Every finding on record at Sherwood Oaks

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions during high contact activities and failed to follow hand hygiene procedures during a dressing change for one of two residents (Resident R6).Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) Policy last reviewed 3/3/25, indicated team members are required to use gown and gloves during high-contact resident care activities that might result in transfer of Multi Drug Resistant Organisms (MDROs) to staff hands and clothing. Examples of high contact resident care activities requiring a gown and gloves for EBP include transfers. EBP should be in place for the resident's entire stay in the community unless the wound closes. Review of the facility policy Handwashing/Hand hygiene last reviewed 3/3/25, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. For washing hands, vigorously lather hands with soap and water and rub them together, creating friction, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry towel. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), muscle wasting and atrophy, and Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues). Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/3/26, revealed the diagnoses were current. Review of Resident R6's physician order dated 2/13/26, indicated to cleanse the left heel wound with normal saline solution (wound cleanser), pat dry, apply veris dressing (an advanced wound care product that combines collagen and Manuka honey) to wound bed. Cover with abdomen and wrap and Kling every day. Review of Resident R6's physician order dated 2/17/26, indicated to implement Enhanced Barrier Precautions. During an observation on 2/18/26, at 7:40 a.m. the Director of Nursing (DON) and Registered Nurse (RN), Employee E1 failed to implement Enhanced Barrier Precautions to transfer Resident R6 from the wheelchair to recliner in his room. During an observation of Resident R6's wound dressing change on 2/18/26, at 7:43 a.m. RN, Employee E1 failed to follow proper hand hygiene procedures for seven of seven opportunities. RN, Employee E1 failed to ensure handwashing was completed for a minimum of 20 seconds. RN, Employee E1 failed to turn off faucets with a clean, dry paper towel for two of seven occasions. During an interview on 2/18/26, at 8:00 a.m. RN, Employee E1 and the DON confirmed the facility failed to follow enhanced barrier precautions during transfers and failed to follow hand hygiene procedures during a dressing change for one of two residents (Resident R6). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of seven residents (Resident R1) identified as having a high risk for wandering. Findings include: Review of the facility policy Skilled Nursing-Elopement and Wandering Policy dated 2/7/25, indicated this community ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The community is equipped with door locks/alarms/wander management systems to help avoid elopements. Alarms are not a replacement for necessary supervision. Team members are to be vigilant in responding to alarms in a timely manner. The community shall establish and utilize a systematic approach to identifying, monitoring and managing residents at risk for elopement or unsafe wandering, including assessment of risk. Review of the facility policy Skilled Nursing-Comprehensive Care Plans dated 2/7/25, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/3/25, indicated the diagnoses of altered mental status, encephalitis (inflammation of the brain), and unspecified lack of coordination. Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of three - severe cognitive impairment. Section GG0170 Mobility indicated Section I walk ten feet required partial to moderate assistance. Review of Resident R1's Elopement evaluation, upon admission, dated 5/30/25, at 9:37 p.m. indicated the following:-History of elopement while at home: No.-Does the resident have a history of elopement or attempted leaving the facility without informing staff: No.-Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No.-Does the resident wander: No.-Is the wandering behavior a pattern, goal directed: Blank.-Does the resident wander aimlessly or non-goal directed: Blank.-Is the resident's wandering behavior likely to affect the safety or well-being of self/others: No.-Is the resident's wandering behavior likely to affect the privacy of others: No.-Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation: No.-Score of one or higher indicates risk of elopement-Risk for wandering/elopement identified: blank. Review of Resident R1's Elopement evaluation, dated 6/5/25, at 11:10 a.m. indicated the following:-History of elopement while at home: No.-Does the resident have a history of elopement or attempted leaving the facility without informing staff: No.-Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No.-Does the resident wander: Yes.-Is the wandering behavior a pattern, goal directed: Yes.-Does the resident wander aimlessly or non-goal directed: Yes.-Is the resident's wandering behavior likely to affect the safety or well-being of self/others: Yes.-Is the resident's wandering behavior likely to affect the privacy of others: Yes.-Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation: Yes.-Score of one or higher indicates risk of elopement-Risk for wandering/elopement identified: blank. Review of Resident R1's physician orders dated 6/5/25, indicated wander guard check function every shift. Wander guard check placement every shift - placement right lower leg. Review of Resident R1's care plan dated 6/25/25, (twenty days later) indicated the resident is at risk for wandering/elopement per wander risk assessment. Goal - the resident's safety will be maintained. Interventions - engage resident in purposeful activity. Provide care in a calm and reassuring manner. Provide clear, simple instructions. Provide reorientation to surroundings and environment. The resident is at risk of disorientation while on skilled due to being an independent living resident of the community prior to skilled admission. The resident is reoriented to skilled as the current living arrangement and updated on the situation. Review of Resident R1's progress notes indicated the following:-6/5/25, at 11:22 a.m. Resident wandering in the hall looking for the exit to the main building. Resident stated they were looking for the place where all the people and activity took place. Resident was not able to be redirected. Resident not able to answer questions appropriately. Elopement assessment was completed and a wander guard placed on the left ankle.-6/5/25, at 3:01 p.m. resident has confusion to the level of reality. Resident is not on the same level as questions asked. Staff spent 15 minutes with resident during a conversation/assessment and the only questions resident answered yes to were, liking dogs and church. Resident is friendly but has difficulty remaining for duration and comprehension of some activities. -6/6/25, at 12:05 p.m. physician note - resident remains confused since baseline. Resident is alert answering questions vaguely. Acute confusion- temporal lobe abnormalities (usually manifested in neurological and cognitive issues and can contribute to memory problems, language difficulties and psychiatric symptoms).-6/6/25, at 2:17 p.m. resident was wandering this shift stated needing to go to first floor. Redirected to environment and was able to redirect resident effectively.-6/7/25, at 2:10 p.m. resident is happy, smiling, fidgety, and wandering. Resident having increased confusion and exit seeking this shift. Education given and was understanding but can be forgetful. -6/8/25, at 2:49 p.m. resident is happy, pleasant, and wandering. Wandering this shift but effective with redirection.-6/9/26, at 11:37 a.m. resident is pleasant, smiling, wandering, and confused. Looking for father. While looking at the bulletin board resident stated if you call the Ombudsman (individual who investigates and helps resolve complaints) that was the resident's father. Confused and unable to redirect. Answers questions inappropriately. Wanders the halls and tried to sign out but not sure where to go.-6/10/25, at 9:42 a.m. resident is happy and wandering. Alert to self with baseline confusion. -6/11/25, at 10:57 a.m. physician note acute confusion- temporal lobe abnormalities. No significant improvement in cognition to date. The patient is physically able to participate with therapies but needs step by step, constant cues to complete tasks. -6/11/25, at 1:43 p.m. resident was wandering this shift. Multiple redirections made and were effective. Resident did self-transfer this shift three times. Redirected, but is forgetful. -6/12/25, at 2:23 p.m. happy and wandering. Self-transferred four times this shift. Redirection provided. Resident is forgetful. Wander guard in place.-6/13/25, at 2:43 p.m. pleasant and wandering. Wandering into rooms this shift. Redirection given multiple times and effective. Out of bed at this time wandering.-6/16/25, at2:15 p.m. wandering noted this shift with redirection successful. -6/17/25, at 1:30 p.m. pleasant and wandering. Resident does wander but is easily redirected.-6/18/25, at 1:47 p.m. pleasant and wandering. Resident did wander but was easily redirected.-6/19/25, at 11:44 a.m. of note patient intermittently wandering into other rooms as she is easily disoriented, requiring frequent reorientation.-6/21/25, at 2:11 p.m. pleasant and wandering. Wandering unit but easily directed.-6/22/25, at 2:23 p.m. wandering unit but easily redirected.-6/23/25, at 2:26 p.m. resident remains confused.-6/25/25, at 4:08 p.m. call placed to resident's family. Notified of resident's elopement from the skilled unit. Physician also notified. Review of facility provided documentation dated 6/25/25, at 8:35 a.m. Resident R1 independently navigated off the skilled unit to the lower level of the community center from timeframe of 8:35 a.m. - 8:46 a.m. During this time the resident was previously identified as a wander risk and had a wander management bracelet in place. Assessed with no injuries. Review of Nurse Aide (NA) Employee E1's signed statement form dated 6/25/25, indicated staff saw Resident R1 in the wheelchair on the [NAME] Hall wheeling around the unit. Staff then started providing care to another resident. Review of NA Employee E2's signed statement form dated 6/25/25, indicated staff member came out of a resident room and upon leaving approximately at 8:35 a.m. staff witnessed Resident R1 wheeling independently through the doors on the Founders hallway. Resident indicated being okay. Dietary staff member was right behind resident and guided the resident back inside the skilled unit. Review of NA Employee E3's signed statement form dated 6/25/25, indicated staff member was informed of the incident by another staff member, and did not witness the event; however, did observe resident going down [NAME] Hall in the wheelchair around 7:15 a.m. that morning. Review of Licensed Practical Nurse (LPN) Employee E8's signed statement form dated 6/25/25, indicated Resident R1's last known location was at the nurses station. Review of NA Employee E4's signed statement form dated 6/25/25, indicated staff member wasn't aware Resident R1 was off the unit and didn't hear the alarm go off when resident left the unit. Review of NA Employee E5's signed statement form dated 6/25/25, indicated staff member observed Resident R1 sitting near the elevator around 8:30 a.m. and the alarm was not sounding when resident was sitting there. Review of Registered Nurse (RN) Employee E6's signed statement form dated 6/25/25, indicated staff member observed Resident R1 hanging out near the medication cart with RN for some time this morning, and at some point, resident was noted to be headed away toward the [NAME] Hall. RN continued to pass medications and was not certain to the exact time, but it didn't seem like a long time until RN observed Resident R1 being brought to the unit by another staff member indicating they were bringing resident back. Resident got out the doors, even with the wander guard on. Staff member indicated they were unaware how Resident R1 got out and asked staff to try to keep an eye on resident and keep resident down on this end. Review of RN Employee E7's signed statement form dated 6/25/25, indicated staff member was the RN on the Founder's hall at the time of the event. RN was in the middle of medication pass between 7:30 a.m. and 9:30 a.m. RN did not see Resident R1 until resident returned to the unit through the Founder's Hall entrance. Interview on 8/12/25, at 12:35 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 6/25/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 8/12/25, at 3:55 p.m. an immediate action plan was received and accepted which included the following interventions:Immediate action:-Resident was assessed post elopement when returned to the unit on 6/25/25. No signs or symptoms of any adverse effects from time off the unit.-Resident's care plan was updated to reflect the elopement.-Physician and family notified.-Root cause of elopement - a staff member turned off the wander guard system for the elevator, triggered by another resident without confirming other wandering residents were not in the vicinity. A resident entered the elevator with a disabled alarm. System Correction:-All nursing staff were re-educated on knowing who is in your surroundings when disabling an alarming wander guard.-Wander guard system was reassessed on 6/25/25, by the Maintenance Director. Zone and reset times were adjusted to lower settings to allow for faster system resetting.-All residents will be reassessed by the nursing department for elopement risk, completed by 8/13/25. Plan of care will be updated as indicated. For residents who require updated plans of care, physician and families will be notified.-The policies surrounding elopement risk and wander guard use have been reviewed by the Nursing Home Administrator and Director of Nursing.-All staff will be re-educated on elopement risk and assessments, care plans, supervision of residents and precaution when resetting the wander guard alarm by the DON/designee by 8/13/25.-Facility will review the incident in an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting completed by 8/13/25. Monitoring:New admissions will be audited by the DON/designee weekly for four weeks, monthly for two months to ensure elopement assessments are completed and care plan updated as required. Findings of audits will be submitted through facility QAPI program. Verification of the facility's Corrective Action Plan revealed all elements of plan were met as follows:-Resident R1 was returned to the unit and assessed without injuries. Care plan was updated on 6/25/25, to include engage Resident in purposeful activity. Provide care in a calm and reassuring manner. Provide clear, simple instructions. Provide reorientation to surroundings and environment. The pt is at risk of disorientation while on skilled due to being an independent living resident of campus prior to her admission. The pt is reoriented to skilled as her living arrangements and updated on her situation. -Physician and family were notified on 6/25/25.-Root cause identified as a staff member turned off the wander guard system for the elevator triggered by another resident without confirming other wandering residents were not in the vicinity. Resident R1 entered the elevator when it was disabled of an alarm.-74 of 79 Staff in all departments were re-educated on knowing who is in your surroundings when disabling an alarming wander guard and increasing supervision of exit seeking residents, how to complete the elopement risk assessment, and steps taken once a resident is identified as an elopement risk.-31 in person interviews confirmed training, 21 read receipt via education email, 74 employee signatures received education and ten telephonic calls attempted receiving four confirmations of training and understanding.-Zone and reset times were adjusted to lower settings to allow for faster system resetting on 6/25/25, by the maintenance director.-32 of 32 residents were assessed for elopement risk.- Six of 32 residents at risk for elopement care plans were reviewed or updated. Zero new elopement risk residents were identified. Zero physicians and families required notification of newly identified elopement risk residents.-The policies around elopement risk and wander guard use have been reviewed by NHA and DON on 8/13/25.-The incident was reviewed during an ad hoc QAPI meeting completed on 8/13/25.-The audit tool for future monitoring of new admissions was reviewed and appropriate. The Nursing Home Administrator was made aware the Immediate Jeopardy was lifted on 8/13/25, at 2:35 p.m. Interview on 8/13/25, at 2:35 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement. This failure created an immediate jeopardy situation for one of seven residents (Resident R1) identified as having a high risk for wandering. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include:The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.The job description for the Director of Nursing specified the primary purpose of the job position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times. Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation. The facility failed to provide fundamental principal that apply to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and facility policies. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medications carts (West cart, Founder Cart, and Lake Cart). Findings include: Review of the facility policy Disposition of Medications dated 2/7/25, indicated medications that are no longer required for example, expired medications should be dispositioned as indicated. Observation on 3/4/25, at 8:14 a.m., the [NAME] medication cart revealed the following medication stored improperly: -Ipratropium/albuterol (an inhaled medication to breathe easier) with a multi-dose foil package opened and without a date. Interview on 3/4/25, at 8:14 a.m., Registered Nurse (RN) Employee E2 confirmed that the medication should have been dated when opened and was stored improperly. Observation on 3/4/25, at 8:37 a.m., the Founder's medication cart revealed the following medication stored improperly: Ipratropium/albuterol with a multi-dose foil package opened and without a date. Interview on 3/4/25t, at 8:37 a.m., Licensed Practical Nurse (LPN) Employee E3 confirmed the medication should have been dated when opened and was stored improperly. Observation on a.m., the Lake medication cart revealed Xdemvy eye drop container (used to treat blepharitis- mites live on the skin) opened and without a date. Interview on 3/3/25 at 10:54 a.m., RN Employee E4 confirmed that the medication should have been dated when opened and was stored improperly. Interview on 3/6/25, at 12:45 p.m., the Director of Nursing confirmed that the facility failed to properly store medications in three of four medications carts (West cart, Founder Cart, and Lake Cart). 28 Pa. Code: 211.10(c.) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two of five residents (Residents R13 and R23). Findings include: Review of facility policy SRC-Resident Centered Care Plan-6.0, dated 2/7/25, indicated that the facility will develop a plan of care that is tailored to the resident's specific wishes and clinical care needs and in keeping with the resident and family's overall goals of care; to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. The care plan will be individualized for each resident based upon all available resident-specific information. The care plan is formally reviewed and completed within 21 days after admission at the Interdisciplinary Care Plan Conference and communicated to appropriate staff. The care plan is reviewed and updated at least quarterly, and is based on ongoing assessment and evaluation of resident needs and goals of care. It may specifically be reviewed and updated as the resident's condition changes. A review of the clinical record revealed Resident R13 was admitted to the facility on [DATE], with diagnoses that included diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), high blood pressure, and stroke (damage to the brain from an interruption of blood supply). A review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/27/24, indicated the diagnoses remain current. Review of Resident R13's physician order dated 11/18/24, indicated Dexcom G7 Receiver Device (Continuous Glucose System Receiver) inject one device subcutaneously (fat layer) in the morning every 10 days. May change every 12 hours as needed for dislodgement or malfunction. A review of the clinical record failed to reveal a person-centered care plan was developed for Resident R13 to address goals and interventions relating to Dexcom G7 Receiver Device (Continuous Glucose System Receiver) as required. Interview on 3/4/25, at 2:40 p.m. the Director of Nursing confirmed the clinical record failed to reveal a person-centered care plan for Resident R13 to address goals and interventions relating to Dexcom G7 Receiver Device (Continuous Glucose System Receiver) as required. A review of the clinical record revealed Resident R23 was admitted to the facility on [DATE], with diagnoses that included Parkinsonism (a clinical syndrome characterized by tremor, bradykinesia [slowed movements], rigidity, and postural instability), chronic pain syndrome (a condition where people experience symptoms beyond pain alone, such as depression and anxiety, which interfere with their daily lives), and polyneuropathy (a condition in which a person's peripheral nerves are damaged). A review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS Section N: Medications, Question N0415 indicated Resident R23 received antiplatelet medication seven days a week. Review of Resident R23's physician order dated 10/16/24, indicated Clopidogrel (Plavix - medication used to prevent heart attacks and strokes in person's with heart disease) tab 75 mg (milligrams) one time a day for CVA (cerebrovascular accident) prophylaxis related to transient cerebral ischemic attacks and related syndromes. A review of the clinical record failed to reveal a person-centered care plan was developed for Resident R23 to address goals and interventions relating to antiplatelet medication (Plavix) usage for CVA prophylaxis. During an interview on 3/5/25, at 10:38 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that Resident R23's care plan failed to contain goals and interventions relating to antiplatelet medication use. During an interview on 3/5/25, at 12:45 p.m., the Director of Nursing (DON) confirmed that the facility failed to develop comprehensive care plans to meet resident care needs for two of five residents (Residents R13 and R23). 28 Pa. Code 211.10(c.) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow physician orders for a lab test for one of four residents (Resident R31). Findings include: Review of the facility policy Physician Orders dated 2/21/24, indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. To ensure that the residents receive all medications and treatments that are ordered by the physician in a timely manner. Review of the admission record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/27/24, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and atrial fibrillation (irregular heart rhythm), and long-term use of anticoagulant (used to prevent and treat blood clots in blood vessels and the heart). Review of physician's order dated 11/5/24, indicated Coumadin (an anticoagulant medication) 3 mg (milligrams) one tablet every Tuesday, Thursday, Saturday, and Sunday in the evening, and Coumadin 4mg one tablet every Monday, Wednesday, and Friday in the evening. Review of Resident R31's Medication Administration Record indicated the coumadin was being given as ordered in November 2024, and December 2024. Review of Resident R31's coumadin flow sheet dated 10/21/24, indicated the INR (International Normalized Ratio lab values - measures how long it takes for blood to clot) was 2.3 with physician orders to recheck in one month. Review of Resident R31's physician order indicated the recheck INR should have been completed on 11/14/24. Review of facility provided documentation dated 12/27/24, indicated the INR ordered for 11/14/24, was not correctly transcribed in the electronic health record and therefore; was not obtained as ordered. Review of Resident R31's progress note dated 12/20/24, at 9:10 p.m. indicated staff observed miscellaneous bruises on resident arms and back. Resident indicated she bumps into bed while attempting to get into closet. Bruises easily no complaints of pain or discomfort. Review of Resident R31's progress note dated 12/25/24, at 1:06 p.m. indicated staff reported new bruise to resident's rear right flank (side of the back, below the ribs and above the hips). Resident takes blood thinners and has a history of easy bruising. Review of Resident R31's progress note dated 12/26/24, at 2:30 a.m. resident complaints of nausea and vomited small amounts of coffee ground emesis (vomit). Resident is pale and stated she isn't feeling well. Denied abdominal pain. Resident takes coumadin routinely, obtained INR with machine which read >8.0. Physician on call indicated to give Vitamin K (used to treat bleeding) 10ml (milliliters) intramuscularly times one dose and send to the emergency room . Review of Resident R31's emergency room information indicated the INR level to be 10.7 (extremely high). Review of facility provided documentation dated 12/27/24, indicated the root cause of the residents high INR was associated with the missed INR testing from 11/14/24. Review of physician history and physical note dated 1/8/25, at 12:57 p.m. as late entry for 1/7/25, readmission to the facility from coagulopathy (a condition that prevents the blood from clotting properly), and hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain). Interview on 3/5/25, at 9:21 a.m. the Director of Nursing confirmed the facility failed to follow physician orders for a lab test for one of four residents (Resident R31). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of four residents (Resident R6). Findings include: Review of the facility policy SRC- Safety - 2.0 Accidents and Incidents (Residents) dated 2/21/24, indicated an accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. It may be an accident or a situation which might result in an accident. Review of admission record indicated Resident R6 was admitted to the facility 5/10/17. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/3/24, indicated diagnoses of muscle weakness, macular degeneration (eye disease that causes vision loss), and allergic rhinitis (an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms). -Section C indicated a Brief Interview for Mental Status (BIMS -screening test that aides in detecting cognitive impairment) a score of 12 ( 8-12: indicates moderately impaired cognitive ability). -Section GG0130 indicated 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers. Dependent for toileting, transfers, and shower/bathe. -Personal hygiene such as combing hair, applying make-up, drying face and hands is 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. -01 sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed (dependent) required for the resident to complete the activity. Review of the care conference progress note dated 8/16/24, indicated Resident R6's son told the team Resident R6 tells him she enjoys the meals but forgets soon after. Review of Resident R6's progress note dated 1/5/24, at 6:50 p.m. indicated called into room by walkie for nurse STAT. Resident lying on bathroom floor, feet at sink and head at doorway lying on right side. Wheelchair in upright position with left chair on and right chair lock off, acing toilet. Resident eye open but not communicating with staff when spoken to. When attempting to assist to roll resident over, observed laceration on right side of head, with hematoma (collection of blood outside a vessel) present. Moderate amount of bright red blood present. Noted skin tear to left forearm. Vitals obtained, resident becoming nauseated, but no vomit noted. Ambulance left with resident on stretcher at 7:18 p.m. Review of facility provided documentation indicated Resident R6 suffered a comminuted proximal humeral fracture of the right arm through the humeral head and neck (a severe shoulder injury where the upper part of the humerus bone (near the shoulder joint) is broken into multiple pieces, with the break extending through both the ball like joint surface and the narrow area connecting the head to the bone shaft). Right forehead laceration was sutured at the emergency room and will require removal in 10 - 12 days. Right upper arm shoulder sling in place. Review of Nurse Aide (NA) Employee E5's Employee Statement Form dated 9/2/24, indicated Resident R6 was at the sink to brush her teeth. NA Employee E6 locked both wheelchair locks and gave her the toothbrush, got the room ready for bed. Resident was asked if she was okay or needed more time. Resident replied Yes to more time. We told resident to ring when she was done. Cord of bathroom call bell draped around sink faucet. Around 6:40 p.m. we checked in on her and she was washing her face. We went to care for another room and on the way back resident was opening her lotion to put on her face around 6:45 p.m. Went to care for another room and were walking back we heard a thud. Ran into room and found Resident R6 on her right side on the floor with blood coming from her head. The right wheelchair lock was not locked upon discovering resident. Review of NA Employee E6's Employee Statement Form Dated 9/2/24, indicated the same timeline as NA Employee E5, with the addition of adding they asked the resident if she wanted privacy, and the resident said yes. Review of NA Employee E7's Employee Statement Form Dated 9/2/24, indicated I heard my coworkers shout, and I entered Resident R6's room . Resident was lying on the floor diagonal to the bathroom door. NA Employee E6 was in the bathroom with her. The right wheel of the chair was unlocked, and the left was locked. We placed a towel on residents head to clot (stop) the bleeding. Resident was very sweaty, confused and unaware of the situation. Blood pressure was significantly low (93/55), and she appeared nauseous. Interview on 3/5/25, at 9:21 a.m. the Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of four residents (Resident R6). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six of eight residents (Residents R2, R4, R5, R6, R7 and R8). Findings Include: Review of the facility policy Call Lights last reviewed 2/21/24, indicates all residents have a call light or alternative communication device within their reach at all times when unattended. Facility personnel will answer a call light as soon as possible. To ensure safety and communication between staff and residents in order to timely meet their needs. Respond to emergency call lights immediately. Respond to call lights and communication devices promptly and in person whenever possible. Review of the facility policy Resident Rights last reviewed 2/21/24, indicates a resident has the right to receive the services and items included in the resident's plan of care. A resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. A resident has the right to have grievances promptly resolved, in accordance with law. Review of the facility policy Nursing Service last reviewed 2/21/24, indicates nursing care includes the provision of all prescribed medications and treatments, personal care, hygiene, and nursing interventions in response to physical, emotional, or behavioral needs/problems. All nursing care is directed at attaining and maintaining optimal levels of health and functioning. To safely and effectively meet the nursing needs of the resident. Review of facility provided grievance dated 10/31/24, indicates received a phone call from Resident R2's son with concerns that Resident R2 called him the morning of 10/31/24, to report that no one is answering her call bell. Son stated that my mother previously fell in the bathroom and he is concerned that extended call bell responses times add to her potential for falls. Further review revealed that on 11/15/24, son again reported continued issues with call bell response via e- mail at approximately 9:55 p.m. yesterday evening my mother phoned me from her bed to say she needed to urinate, but no one was responding to her calls for assistance. Review of Resident R2's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/28/24, indicated the diagnoses of hypertension (high Blood pressure), hyperlipidemia (high fat in the blood) and hyperglycemia (high sugar in the blood). Section C0100 brief interview for mental status (BIMS- a structured evaluation aimed at evaluation aspects of cognition in the elderly a score 0-7 indicates severe cognitive impact, 8-12 moderate impairment, 13-15 intact cognitive response.) indicated a score of 12 moderate impairment. Review of the facility provided work order on 9/5/24, indicates round flat call bell isn't working room [ROOM NUMBER] please check. Response noted: tested call bell twice it is working. Review of the facility provided work order dated 11/15/24, indicates the call bells in room [ROOM NUMBER] and 426 are not working. Response: replaced batteries in call bell tested twice all is good. Observation and interview on 12/3/24, resident was sitting in her wheelchair next to bed, her over the bed tray table was next to her and had a flat call bell pressure pad as well as a silver bell that dings when tapped. Resident is dressed and well groomed. Upon asking resident about the call bell response time on the day she called her son, she replied it's been several years ago, I can't remember. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 426 11/15/24, 1:38 p.m. 1:52 p.m. 13 m 8's Area: Bed 426 11/16/24, 1:08 p.m. 1:24 p. m. 15 m 53's Area: Bed 426 11/16/24, 7:09 p.m. 7:36 p.m. 27m 14's Area: Bed 426 11/17/24, 11:40 a.m. 11:50 a.m. 10m 4s Area: Bed 426 11/17/24, 9:53 p.m. 10:04 p.m. 10m 38s Area: Bed 426 11/18/24, 8:33 p.m. 9:01 p.m. 28m 53s Area: Bed 426 11/19/24, 9:30 p.m. 10:03 p.m. 33m 20s Area: Bed 426 11/20/24, 10:38 p.m. 10:57 p.m. 18m 54s Area: Bed 426 11/21/24, 2:51 a.m. 3:20 a.m. 29m 35s Area: Bed 426 11/22/24, 1:27 p.m. 1:55 p.m. 27m 34s Area: Bath 426 11/22/24, 8:26 p.m. 8:45 p.m. 19m 32s Area: Bed 426 11/23/24, 2:39 a.m. 3:01 a.m. 21m 34s Area: Bed 426 11/23/24, 9:05 p.m. 9:31 p.m. 26m 7s Area: Bed 426 11/23/24, 9:38 p.m. 9:52 p.m. 13m 36s Area: Bed 426 11/24/24, 8;33 p.m. 8:57 p.m. 24m 0s Area: Bed 426 11/26/24, 9:11 p.m. 9:31 p.m. 20m 28s Area: Bed 426 11/27/24, 11:00 a.m. 11:30 a.m. 29m 59s Area: Bath 426 11/29/24, 9:14 a.m. 9:34 a.m. 19m 52s Area: Bed 426 12/1/24, 8:03 p.m. 8:37 p.m. 33m 56s Area: Bed Review of Resident R4's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/24, indicated the diagnoses of hypertension (high Blood pressure), hyponatremia (low sodium levels), and hyperlipidemia (high fat in the blood). Section C0100 BIMS- indicated a score of 12 moderate impairment. During an interview completed on 12/3/24, at 10:26 a.m. Resident R4, was resting in her bed, upon asking if staff was answering her call bell timely Resident R4 stated It takes a long time for them to answer my bell, sometimes I will pee in my bed. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 431 11/15/24, 7:17 p.m. 7:43 p.m. 25m 33s Area: Bed 431 11/16/24, 5:12 p.m. 5:24 p.m. 12m 18s Area: Bath 431 11/17/24, 7:06 p.m. 7:25 p.m. 18m 58s Area: Bed 431 11/19/24, 7:10 p.m. 8:44 p.m. 94m 4s Area: Bed 431 11/20/24, 5:24 p.m. 5:49 p.m. 25m 1s Area: Bed 431 11/21/24, 7:01 p.m. 7:52 p.m. 50m 57s Area: Bed 431 11/22/24, 8:32 p.m. 9:04 p.m. 31m 51s Area: Bed 431 11/23/24, 7:14 a.m. 7:27 a.m. 12m 37s Area: Bed 431 11/24/24, 9:06 p.m. 9:40 p.m. 33m 36s Area: Bed 431 11/25/24, 7:15 a.m. 7:45 a.m. 29m 14s Area: Bed 431 11/27/24, 8:49 p.m. 9:28 p.m. 39m 35s Area: Bed 431 11/28/24, 12:52 p.m. 1:29 p.m. 37m 23s Area: Bed 431 11/29/24, 10:26 p.m. 11:05 p.m. 39m 16s Area: Bed 431 12/1/24, 6:38 p.m. 7:02 p.m. 24m 26s Area: Bed Review of Resident R5's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Review of Resident R5's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/7/24, indicated the diagnoses of skin cancer, anemia (low iron in the blood), and hypertension. Section C0100 BIMS- indicated a score of 15 intact cognitive response. During an interview on 12/3/24, at 10:08 a.m. Resident R5, room [ROOM NUMBER], indicated it can take staff a while to answer her light and stated oh my God at least 20 minutes. I have had accidents it's not my fault, I ring the bell, I keep hearing we are short of help. It's even during the day, I can't walk, I use the bed pan. Just once a couple of weeks ago they left me on it, it hurt, it was more than half an hour. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 409 11/15/24, 10:31 a.m. 10:43 p.m. 11m 32s Area: Bed 409 11/16/24, 8:06 a.m. 8:53 a.m. 47m 11s Area: Bed 409 11/19/24, 9:31 a.m. 9:58 a.m. 26m 45s Area: Bed 409 11/19/24, 1:31 p.m. 1:49 p.m. 18m 39s Area: Bed 409 11/21/24, 748 a.m. 8:06 a.m. 18m 5s Area: Bed 409 11/22/24, 7:33 a.m. 7:47 a.m. 14m 3s Area: Bed 409 11/23/24, 6:06 p.m. 6:24 p.m. 18m 28s Area: Bed 409 11/23/24, 8:19 p.m. 8:50 p.m. 31m 17s Area: Bed 409 11/24/24, 4:39 p.m. 4:50 p.m. 11m 6s Area: Bed 409 11/25/24, 2:18 p.m. 2:57 p.m. 39m 17s Area: Bed 409 11/27/24, 6:43 p.m. 8:15 p.m. 92m 21s Area: Bed 409 11/27/24, 9:02 p.m. 9:31 p.m. 28m 58s Area: Bed 409 11/28/24, 8:14p.m. 8:28 p.m. 14m 19s Area: Bed 409 11/30/24, 9:29 a.m. 9:40 a.m. 11m 41s Area: Bed 409 12/1/24, 9:57 a.m. 10:15 a.m. 18m 34s Area: Bed During an interview completed on 12/3/24, at 11:00 a.m. Resident R6 stated he has on occasion had to wait for his call bell to be answered and stated we were short staffed over the holiday weekend. During an interview completed 12/3/24, at 11:05 a.m. Resident R7 stated I just go on my own, I don't have to wait. During an interview completed on 12/3/24, at 10:38 a.m. Resident R8 stated at night sometimes they run short. Review of facility provided matrix dated 12/3/24, indicated current in-house census at 31. Review of facility provided Care Plan/Task listing report dated 12/4/24, indicated eleven residents require an assist of two for transfers. Seven residents requires an assist of two for bed mobility. During an interview completed on 12/3/24, at 2:50 p.m. upon asking the Director of Nursing (DON) what the expectation time frame is for staff is to answer call bells the DON stated, a reasonable time frame less than twenty minutes. During an interview completed on 12/4/24, at 8:55 a.m. upon asking the Nursing Home Administrator (NHA) what is the expectation for answering call bells stated, based upon what is going on at that time, that is I would expect it to be answered. Upon asking for clarification concerning the extended call bell answer times on the facility provided device activity report the NHA responded You are looking at data that few places could provide, strapping it out. The majority are answered prompt, more than you would see anywhere else. The expectation is prompt call bell response, upon asking what he would consider as prompt, the NHA sated prompt would be a wide variety, I don ' t know how to answer that question. During an interview completed on 12/4/24, at 12:20 p.m. the DON stated after 7:00 p.m. it's the busy time for getting the residents to bed. I think they try to get in as soon as possible. Upon asking about Resident R2's son call bell response concerns the DON stated I'm in constant communication with the staff addressing his concerns (referring to Resident R 2's son) about call bells. I would expect that there is a lot of competing factors with the activities of daily living (ADLs) and nighttime care. We are transparent about concerns being recorded. The floor Resident R2 is on has a high number of resident's that require an assist of two. We are addressing our call bell times in general and in our quality assurance performance improvement (QAPI) plan, confirming that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of eight residents (Residents R2, R4, R5, R6, R7 and R8). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of three residents (Residents R1, R2, and R3). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/21/24, indicated diagnoses of hypertension, anemia (too little iron in the body causing fatigue), and atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls). Review of the clinical record indicated Resident R1 was transferred to the hospital on 8/30/24 and returned to the facility on [DATE]. Review of Resident R1's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of osteoporosis (condition when the bones become brittle and fragile), obstructive sleep apnea (disorder that causes breathing to repeatedly stop and start during sleep), and dysphagia (difficulty swallowing). Review of the clinical record indicated Resident R2 was transferred to the hospital on 9/20/24 and has not returned to facility. Review of Resident R2's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of hypertension, arthritis (inflammation of one or more joints, causing pain and stiffness), and thyroid disorder (any dysfunction of the butterfly-shaped gland at the base of the neck). Review of the clinical record indicated Resident R3 was transferred to the hospital on 9/23/24 and has not returned to facility. Review of Resident R3's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. During an interview on 9/25/24, at 1:07 p.m. Nursing Home Administrator (NHA) stated, I am not aware of Ombudsman notification for this. During an interview on 9/25/24, at 1:15 p.m. NHA confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of three residents (Residents R1, R2, and R3). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to identify a resident's risk for elopement and failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R4) and failed to routinely assess residents for elopement risk for two of five residents reviewed (Resident R5, and R6). Findings include: Review of facility policy Elopement Prevention reviewed 2/21/24, indicated that the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial evaluation to identify behaviors and collect history. A care plan will be developed that reflects the potential for elopement and preventative measures. Additionally, upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Evaluation. Review of Resident R4's clinical hospital records from 9/2/24, included a Physical Therapy note that stated the following: Resident R4 is only requiring supervision with cues from transferring from sitting to standing and to ambulate (walk, or move about) 150 feet with a wheeled walker. Review of clinical records from the hospital indicated that Resident R4 was discharged on [DATE] to a skilled nursing facility. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. A review Resident R4's Minimum Data Set Assessment (MDS-periodic assessment of care needs) dated 9/9/24, included diagnoses of non-Alzheimer's dementia (a group of symptoms that affects memory, thinking and interferes with daily life), aftercare following joint replacement surgery, and high blood pressure. Review of Resident R4's clinical record revealed a Wander Risk Assessment completed on 9/3/24, at 1:43 p.m. which consisted of the following information: The following questions are to be asked of the resident and/or responsible party upon admission/reassessment to determine the resident's risk for wandering. If the assessment indicates a yes to any question, consider initiating/update a care/service plan for wander risk. 1) The resident has attempted to leave a residence or other place unescorted that placed him/her in danger. No 2) The resident is cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented all the time) and independently ambulatory. No 3) The resident has a history of elopement. No 4) The resident is on medication to manage the wandering behavior. No 5)There has been a recent change in this medication. No 6)Resident has verbalized intent to leave the facility. No 7)Resident is wandering/seeking to find spouse or family. No 8)The resident is wandering aimlessly. No 9) The resident is actively exhibiting exit-seeking behavior. No If the assessment indicates YES to any question, consider initiating a care plan for elopement risk. Review of clinical record revealed Resident R4 was not initiated for elopement risk at this time per review of her care plan. Review of Resident R4's clinical record revealed a nursing progress note dated 9/3/24, at 10:41 p.m. that stated the following: Resident self-transfers repeatedly, reminded often to call for assistance. Found out in hall about 9:15 p.m. by staff. Confusion increases after sundown. Review of Resident R4's clinical record revealed a nursing progress note dated 9/4/24, at 7:47 a.m. that stated the following: Reeducated resident to use of call bell related to getting out of bed unassisted. Review of Resident R4's clinical record revealed a nursing progress note dated 9/5/24, at 10:55 p.m. that stated the following: Resident walked out of her room by herself with walker asking for help to go to the bathroom. Resident did not utilize call bell or call for assistance prior to walking out of room. Resident reminded importance of utilizing call bell when needing assistance. Resident verbalized understanding, but also has moments of confusion. Review of Resident R4's clinical record revealed a nursing progress note dated 9/8/24, at 1:47 a.m. that stated the following: Despite clipping call bell directly to resident's shirt on her chest only several minutes after this RN (Registered Nurse) left room, resident self-transferred and was found starting to attempt to ambulate in hall. Review of Resident R4's clinical record revealed a nursing progress note dated 9/9/24, at 2:04 a.m. that stated the following: Resident repeatedly unable to remember nursing re-education on fall/safety precautions and call bell use due to cognitive deficits related to dementia. Despite frequent reminders and frequent checks with resident to assess toileting needs, resident not using call bell to notify staff of need to use bathroom. Instead, resident found self-transferring and either waiting in room doorway or attempting to ambulate down hall with walker instead of using call bell. Review of documentation provided by the facility on 9/16/24, stated the following in reference to Resident R4: [AGE] year-old resident admitted on [DATE] status post right hip replacement admitted on anterior (front) hip precautions (a set of instructions on how to care for the hip, weight bearing as tolerated, ambulatory with assist of two people. Resident later upgraded to assist of one on 9/6/24. Resident was determined to have eloped from the skilled nursing unit at approximately 3:20pm on 9/14/24 after having been assisted to the bathroom and helped to her reclining chair at approximately 3:15 p.m. At 3:30 p.m. staff walked past residents' room and noticed she was not in her room. A systematic search of the unit and immediate vicinity was conducted. This included checks of all skilled residents' rooms including bathrooms and shared spaces including day rooms, dining spaces, and nursing stations. Campus security was alerted when resident was not located immediately. Search expanded to include neighboring spaces including stairwells, personal care unit, the residents' onsite patio home, lakeside apartments and all common areas of the health center. Radio communications were established with security and resident's descriptions was shared. Additional staff from other departments enlisted to participate in search. At 3:58 p.m.Director of Nursing and administrator notified of missing resident. Call placed to family and voicemail left requesting return call. At approximately 4:10 p.m. family returned the call and were made aware that resident was last seen at approximately 3:30 p.m. and her current whereabouts are unknown. Family stated that she is known to frequent main dining room and spaces adjacent to her patio home. Search of these locations conducted to no avail. Resident found by security walking with rollator (a type of wheeled walker) near adjacent building. She reports having left the skilled unit in an attempt to 'feed her fish'. Resident assisted back to skilled nursing. Family made aware of residents return. Doctor updated. Physical assessment conducted by nursing staff. Resident at baseline. No injury identified. Description of Follow-up Action: Follow up action included a Wander Risk Assessment which supported the implementation of a Wanderguard (a device used to alert staff when someone leaves a safe area). This was placed on the resident's ankle. The residents care plan was reviewed and updated. Resident had a Wander Risk Assessment conducted at the time of admission on 9/3/24. At this time, there were no identified concerns for wandering behavior. Resident did not ambulate independently, did not demonstrate exit seeking behavior, and was not on psychoactive medications. Prior to the placement of a Wanderguard following the elopement event on 9/14/24, measures in place to prevent wandering included resident residing in a room near the nursing station to support frequent observation. Additionally, the resident was engaged in group activities and was observed frequently during med pass, meals, activities, during ADL care to include toileting. To prevent future occurrences of wandering, resident was reassessed for wander risk. Based on the results of this assessment, a Wanderguard was placed on the resident. Resident was located at 4:32 p.m. by security ambulating with rollator on the sidewalk near a building across the driveway from the skilled nursing center. Total time resident's physical whereabouts were unknown was approximately 1 hour. During an interview on 9/24/24, at 12:06 p.m. RN Employee E1 stated that she worked on the day of Resident R4's elopement and had been her nurse earlier that day until her shift was over at approximately 3:00 p.m. RN Employee E1 stated that she was aware that Resident R4 could walk independently as she had seen her walking in the hallway the day before the elopement. RN Employee E1 stated that the day of the elopement she had walked Resident R4 to an activity and told Activities Staff to escort her back to her room after they were done and this was completed as instructed. When RN Employee E1 was asked why she felt the need to provide Resident R4 with an escort, she replied: I didn ' t trust her to be on her own because of her cognition, she may not make it back. During an interview on 9/25/24, at 11:54 a.m. RN Employee E2 stated that Wander Risk Assessments are completed at admission, re-admission, significant change and reevaluated with increased confusion and increased ambulation, and quarterly. RN Employee E2 stated that any nurse on the unit is able to complete a Wander Risk Assessment. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE]. A review of the Resident R5's MDS dated [DATE], included diagnoses of anemia (too little iron in the body causing fatigue), coronary artery disease (damage or disease in the heart's major blood vessels), and high blood pressure. Further review of Resident R5's clinical record revealed that a quarterly review had been completed on 5/4/24, however there was no accompanying Wander Risk Assessment completed at this time. Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE]. A review of the Resident R6's MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) muscle spasm, and high blood pressure. Further review of Resident R6's clinical record revealed that a quarterly review had been completed on 5/24/24, however there was no accompanying Wander Risk Assessment completed at this time. During an interview on 9/25/24, at 2:19 p.m. Director Nursing confirmed that the facility failed to re-evaluate Resident R4's elopement risk when Resident R4 was able to demonstrate that she could ambulate independently and displayed confusion. During an interview on 9/25/24, at 2:21 p.m. the Nursing Home Administrator confirmed that the facility failed to identify a resident's risk for elopement and failed to provide adequate supervision for Resident R4 which resulted in an elopement from the facility, and failed to conduct routine Wander Risk Assessments for two of five residents reviewed (Resident R5, and R6). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for four of six residents reviewed (Resident R2, R134, R135 and R9). Findings include: The facility's policy Abuse Neglect, and Exploitation Policy dated 2/21/24, with a previous review date of 4/4/23, indicated it is the facility's policy to provide a safe environment where residents are protected from all forms of abuse and strive to achieve a culture that treats every resident with dignity and respect while providing person centered care and services. The facility goal is to prevent and prohibit all types of abuse, neglect, misappropriation of property and exploitation. The facility assures that residents are free from neglect by identifying the needed care and services to all residents. Review of clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included dementia, repeated falls, anticoagulant use, history of fractures of face and arm, and difficulty walking. A MDS (Minimum Data Set- a periodic review of resident care needs) dated 2/26/24, indicated the diagnoses remained current. Review of Resident R2's MDS dated [DATE], Section G0110 indicated Resident R2 required the assistance of two staff for transfers. Review of Resident R2's plan of care dated 12/7/20 through current indicated Resident R2 was a transfer of two staff for all transfers. Review of a facility provided document dated 8/6/23, indicated that Resident R2 had been transferred with assistance of one Nurse Aide using the pivot disc and when Resident R2 slid off of the bed, the Nurse Aide had to lower Resident R2 to the floor. The incident did not cause any injuries for Resident R2. The document indicated that the Nurse Aide was re-educated. Review of the clinical record indicated that Resident R134 was admitted to the facility on [DATE], with diagnoses which included heart failure, hallucinations, Myelodysplastic disease (cancer of blood cells causing bone marrow to not mature causing fatigue, bleeding disorders and shortness of breath), heart disease with heart valve disease and need for a pacemaker and osteoporosis. MDS dated [DATE], indicated Resident R134 diagnoses remained current with additional diagnosis of a fractured right hip after a fall on 9/4/23, during a transfer. Review of an MDS Section G0110 dated 9/14/23, indicated Resident R134 was an assistance of two staff for all transfers. Review of Resident R134's plan of care dated 12/12/22, indicated Resident R134 was to be transferred with two staff and use of a full body lift. Review of a facility provided document dated 10/31/23, indicated that Resident R134 had been transferred with assist of two staff and a walker. Resident R134 was determined to not have any injuries. The two Nurse Aides were removed from his care and re-educated. Review of the clinical record indicated that Resident R135 had been admitted to the facility on [DATE], with diagnoses which included dementia, heart disease, a brain bleed, falls with fractures and a cognitive communication deficit. A MDS dated [DATE] indicated the diagnoses remained current. Review of a facility provided document dated 10/31/23, indicated Resident R135 had fallen in her room and three Nurse Aides had responded to LPN Employee E4 call for assistance to get Resident R135 off of the floor and as statements indicated that LPN Employee E4 kicked Resident R135 's foot and stated move I need to get in there and Resident R135 stated don't be so rough to her. Review of clinical record indicated that Resident R9 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), hyperlipidemia (high fat in the blood), and osteoarthritis (pain, swelling and stiffness of joints). A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R9's plan of care dated 8/23/22, through current indicated resident R9 was a transfer with a sit to stand lift and assist of two for all transfers. Review of a facility provided document dated 2/18/24, indicated that Resident R9 had been transferred with assistance of one Nurse Aide (NA) to a chair when Resident R9 ' s legs began to slide. The NA had to lower Resident R9 to the floor. The incident did not cause any injuries for Resident R9. The document indicated that the Nurse Aide was immediately re-educated. During an interview on 4/25/24, at 9:48 a.m. the Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse and neglect for four of six residents reviewed (Resident R2, R134, R135 and R9). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly disinfect reusable equipment between residents for one of three medication carts (medication cart assignment two) and failed to implement infection control practices during administration of eye drops on two of three residents (Resident R27) Findings include: Review of facility policy Cleaning of Non-critical Patient Care Equipment dated 10/2/23, last reviewed 4/4/23, indicated it is the policy to clean and disinfect shared noncritical patient care equipment in a manner that prevents the transmission of microorganisms while maintaining the integrity of the equipment. Non-critical items are those that come in contact with intact skin but not mucus membranes. Review of facility policy Medication Administration: Eye dated 12/1/06, last reviewed 4/4/23, indicate to provide a safe, effective eye medication administration process including but not inclusive to carry medication into resident room, put on clean gloves, instill eye drops. During an observation on 4/24/24, at 8:37 a.m. Registered Nurse (RN) Employee E1 was completing medication pass, during the medication pass RN Employee E1 removed a pulse oximeter (equipment used for non- invasive method for monitoring a person ' s blood oxygen saturation) from the side section of medication cart. Employee E1 took the pulse oximeter into resident R16's room and placed on finger to obtain reading. RN Employee E1 then placed the pulse oximeter back into the side section of medication cart. During an interview on 4/24/24, at 8:56 a.m. RN Employee E1 confirmed the pulse oximeter was not properly disinfected. During an observation on 4/24/24, at 9:05 a.m. RN Employee E2 was completing a medication pass. RN Employee E2 took Resident R27's Systane eye drops (for dry eyes) into room with oral medications, after administering oral medications RN Employee E2 proceeded to instill the eye drops without utilizing gloves. During an interview on 4/24/24, at 9:40 a.m. RN Employee E2 confirmed the failure to implement infection control practices during administration of eye drops. 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three medication carts (medication cart assignment two). Findings include: Review of facility policy Resident Rights dated 1/31/17, reviewed 4/4/23, indicates a resident has a right to personal privacy and confidentiality of their personal and medical records. During an observation on 4/24/24, at 8:37 a.m. Registered Nurse (RN), Employee E1 went into Resident R16's room to administer medications. RN, Employee E1 left the computer screen open with resident information visible to anyone passing by in the hallway. A report sheet with resident information was also present on the medication cart along with a binder that had a sheet of paper labeled fluid restrictions with a resident's name, all visible to anyone passing by in the hallway. During an interview on 4/124/24, at 8:56 a.m. RN, Employee E1 confirmed the facility failed to provide privacy and confidentiality of resident health information on one of three medication carts (medication cart assignment two). 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code: 211.5(b) Clinical records.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of five residents (Resident R134). Findings include: Review of the facility policy Abuse, Neglect, Exploitation last reviewed on 2/21/24, with a previous review date of 4/4/23, indicated that the facility shall provide a safe environment where residents are protected from all forms of abuse including injuries of unknown origin. Some cases if abuse may not be directly observed and these areas shall be identified and investigated reported to the state agencies as required. Review of the clinical record indicated that Resident R134 was admitted to the facility on [DATE], with diagnoses which included heart failure, hallucinations, Myelodysplastic disease(cancer of blood cells causing bone marrow to not mature causing fatigue, bleeding disorders and shortness of breath), heart disease with heart valve disease and need for a pacemaker and osteoporosis. A MDS dated [DATE], indicated his diagnoses remained current with additional diagnosis of a fractured right hip after a fall on 9/4/23, during a transfer. Review of a progress note dated 11/1/23, indicated that Resident R134 had a skin assessment revealing an abrasion of his left hip measuring 6.2 cm x 1.7 cm and a dark purple bruise of his right lateral back measuring 2.1 cm x 0.8 cm. During an interview on 4/24/24, at 9:35 a.m., the Director of Nursing confirmed that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of five residents (Resident R134). 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate protection from hazards for hot pack use for one of five residents (Resident R18), which resulted in a erythema (reddened) area requiring monitoring until identified as healed 8 days later. Findings include: Review of the facility policy Accidents and Incidents dated 2/21/24, with a previous review date of 4/4/23, indicated a safe environment will be promoted for all residents, report occurrences appropriately, and review and analyze for the opportunity for preventative measures. Review of the facility policy Heated Compress last reviewed on 2/21/24, with a previous review date of 4/4/23, indicated that warm moist heat such as a heating pad, gel pack or instant pack may be used as nursing intervention or as a physician order. Review of the clinical record indicated that Resident R18 was admitted on [DATE], with diagnoses which included repeated falls and bilateral primary osteoarthritis of knees. A MDS (Minimum Data Set- a periodic review of resident care needs) dated 2/8/24, indicated the diagnoses remained current. Review of Resident R18's plan of care for pain management, joint pain initiated 11/30/22, application of hot/cold packs to bilateral knees per her request. Leave in place for 20 minutes and check skin after pack removal and report concerns to nurse. Review of a facility provided document dated 3/4/24, indicated that Resident R135 had a hot pack placed on her right knee by Nurse Aide(NA) Employee E6 and developed a 3.5 cm x 2 cm area of erythema with no blistered area once the hot pack was removed. Registered Nurse(RN) Employee E5 assessed the area and initially applied Calazime barrier cream and after assessed by the Nurse Practitioner, the area was to be left open to air with no treatment and monitor. During review of Resident R135's statement indicated that she remembered the hot packs being very warm. Review of the statement from NA Employee E6 dated 3/5/24, regarding the incident of 3/3/24, stated that at 7:30 p.m., he placed a hot pack wrapped in a pillowcase on each of Resident R135's knees and when checking if resident R135 needed a brief change at 10:40 p.m., he repeated the hot packs. Review of skin assessment documentation from 3/4/24, through 3/12/24, did not identify any new areas and on 3/12/24, the area was healed . Review of a facility provided email document dated 3/5/24, indicated the Director of Nursing (DON) sending all staff a Must Read document indicating Resident R135 having a minor burn and also called it superficial. The document indicated that Nurse Aides are not to place or remove hot/cold packs, only Nurses are responsible for doing so. Review of a training provided to all nursing staff indicated only nurses are to apply/remove hot/cold packs and that staff are not to heat anything in the microwave. Any use must be care planned. A staff attendance was attached with the names of the staff involved on the form. During an interview on 4/24/24, at 8:35 a.m., NA Employee E7 stated that she is not allowed to place hot/cold packs, only nurses can do so. During an interview on 4/24/24, at 8:38 a.m., NA Employee E8 stated that nurses can only place hot/cold packs. During an interview on 4/24/24, at 8:40 a.m., NA's Employee E9 and E10 stated they ask the nurses to place and remove them. During an interview on 4/24/24, at 8:42 a.m., NA Employee E11 stated that nurses can only place and remove hot/cold packs. During an interview on 4/25/24, at 9:13 a.m., the DON confirmed that the facility failed to provide adequate protection from hazards for hot pack use for one of five residents (Resident R18), which resulted in a erythema (reddened) area requiring monitoring until identified as healed 8 days later. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure medications in one of three medication carts (medication cart assignment two). Findings include: Review of the facility policy Medication Storage dated 12/16, reviewed 4/4/24, indicate medications are stored and maintained under strict conditions to accept standards. During an observation on 4/24/24, at 8:37 a.m. Registered Nurse (RN) Employee E1 was completing a medication pass for Resident R16. RN Employee E1 administered medications for Resident R16, after using Trelegy Ellipta inhaler (relaxes and opens airways in lungs) she placed inhaler on top of medication cart and returned to room to complete medication administration. The medication cart was placed outside of Resident R16 's room and the medication was left unattended. During an interview on 4/24/24, at 8:56 a.m. RN Employee E1 confirmed the medication (Trelegy Ellipta inhaler) was left unattended and not properly secured on top of the medication cart accessible to anyone passing by in the hallway. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to develop and implement comprehensive care plans to meet resident care needs for two of six residents (Residents R3 and R15). Findings include Review of the facility policy Care Plan and Interdisciplinary Care Conferences last reviewed on 4/4/23, with a previous review date of 4/7/22, indicated that an individualized, interdisciplinary care plan is initiated within 24 hours. The care plan is a working tool that is reviewed and revised and is to reflect response to care and changing needs, goals and wishes of each resident and family's overall goals of care. Review of the clinical record indicated that Resident R3 was readmitted to the facility on [DATE], with diagnoses which included Diabetes, heart failure, dementia, insomnia, delusional disorder. A MDS(Minimum Data Set- a periodic assessment of resident care needs) dated 4/13/23, indicated the diagnoses remained current. Review of Resident R3's identified as the current plan of care did not include a plan of care for the diagnosis of dementia or interventions related to the diagnosis. Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses which included back pain, behaviors, wandering and falls . An MDS dated [DATE], indicated the diagnoses remained current. The MDS Section P0200 indicated Resident R15 wore an alarm/elopment bracelet daily. Section E0900 indicated Resident R15 wanders 4-6 days, but not daily, and Section E 1000 indicated Resident R15 was at risk for wandering/elopment. Review of the identified as the current plan of care for Resident R15 did not include wandering and interventions for this diagnosis. During an interview on 6/2/23, at 9:55 a.m., the Director of Nursing confirmed that the facility failed to develop and implement comprehensive care plan for Resident R3 to include dementia and comprehensive plan of care for wandering for Resident R15. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan.

Based on review of facility documentation, clinical record and staff interview it was determined that the facility failed to submit a complete a MDS for one of six residents (Resident R15). Findings include: Review of facility documentation CMS's RAI Version 3.0 Manual (Resident Assessment Instructions) indicated the following: Use a check mark for boxes where the instructions state to check all that apply. Review of Resident R15 clinical record indicated resident was admitted on [DATE], with diagnosis of hypertension (abnormally high blood pressure), and hyperthyroidism (overactivity of thyroid gland resulting in a rapid heartbeat increased rate of metabolism . Which remained current as of the MDS (minimum data set a periodic assessment of resident needs) dated 3/27/23. Review of Resident R15 MDS dated [DATE], Section F0300 Customary Routine and Activities indicated the following: Section F0300 had dashes in all sections and failed to address any of the questions asked. During an interview on 6/2/23, RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed that section F0300 Preferences for Customary Routine and Activities with two sections for daily preferences and activity preferences was incomplete with dashes in both boxes. Resident R15 preferences were not indicated in either section nor in the staff or family section for preferences. During an interview on 6/2/23, at 10:39 a.m. RNAC Employee E1 confirmed that Section F0300 had dashes and that the section was not completed nor were the questions asked or the information gathered prior to the submission of the MDS. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain that outdated biologicals were discarded in one of two medication rooms (Lake Hall medication room). Findings include: Review of the facility policy Medication and Biological Storage last reviewed on [DATE], indicated that all medications and biologicals are stored and maintained under strict conditions according to accepted standards. All drugs and biologicals will be checked to ensure date prior to use. During an observation of the Lake Hall medication room on [DATE], from 9:50 a.m. through 10:10 a.m., the following was identified: 22 packages of secondary intravenous bag tubing was expired dated [DATE]. 2 bottles of culture expired dated [DATE]. 3 culture swabs expired dated [DATE], and one dated [DATE]. During an interview on [DATE], at 10:10 a.m., Registered Nurse Employee E4 confirmed the biologicals were expired and the facility failed to discard out of date biologicals. 28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy services.

Based on review of facility policies, observation and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of four residents (Resident R7). Findings include: Review of the facility policy Wound Dressing Change last reviewed on 4/4/23, indicated all wound care will be performed using a clean technique unless otherwise ordered. Adherence to all standard precautions with all wound dressing changes as indicated. Individual resident supplies may be placed on the over-the-bed table after it has been disinfected and dried using an approved cleaning agent and protective barrier applied. During an observation of the pressure ulcer dressing change on 6/1/23, from 9:51 a.m. through 10:31 a.m., the following occurred: Registered Nurse(RN) Unit Manager Employee E3 placed barrier onto residents overbed table without removing Resident R7's personal items including a glass of water, tissue, remote control, etc., and without cleaning table before and after performing dressing change. During an interview on 6/1/23, at 10:31 a.m. at 10:31 a.m., RN Unit Manager Employee E3 confirmed that the facility failed to prevent the potential for cross-contamination during Resident R7's dressing change. 28 Pa. Code: 201.14(a) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.