revealed that the facility in-serviced 90 percent of the facility staff on proper hot water temperatures. Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation, the Immediate Jeopardy was lifted on June 16, 2021, at 12:48 p.m 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, facility documentation, and facility policies and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent accidents resulting in actual harm to Resident R1 who sustained a laceration to the right leg during an unassisted and unsupervised transfer, transfer to the hospital via Emergency Medical Services and requiring 15 sutures to the resident's right lateral lower leg and actual harm to a Resident R2 who eloped from the facility and sustained fractures to three toes for two of 11 clinical records reviewed (Residents R1 and R2). Findings include: Review of facility policy, Falls and Fall Risk, updated January 15, 2020, revealed that for residents who were identified as a fall risk, and who have had previous falls, staff would continue the interventions that have been implemented to prevent further falls. Review of facility policy, Elopement, updated January 2020, revealed that it was the policy of the facility to put measures into place to prevent residents from eloping (leave without staff knowledge) from the facility. Review of the clinical record for Resident R1 revealed an annual Minimum Data Set assessment (MDS-periodic assessment of resident's needs) dated May 28, 2020, indicated the resident had diagnoses of non-Alzheimer's dementia (irreversible, progressive [CONDITION(S)] disease of the brain, resulting in loss of reality contact and functioning ability). Further review of the MDS assessment revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 3, indicating the resident was severely cognitively impaired. Review of the Resident R1's Care Area Assessment (CAA) Summary for the annual MDS of May 28, 2020, indicated that the resident triggered for fall risk as a care need and that a care plan was developed. Review of the resident's care plan with a dated initiated of October 9, 2017, revealed that the resident was at risk for falls. The interventions included for the resident's bed to be placed at a low position, encourage resident to stay in supervised areas, footwear to prevent slipping, self- locking breaks to wheelchair and a define perimeter mattress. Review of a Physical Therapy Evaluation and Plan of Treatment report, dated June 17, 2020, revealed Resident R1 demonstrated weakness in her bilateral (both sides) upper extremities (arms) and bilateral lower extremities (legs); had difficulty with transfers requiring maximum assistance; demonstrated poor cognition with lack of insight of unsafe behaviors; and that the resident was not following commands consistently. The Physical Therapy Evaluation and Plan of Treatment report went on to state that due to the documented physical impairments and associated functional deficits, Resident R1 was at risk for falls. Review of a nursing progress note, dated June 25, 2020, at 11:36 p.m. revealed that a nursing assistant, Employee E3 told the licensed nursing staff, Employee E6 that nursing assistant, Employee E3 went to get another staff member to assist Resident R1 to bed and found Resident R1 sitting on the floor mat, in front of the resident's wheelchair, near the resident's bed. The nursing progress note went on to state that Resident R1 had, forgetfulness per baseline, and that the resident stated that she was transferring self from her wheelchair into bed, lost her balance, and fell on her buttock. Review of a nursing progress note completed by the Director of Nursing, dated June 27, 2020, at 12:42 a.m. regarding the resident's fall on June 25, 2020, revealed that prior to Resident R1 being found on the floor, the resident was left in her room sitting in her wheelchair, that the staff member (Employee E3) left the resident's room to ask another staff member for assistance to transfer the resident from wheelchair to her bed, and that verbal education was provided to staff regarding not leaving Resident R1 unattended in her room. Review of the plan of care for Resident R1 for falls, updated June 27, 2020, indicated that staff were to not leave the resident unattended in the room to prevent future falls. Review of an On-the-Spot Education sheet dated June 30, 2020, revealed that education was provided to Employee E3 that when taking Resident R1 into her room, Employee E3 should ensure all equipment or staff needed is in place prior to entering the room with Resident R1. The education sheet added that, This will prevent you from having to walk away from her [Resident R1], leaving her to attempt to transfer herself. Review of a nursing progress note dated July 14, 2020, at 8:11 p.m. indicated that nursing assistant (Employee E3) assisted Resident R1 to her room to provide HS (medical abbreviation for hours-sleep/bedtime) care, that the resident was a two person assist for transfer, and that the nursing assistant exited the room to obtain assistance of another staff member (to put the resident into bed). The nursing progress note went on to state that upon the nursing assistant's return to Resident R1's room, the resident's right side of her body was, slightly supporting against her bed sliding to the floor with her left hand holding onto the arm of the wheelchair, and that the nursing assistant observed blood on the floor mat. The nursing progress note added that an L shaped skin tear was observed by the licensed nurse on the resident's right leg measuring approximately 20 centimeters (cm) long by 2.0 cm wide with 1.0 cm in depth. The nursing progress note added that a tourniquet (tight band applied in emergencies to stop bleeding) was applied to the resident's right leg, and that Resident R1 was sent to an acute care hospital for evaluation. Review of a nursing progress note, dated July 15, 2020, at 6:31 a.m. revealed the resident returned from evaluation at an acute care hospital with sutures in place to the right lower leg. Further review of nursing progress note, dated July 15, 2020, at 2:40 p.m. stated that Resident R1 received 15 sutures at the hospital for the right lateral (side) lower leg skin tear. Review of a nursing progress note, dated July 15, 2020, at 4:16 p.m. regarding the events surrounding the resident's skin tear on July 14, 2020, indicated that staff (Employee E3) was preparing Resident R1 for bed, left the room to obtain another staff member's assistance with transferring the resident from wheelchair to her bed, and that the resident sustained a semicircular shaped skin tear to her right lateral calf area measuring 23 cm long by 10 cm wide. The nursing progress note went on to state that upon investigation, Resident R1 stated that she recalled trying to move herself closer to the head of her bed, that her right foot got caught between the bed frame and her wheelchair, and that Resident R1 stated, I felt my foot burning but did not think anything of it. Review of an employee witness statement from Employee E3 dated July 14, 2020, revealed Employee E3 took Resident R1 to her room to get her ready for bed while waiting for another staff member to assist Employee E3 with transferring the resident from the wheelchair into her bed. The statement added that when Employee E3 finished washing up the resident, the other staff member had not arrived, that Employee E3 positioned the resident in her wheelchair along the left side of her bed, and informed the resident that Employee E3 was going to get the other staff member. The employee witness statement stated, I [Employee E3] went to room 105 and told [Employee E4, nursing assistant] I was ready. When we returned to the room, we saw the resident holding onto her bed with her upper body on the bed and she was sliding to the floor . After we got her into bed, we observed she was bleeding and had a skin tear to her right calf. Review of a consultant wound nurse progress note, dated July 30, 2020, at 8:37 a.m. revealed that the peri wound (surrounding area around a wound) of Resident R1's right calf skin tear, now with [CONDITION(S)] [redness] and heat, documented a diagnosis of [CONDITION(S)] (bacterial infection involving the inner layers of the skin), and recommended to treat with [MEDICATION(S)] (oral antibiotic medication) 500 mg (milligrams), four times a day, for seven days. Review of a nursing progress note completed by licensed nursing staff Employee, E5, dated July 30, 2020, at 10:35 a.m., revealed Resident R1 was evaluated by the consultant wound nurse for the right leg skin tear with sutures and that per recommendations of the consultant wound nurse, a new physician's order was obtained to administer [MEDICATION(S)] 500 mg, four times a day, for seven days. Telephone interview with the Nursing Home Administrator and Director of Nursing on September 2, 2020, at 3:30 p.m., confirmed Employee E3 was educated on June 30, 2020, to not leave Resident R1 unattended in her room to prevent further falls or injury. The telephone interview additionally confirmed Employee E3 left Resident R1 unattended in her room to obtain assistance from another staff member on July 14, 2020, and that Resident R1 sustained a skin tear to her right lower leg/calf area, requiring sutures, while she was attempting to self-transfer from wheelchair to bed. The facility failed to ensure that Resident R1 received supervision to prevent falls which resulted in actual harm to Resident R1 falling, sustaining a laceration to the the right lower leg/calf area, requiring transfer to an acute care hospital and requiring 15 sutures. Review of the clinical record for Resident R2 revealed a quarterly MDS assessment dated [DATE], indicated the resident had diagnoses on non-Alzheimer's dementia and generalized muscle weakness. Further review of the MDS assessment revealed a BIMS score of 14, indicating that the resident was cognitively intact. Review of a nursing progress note, dated February 14, 2020, at 5:00 p.m. revealed Resident R2 was observed by a staff member at a McDonald's restaurant (located 0.4 miles from the facility per [NAME] Maps), that the resident returned to the facility, and that a Wanderguard (bracelet that alarms doors and alerts staff of the wearer exiting through the sensored doors) was placed on the resident. Review of Resident R2's plan of care dated initiated February 15, 2020, revealed the resident was an elopement risk due to elopement on February 14, 2020, that staff would check placement and function of the Wanderguard every shift, and that staff would redirect the resident if an elopement attempt is made. Review of a nursing progress note dated February 15, 2020, at 8:30 a.m. revealed Resident R2, cut off his wanderguard. States, 'It took me 10mins [sic] to cut it off.' Seen placing it in his right jacket pocket. Review of a nursing progress note dated February 15, 2020, at 10:05 a.m. revealed the Wanderguard was placed on Resident R2's left ankle but that, resident wasn't happy, stated: take it off. I didn't run away yesterday, I went to RiteAid (pharmacy) to get candy for someone. Resident said: If you leave this thing on, I will tear it off. Review of a nursing progress note dated February 15, 2020, at 6:30 p.m. revealed Resident R2 removed his Wanderguard bracelet, that the resident admitted to removing the device, and that he promised not to run away, stating, I made a mistake. Review of the psychiatric certified registered nurse practioner (CRNP) progress note dated February 18, 2020, at 5:09 p.m. indicated that staff reported to the CRNP that Resident R2 recently walked out of the facility, was found down the street unattended and unharmed, and that the resident stated that he did not elope and just wanted to go to purchase candy. The CRNP psych progress note went on to state that Resident R2 had some forgetfulness but easily re-directed, and recommended that if staff suspect further elopement risk or attempt, transfer resident to the second floor to minimize risk. Review of a nursing progress note by Employee E7, Licensed Practical Nurse, dated August 8, 2020, at 10:43 a.m. revealed Resident R2 was witnessed by Employee E7, punching security code to front door, that Employee E7 put a work order in for the code to be changed, and that, This patient is none compliant [sic-non compliant] with safety precautions and is high risk for safety to self. Review of a nursing progress note dated August 8, 2020, at 12:30 p.m. by Employee E7 revealed that Resident R2 was witnessed by Employee E7, punching in security code to get back into building, and that, Security code needs to be changed immediately for pt. [patient] safety. Review of a nursing progress note dated August 8, 2020, at 1:30 p.m. by Employee E5 revealed that there were safety concerns due to Resident R2's ability to exit the building, that this was addressed with administration, and that, Door codes will be changed next week. Resident remains under close supervision. Advised resident to report to charge nurse when he leaves/return to floor, also sign in/out when exiting bldg [building]. Resident remains AAOx3 [awake, alert and oriented to person place and time]. Review of a nursing progress note by Employee E5, Registered Nurse dated August 9, 2020, at 6:53 p.m. revealed, At about 5 pm resident reported to staff that he is going to ground floor kitchen to talk to manager, he got on elevator independently as usual. After 15-20 min resident fail to return to floor. Search of bldg. initiated and shortly thereafter resident was found walking on the parking lot up the hill toward to bldg. entrance of 1st floor. Resident was escorted inside of bldg. where he told staff that he didn't want to wait for the elevator, instead walk out to parking lot. Review of a nursing progress note by Employee E7, Licensed Practical Nurse, dated August 10, 2020, at 6:32 a.m. revealed Resident R2, Knows security code to getting in and getting out of building through all exits except emergency exit. Administration aware to change code. Review of a nursing progress note by Employee E8, Registered Nurse, dated September 6, 2020, at 6:52 a.m. indicated that Resident R2 was reported missing from his room at 4:30 a.m., and that he was last seen in the hallway on the first floor at 3:30 a.m. by staff. Review of a nursing progress note by Employee E5, Registered Nurse, dated September 6, 2020, at 1:07 p.m., revealed Resident R2 returned to the building at approximately 12:00 p.m., on September 6, 2020. Review of a nursing progress note by the Director of Nursing dated September 6, 2020, at 5:03 p.m., indicated that Resident R2, left his room staged with bedding and a pair of shoes in place to indicate as if he is sleeping. Bedding was and fully covered with only the shoes exposed. Review of the information submitted by the facility dated September 6, 2020, revealed that Resident R2 was located 17 miles from the facility (per [NAME] Maps), by his family at approximately 10:15 a.m. on September 6, 2020 (seven hours from when Resident R2 was last at 3:30 a.m. by staff). The information added that when Resident R2 was interviewed by staff regarding his elopement, he stated that within a block or two of leaving the facility, someone driving by stopped and gave him a ride to his home town, and this was not someone the resident knew. Review of a nursing progress note dated September 6, 2020, at 9:06 p.m., revealed Resident R2's dorsum (top) area of his right foot was noted with redness and [CONDITION(S)] (swelling), with the resident stating that he hit his foot against a rock when he was leaving the facility earlier. Review of a nursing progress note dated September 7, 2020, at 3:07 p.m., revealed Resident R2's right foot was mildly swollen with redness noted to dorsum area of right foot, and noted limping when walking. Review of a nursing progress note dated September 7, 2020, at 6:51 p.m., revealed an x-ray was performed on the resident's right foot and revealed acute (new) or subacute (unknown age) fractures of the second, third and fourth metatarsal bones (bones of the mid-foot, one located on each of the three middle toes). Further review of the clinical record revealed no documentation that after Resident R2's attempt to elope from the building using the punch-key pads on August 8 and 9, 2020, that the resident was reassessed for elopement risk and evaluated to possibly move to the second floor to minimize future elopement risk as recommended by the psych CRNP on February 18, 2020. Interview with the Nursing Home Administrator on September 18, 2020, at 2:30 p.m., revealed the security code to all exit doors with a punch-key pad was changed on August 10, 2020, (after Resident R2's elopment attempts on August 8 and 9, 2020) and was the last time that code was changed. Further interview with the Nursing Home Administrator and Director of Nursing on September 18, 2020, at 4:30 p.m., confirmed that Resident R2, a resident with a history of obtaining and using the facility's punch-key code to exit the building, eloped from the facility sometime between 3:30 a.m. and 4:00 a.m. on September 6, 2020, had exited the building by operating the electronic punch-key lock to disable the alarm on the door, was found by family members in another city approximately 17 miles from the facility, and sustained fractures of three bones in the resident's right foot. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of clinical records, facility policies and procedures, facility documentation and interviews with residents and staff it was determined that the facility failed to adequately assess and monitor to ensure acceptable parameters of nutritional status were maintained for one of 18 residents reviewed (Resident R20). Findings include: Review of facility policy, Weight Assessment and Intervention Created: (MONTH) (YEAR), revealed any weight change of 5% or more since the last weight assessment will be retaken the next day; and that a weight loss of more than 5% in one month is severe; and that the physician and multidisciplinary team will identify conditions and medication that may be causing the anorexia, weight loss or increasing the risk of weight loss; and that the multidisciplinary individualized care plan shall address the identified causes of weight loss, goals and benchmarks for improvement and timeframe and parameters for monitoring and reassessment; and that interventions for undesirable weight loss should consider resident choice, nutrition needs, functional and environmental factors affecting eating status and chewing and swallowing abnormalities and the need for diet modification. Review of the clinical record for Resident R20 revealed a Quarterly Minimum Data Set assessment (MDS- periodic assessment of resident's needs), dated (MONTH) 2, (YEAR), indicating [DIAGNOSES REDACTED]. The MDS also revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 11 indicating moderate cognitive impairment. The MDS additionally indicated that Resident R20 required supervision (oversight, encouragement or cueing) for self-performance with eating and required support of one staff persons physical assistance during meals. The MDS also revealed that the resident required a mechanically altered diet (change in texture of food or liquids). Review of the clinical record for Resident R20 revealed a (MONTH) 3, (YEAR) weight of 161.4 Lbs and a (MONTH) 2, (YEAR) weight of 142.3 Lbs for an unintended weight loss of 19.1 lbs or 11.8% in one month for a severe weight loss. Interview with Resident R20 confirmed the weight loss with the resident stating he is having problems eating due to missing his upper dentures and having difficulty with his mechanical soft diet. Resident states he is not having a problem with his appetite, but rather he cannot chew without his upper dentures. Review of Resident R20's clinical record revealed a (MONTH) 21,2017 Care Plan for nutritional risk related to [MEDICAL CONDITION], history of decreased oral intake and the need for a mechanically altered diet, however the last update for Goals and Interventions was (MONTH) 04, (YEAR) which included monitoring weight and meal consumption. Interview with the Dietitian, Employee E4 on (MONTH) 28, (YEAR) at 12:45 p.m., confirmed that she was unaware of the 19.1 lb weight loss, stating it was her second day at the facility. Review of Resident R20's clinical record revealed a Nutrition Note dated (MONTH) 28, (YEAR), at 2:00 p.m. (after the above interview) which addressed the resident's missing dentures and difficulty eating, but not the severe weight loss and did not suggest updating the nutrition care plan, but rather requested the Food Service Director and the Speech Therapist follow up with the resident to update preferences and ensure a safe diet consistency. The last nutrition progress note prior to this survey was written on (MONTH) 3, (YEAR) when the previous dietitian noted a current body weight of 160.1 lbs. Interview with Nursing Home Administrator (NHA), Employee E1, on (MONTH) 28, (YEAR) at 1:30PM confirmed that the facility had been without a clinical dietitian since early May, (YEAR) and that the current Dietitian, Employee E4, works at the facility one day a week and had started the previous week. Further review of Resident R20's medical record revealed a (MONTH) 12, (YEAR) Nursing Note stated a re-weight obtained today at 148.6 lb, verified by this nurse. Resident stated I'm losing weight. There was no referral to a dietitian or physician available to review. The facility failed to adequately and accurately assess, monitor and intervene to maintain Resident R20 acceptable parameters of nutritional. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 4/1/16 and 5/10/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 4/1/16 and 5/10/17. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/1/16 and 5/10/17. 28 Pa. Code 211.10(c) Resident care policies Previously cited 4/1/16 and 5/10/17. 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 4/1/16 and 5/10/17. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 4/1/16 and 5/10/17.

Based on a clinical record review, review of facility documentation, and interviews with facility staff, it was determined that the facility failed to ensure that a resident with a history of suicide attempts was provided with psychosocial services to prevent a suicide attempt that resulted in actual harm for one of one resident reviewed (Resident R1). Findings include: Review of Resident R1's clinical record on [DATE], revealed admission physician's orders [REDACTED]. Review of the clinical record for Resident R1, revealed the "Pennsylvania Preadmission Screening Resident Review Identification Form", (PA-PASRR-ID), dated February 27, 2014, which indicated that Resident R1, had a targeted [DIAGNOSES REDACTED]. Review of the facility's Psychosocial History/Assessment for Resident R1, dated February 28, 2014, indicated Relevant Health History for Resident R1, depression with history of suicide attempts. An interview with Employee E3, Social Worker, on [DATE], at 2:30 p.m., revealed that this information was identified during the admission process for Resident R1. Employee E3, indicated that Resident R1, attempted suicide on February 17, 2014, prior to being admitted to the facility and presented to the hospital with an overdose [MEDICATION NAME](sleeping pill). Further review of the Psychosocial History/Assessment also indicated that in [DATE], Resident R1, attempted suicide. Review of the clinical record for Resident R1, revealed a nursing note dated [DATE], that indicated Resident R1 was displaying signs of depression. An interview with Employee E5, Licensed Nurse, on [DATE], at 12:35 p.m., confirmed in an interview that no follow up was taken by the facility when Resident R1 was displaying signs of depression. Review of clinical documention revealed the initial facility Psychiatric Evaluation for Resident R1, was on [DATE], by the CRNP, (Certified Registered Nurse Practicioner). The CRNP indicated that Resident R1 had a past history of a suicide attempt, depression, [MEDICAL CONDITION] and anxiety. Resident R1 was found to be withdrawn, stating, "don't want to be here" and prefers to stay in room. The staff reported to the CRNP that Resident R1 had a depressed mood and self isolates. The CRNP recommended, and the physician agreed to, increase [MEDICATION NAME] (antidepressant) to 30 mgs a day, for [MEDICAL CONDITION] and encourage socialization and activities. Further review of the clinical record revealed a social service note dated [DATE], which indicated Resident R1 expressed symptoms of depression. A second psychiatric consult and treatment was ordered on [DATE], secondary to severe anxiety, history of suicidal attempts and adjustment. This was completed on [DATE]. Nursing staff indicated a concern in Resident R1's mood. Review of clinical documentation revealed that the psychiatric consult was not completed for 17 days until Resident R1 was seen by the Psychiatric CRNP. At this time staff reported that Resident R1 was preoccupied, "down" mood and anxious about housing and financial concerns. Resident R1 stated to the CRNP, "I want to get out of here". The CRNP recommended to the staff to monitor Resident R1 for mood changes. There was no evidence that the psychiatrist conducted any onsite visit with the resident or that there was any other psychosocial interventions initiated for Resident R1. An interview with Employee E5, on [DATE], at 1:10 p.m., confirmed that no further psychosocial interventions were offered to Resident R1 after [DATE]. Review of the Facility Investigation dated [DATE], revealed a written statement by Employee E6, Nurse Aide, which indicated that Resident R1, commented to Employee E6, that two other residents were going home, but not her. Employee E6, told Resident R1, "Hang in there". Interviews with Employees E5, Licensed Nurse, E7 and E8, Nurse Aides, and E3, Social Worker, during the onsite visit on [DATE], at 1:45 p.m., described Resident R1, as one that always stayed to self, in room or sitting on the porch smoking and would often indicate to staff about, "Did not want to be here". The facility did not identify, assess and monitor the need for psychosocial services for one resident with a history of multiple suicide attempts which resulted in another suicide attempt and actual harm to Resident R1. An interview with Employee E4, Licensed Nurse, on [DATE], at 1:05 p.m., revealed that Resident R1 had been transferred to the hospital following a suicide attempt on [DATE], where Resident R1 required 18 units of blood at the hospital and also had to be placed on a ventilator (a machine that breathes for you). A telephone interview with the Nursing Home Administrator on [DATE], at 2:10 p.m., revealed that Resident R1 had expired during the evening of [DATE]. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services

Based on review of a clinical record, review of facility documentation and interviews with facility staff, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of a resident identified as a risk of suicide and a history of previous suicide attempts, resulting in actual harm for one of one resident (Resident R1). Findings include: Review of Resident R1's clinical record on [DATE], revealed admission physician's orders [REDACTED]. Review of the facility's Psychosocial History/Assessment for Resident R1, dated February 28, 2014, indicated Relevant Health History for Resident R1, depression with history of suicide attempts (via medications). An interview with Employee E3, Social Worker, on [DATE], at 2:30 p.m., revealed this information was identified during the admission process for Resident R1. Employee E3 indicated that Resident R1 had attempted suicide on February 17, 2014, and presented to the hospital with an overdose of Ambien (sleeping pill). Further review of the Psychosocial History/Assessment also indicated that in [DATE], Resident R1, attempted suicide. Further review of the clinical record revealed a nursing note dated [DATE], written at 8:00 p.m., which indicated that Resident R1, was found lying on the bathroom floor bleeding profusely, with two open parallel wounds to the left inner forearm. The first one measured approximately 10.0 cm x 1.0 cm and the second one measured 9.0 cm x 0.5 cm. The right inner forearm had one parallel wound measuring approximately 7.0 cm x 1.0 cm. Per an interview with Employee E4, Licensed Nurse, on [DATE], at 1:05 p.m., who was the Nurse Manager on duty at the time of the incident, revealed that Resident R1 kept repeating, "I want to die", while using the razor to cut herself. An interview with Employee E1, the Nursing Home Administrator, on [DATE], at 2:45 p.m., revealed that Resident R1, had in her possession, three single blade razors, the kind that would be used with a paint scrapper, and several other hazardous items. The razors were found by a Police Officer at the time of the incident in Resident R1's bathroom. An interview with Employee E4, Licensed Nurse, on [DATE], at 1:05 p.m., revealed that Resident R1 had received 18 units of blood at the hospital and also had to be placed on a ventilator (a machine that breathes for you). Review of Golden LivingCenter - Rosemont Admissions Booklet, dated [DATE], page 13, indicates that residents are not permitted to have in their possession items such as razor blades or any other item that could be considered a weapon or cause injury to residents or the staff. Review of an internal audit of the environment for potential safety issues dated [DATE], revealed that the nursing and social service staff found numerous residents to have in their possession such things as, razors, scissors, push pins, over the counter medication and nail polish remover. An interview with Employee E5, Licensed Nurse, on [DATE], at 1:35 p.m., revealed that most of the residents found with potential safety items were cognitively impaired. A telephone interview with the Nursing Home Administrator on [DATE], at 2:10 p.m., revealed that Resident R1 had expired during the evening of [DATE]. The facility failed to supervise and monitor this resident's safety to prevent an attempt of suicide resulting in actual harm to Resident R1. 28 Pa. Code: 201.18(a)(1) Management. 28 Pa. Code: 211.11(a)(c) Resident Care Plan. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services.