Every finding on record at Southeastern Pennsylvania Veteran's Center

Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure insulin vials were labeled with open and expiration dates for one of six medication carts reviewed (4 CLC B Medication Cart).Findings include:Review of facility policy and procedure titled Medication Labels, revised March 18, 2024, revealed Each prescription medication label includes resident's first and last name, specific directions for use, including route of administration, medication name, strength of medication, prescriber's name, date dispensed, quantity of medication and expiration date of medication. Observation of the 4 CLC B Medication Cart on July 9, 2026, at 12:18 p.m. revealed one open and undated vial of Lispro (long acting) Insulin (a hormone produced by the pancreas that regulates blood sugar levels by allowing cells to absorb glucose from the bloodstream) , one open and undated vial of Novolog (short acting) insulin and two opened and undated vials of Lantus (long acting) Insulin. The above information was conveyed to the Director of Nursing on July 9, 2026, at 1:30 p.m. 28 Pa. Code 211.12(c)(d)(1)(2) Nursing Services

Based on observation, interview, and review of facility policy and records, it was determined that the facility failed to ensure the resident environment was free of accidents and hazards by failing to perform a complete investigation to determine the cause and pattern of the accident for one out of 43 residents reviewed (R191).Findings include: Review of facility policy Temperature Monitoring: Reheating of Food/Beverages, dated Jun 11, 2025 revealed: The purpose of this protocol is to provide guidance.regarding temperature monitoring for foods/beverages that are reheated for resident palatability; while minimizing the risk for unsafe food temperatures coupled with the mitigating of scalding and burn risk.Allow enough standing time for food and beverages to cool to prevent burns/scalds.Review of Resident 191's quarterly MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated April 30, 2026, revealed that Resident 191 was moderately cognitively impaired. Resident 191 required setup with eating and was dependent on facility staff to complete activities of daily living. Resident 191 required moderate assistance to move in bed and was completely dependent upon facility staff to transfer in and out of bed.Review of Resident 191's care plan revealed a preference to eat meals in their room.Review of facility records dated July 2, 2026 revealed, staff identified two open areas on the resident's chest with a thin layer of skin consistent with ruptured blisters. The resident reported that the areas resulted from a burn that occurred about a week ago Monday while eating Cup of Noodles brand soup. Resident stated they squeezed the cup, causing liquid to spill on his chest. Resident stated they did not report the incident at the time.Review of nursing progress notes dated July 2, 2026 revealed, On assessment scald burns of 9.5cm x 4.5cm and 4.5cm x 3.0 cm was noted.Review of provider progress notes dated July 2, 2026 revealed., Burn: acute 2nd degree on chest.Review of the facility's investigation dated July 2, 2026 revealed that the burn occurred due to soup spilled from a flimsy container and the recommended action was a therapy evaluation and using a facility-provided mug with lid for all soup.Review of facility records revealed an occupational therapy evaluation was completed on July 2, 2026 to ensure that Resident 191 could manage eating soup from an insulated cup with a lid. Resident 191 was also educated that the safest option to eat soup is when out of bed.Review of staff statements revealed no staff had noted any skin alterations on Resident 191 between June 22, 2026, and July 1, 2026.Interview with the NHA and DON on July 8, 2026, at approximately 1:15 p.m. revealed that the facility had not yet investigated which staff might have provided the resident the soup, instead focusing on whether or not staff had noted any skin alterations to the resident.Interview with Resident 191 on July 8, 2026, at approximately 2:15 p.m. revealed that Resident 191 requested the soup after dinner. Resident 191 stated that the aide left the cup on the overbed table. Resident 191 stated that they did not pick up the cup right away, but when they did, they squeezed it, and spilled soup on their chest. Resident 191 described the temperature of the soup as hot as hell. Resident 191 confirmed that they did not report the burn to staff.Observation of Resident 191's room, on July 8, 2026 at approximately 2:15 p.m. revealed a bookcase containing multiple kinds of snacks.Interviews with Employees 4 and 5 on July 8, 2026 at approximately 3:00 p.m. revealed that they were aware of the facility policy for reheating food and confirmed that they had received education regarding the new policy for reheating food in a facility-provided container.The facility failed to obtain witness statements relating to the preparation of soup for Resident 191 until July 8, 2026, six days after the injury was identified and no staff admitted to preparing soup for this resident when statements were provided. During the interview with Resident 191 on July 8, 2026, at approximately 2:15 p.m., the resident was able to provide a day, approximate time of shift (after dinner) and an approximate description of the staff who prepared the soup (a female staff who had provided care to the resident on more than one occasion). By failing to obtain witness statements or investigate which staff could have prepared the soup for Resident 191 in a timely fashion, the facility failed to adequately determine the root cause of the burn. These findings were submitted to the NHA, Assistant NHA, and DON in the exit conference on July 9, 2026 at approximately 1:55 p.m. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.14 (a) Responsibility of Licensee

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of 42 residents reviewed (Residents 10).Findings include:The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2025, revealed that Section I was to be coded for diseases that have a direct relationship to the resident's current functional status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Review of Resident 10's initial psychiatric evaluation, dated December 18, 2025, revealed Visit summary - Schizoaffective disorder, bipolar type - historic diagnosis. Alternative diagnosis of bipolar disorder charted - more likely schizoaffective based on history of precedence of psychotic symptoms (disorganized behavior, unusual affect, etc.) with mood symptoms secondary. Will continue to differentiate diagnoses as appropriate based on current presentation.Review of Resident 10's admission MDS with a completion date of January 15, 2026, revealed that diagnosis I6000 - Schizophrenia (e.g. schizoaffective and schizophreniform disorders) was not selected.Interview with Registered Nurse Assessment Coordinator (Employee 3) on July 9, 2026, at approximately 11:45 a.m. confirmed that Resident 10's admission assessment did not include the complete diagnosis. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's assessment was transmitted within 14 days of completing the assessment for one of 42 residents reviewed (Resident 179).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a quarterly MDS assessment was to be transmitted no later than 14 days (completion date + 14 calendar days).A review of the electronic health record for Resident 179 revealed the completion date for the required quarterly assessment was April 24, 2026, however the assessment had not been transmitted. Its status in the electronic health record was in process.An interview with the Registered Nurse Assessment Coordinator (Employee 3) on July 9, 2026, at approximately 11:45 a.m. confirmed that the assessment had not been transmitted in the mandated time frame. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for one of 42 residents reviewed (Resident 10).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.A comprehensive admission MDS assessment for Resident 10, dated January 15, 2026, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on January 15, 2025, which was 28 days after admission.An interview with the Registered Nurse Assessment Coordinator (Employee 3) on July 9, 2026, at 11:45 a.m. confirmed that the admission MDS assessment for Resident 10 was not completed within the required time frames.28 Pa. Code 211.5(f) Clinical Records.

Based on a review of the facility's policy, observation, and interviews with residents and staff, it was determined that the facility failed to ensure the resident was administered the correct medications for one of three residents reviewed (Resident 1). The error resulted in harm and hospitalization due to the medications' side effects. This was a past non-compliance.Findings include: A review of the facility's policy and procedure titled Medication Administration, dated May 1, 2025, revealed that the licensed nurse preparing the medications for administration will follow the six rights of medication administration: right resident, right medication, right dose, right route, right time, and right documentation. The same policy also revealed that residents are identified before medication is administered. Methods of identification include checking identification bands, reviewing photographs attached to medical records, calling residents by name, and, if necessary, verifying resident identification with other facility personnel. A review of Resident 1's diagnoses list includes Diabetes (a group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time), hypertension (high blood pressure), prostate cancer, and congestive heart failure (CHF, A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 1's Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated July 10, 2025, revealed resident was cognitively intact. On September 17, 2025, at 9:45 a.m., Resident 1, was observed sitting on their chair, and reported that a few months ago, a female staff member gave them morning medications. Resident 1 reported questioning the number of pills in the cup, but the staff told them to take it, so they followed the instructions. Resident 1 reported they were sent to the hospital the same day as the incident. A review of the nursing progress notes dated September 9, 2025, at 12:47 p.m. revealed the Unit nurse administered peer's medication to resident at 11:12 a.m., including Bisacodyl 5 mg (a medication to soften the stool), Chlorpromazine 10 mg (Anti-psychotic medication), Diltiazem 120 mg (a medication used to treat high blood pressure), Duloxetine 60 mg (a medication used to treat depression), Loratadine 10 mg (a medication used to treat allergies), Oxybutynin 5 mg (a medication used to treat overactive bladder), Pantoprazole 40 mg (a medication used to decreased the amount of acid in the stomach), Senna Plus 2 tabs (a stool softener), Tramadol 50 mg (a controlled medication used to treat moderate to severe pain), and Vraylar 1.5 mg (Anti-psychotic medication). The same note revealed that the resident was assessed, denied nausea, pain, sedation, and other ill effects. Family and physicians were notified and ordered to hold Resident1's scheduled antihypertensive medications. A review of the physician's notes dated September 9, 2025, at 12:16 p.m., revealed Accidental ingestion of medication-advice monitor full vitals, concerns for abdominal side effects and sedation, and over treatment of bp (blood pressure)-patient educated on possible side effects, may experience it in 3-4 hours or may not have any side effects. A review of the nursing progress notes dated September 9, 2025, at 5:58 p.m., revealed the resident was assessed after a report from the family that the resident was pale with nausea and had vomited. Vitals as follows: blood pressure - 122/60 mmHg (millimeters of mercury), heart rate-56/min, respirations- 18/min. The resident was served dinner but vomited after a few bites. The physician was notified with orders to transfer the resident to the hospital. A review of the hospital Discharge summary dated [DATE], revealed that Hospital Problem List was lightheadedness, ingestion of unknown medications, nausea, and vomiting. admission diagnosis was Medication side effects, near syncope. Clinical record review revealed Resident 1 was returned to the facility on September 12, 2025. A review of the physician's admission notes dated September 12, 2025, at 2:20 p.m., revealed that the resident was admitted (to the hospital) for observation from September 9, 2025, until September 12, 2025, with a diagnosis of near syncope, medication side effect, nausea, and vomiting. The same note revealed the resident was sent to the hospital due to nausea, vomiting, and fatigue after being given another patient's medication. The patient received Intravenous (administered in the vein) fluids and a bowel regimen for constipation (hard stool). The patient has transient bradycardia (a temporary decrease in heart rate that lasts for a short period) likely from Diltiazem. A review of the facility's documentation revealed that a facility investigation was completed on September 9, 2025, related to Medication Discrepancy. A review of a statement from licensed nurse Employee E3, dated September 9, 2025, revealed During med pass, this nurse was prepared to administer medications to (the intended recipient) when I realized I had already given them the medications to (Resident 1). The same statement revealed that when Employee E3 initially entered Resident 1's room, there were two other residents in the room, the roommate and another resident visiting their room. Employee E1 reported that when they called Resident 1's last name, the resident answered Yes, so they proceeded with the medication administration. Employee E3 also reported that Resident 1 was laughing and talking with the other two residents, that they must not have heard Employee E3. Nursing supervisor was notified upon learning about the mistake, the resident was assessed, family and the physician were notified. An interview conducted with the Director of Nursing on October 7, 2025, at 11:00 a.m., revealed that Employee E3 was not Resident 1's regular nurse. A review of the facility's plan for correction included the following: Resident's condition was monitored and assessed.Medication competency completed on nurse who completed the medication error.Residents' photos to be updated for those who have resided here greater than one year.Name bands to be created and applied to all residents.All licensed staff scheduled will have medication competency completed prior to start of their first med pass, PRN staff, light duty and nurses on FMLA will complete competency upon return to work before first med pass.The ADON/designee will audit five random residents' medication administration pass and verify weekly for three months to ensure compliance.Findings will be reported in the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's plan of correction was completed on September 15, 2025. A medication administration observation completed on October 7, 2025, a review of the facility's education/training, recorded audits, and staff interviews confirmed completion of the facility's plan of correction. The above was conveyed to the Commandant and Director of Nursing on October 7, 2025, at 2:00 p.m. The facility failed to ensure Resident 1 was free from a significant medication error, which resulted in the harm of being hospitalized due to the medication side effects. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 7/1/25, 5/9/25 28 Pa. Code 201.18(b)(1)(3)(e)(1) ManagementPreviously cited Previously cited 7/1/25, 5/9/25 28 Pa. Code 201.18(e)(3) ManagementPreviously cited 7/1/25, 5/9/25 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing servicesPreviously cited 7/1/25, 5/9/256/14/24, 3/16/24

Based on facility policy and procedure review, staff and resident interviews, facility documentation review, and clinical record review it was determined the facility failed to ensure that one of 55 residents was free from neglect during care resulting in actual harm causing skin laceration, subdural hematoma, and cervical fractures requiring hospitalization. This deficiency is cited as past noncompliance. (Resident 1) Findings Include: Review of facility policy and procedure titled, Freedom form Abuse, Neglect Exploitation and Misappropriation revised May 7, 2025, revealed the definition of Neglect as the failure of the home, its employees or service providers to provide goods and services to a resident that are necessary to avoid physician harm, pain, mental anguish, or emotional distress. Review of Resident 1's face sheet revealed a diagnosis of Hemiplegia (one-sided paralysis) and Hemiparesis (one-sided muscle weakness) following a cerebral infarction (blocked blood flow to brain) affecting left non-dominant side. Review of Resident 1's care plan dated February 20, 2025, and last revised May 29, 2025, revealed a care plan for ADL (Activities of Daily Living- basic tasks that individuals perform to maintain their daily life) with interventions that included therapy recommendations of bed mobility: assist x 2 (with two people) with side rails. Review of Resident 1's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated May 15, 2025, revealed Resident 1 was dependent on 2 staff for rolling left and right in the bed. Review of Resident 1's hospital Discharge summary dated [DATE], revealed the resident sustained a closed displaced fracture of the first cervical vertebrae (ring shaped bone that begins at base of skull), closed displaced fracture of second cervical vertebrae, cervical compression fracture (small break in bones of spine), subdural hematoma (bleeding inside head), and laceration (skin tear) of the scalp. Review of Resident 1's Progress Notes revealed a nursing entry dated June 16, 2025, at 3:17 p.m. indicating, received call from staff at approximately 1350 (1:50 p.m.) for reports of resident fall needing stat (immediate) assistance. On arrival to unit resident on his/her left side on the floor on the left side of the bed. Unit nurse was present and applying direct pressure to left side head laceration. Provider was present on unit and provider ordered to transfer to ER (emergency room). Review of facility investigation into the injury revealed a witness statement from non-licensed Employee E3 indicating, on Monday June 16, 2025 at 1:54 p.m., [Resident 1] fell out of bed on the floor between the bed and the window, I was changing his/her brief and had him/her all wiped clean but could not put a brief on him/her because his/her wound dressings were full of bowel movement, I looked for the nurse and could not find him/her. So, I go back in the room to find that Resident 1 had another really bad bowel movement. So, I'm trying to get him/her wiped clean again and he/she kept trying to roll on his/her back. I had all the soiled lines (linens) and dirty pad rolled under his/her right hip. He/she kept telling me their right hip hurt, and I was trying to work fast but he/she kept trying to roll on his/her back. Then there was loose bowel movement on the bed itself and I was trying to clean that up. A top sheet fell on the floor and that was when Resident 1 fell out of the bed. Further review of investigation documentation revealed an addendum to Employee E3's witness statement indicating, when the top sheet fell on the floor, I turned to my left to pick it up when the resident fell on the floor. When the resident fell off the bed onto the floor, I had turned away from the bed. Seven additional witness statements were reviewed but no additional witnesses to the fall were found. Review of information dated June 16, 2025 submitted by the facility to Department of Health on June 16, 2025, revealed at approximately 13:45 p.m. (aka 1:45 p.m.), Resident 1 was on the floor lying on his/her left side. Bleeding was noted from left side of head. Resident complaints of head pain and left hip pain. Resident on Eliquis (blood thinner) BID (2x daily) sent to ER (emergency room) for evaluation and treatment per provider. Employee E3 was noted to not be following the resident care plan 2 person assist for bed mobility. The bed was in a high position to provide incontinence care at the time of fall. The resident rolled while lying on his right side in the bed and landed on his left side on the floor. Neglect accusation substantiated. Interview on July 1, 2025 conducted with the Nursing Home Administrator (NHA) and Director Of Nursing (DON) when DON confirmed the resident rolled while lying on his/her right side in bed and landed on his/her left side on the floor. The NHA confirmed Employee E3 was found to not be following the resident care plan of two-person assistance with bed mobility. The facility initiated a plan of correction on June 16, 2025. Employee E3 received Education and retraining on following care plans for resident's bed mobility. All residents requiring two-person assistance for bed mobility and/or continence care were reviewed to ensure accurate information is listed on resident information sheets. Registered Nurse Instructors provided education to direct care staff of the importance of checking resident information sheets, how to follow information sheets, and where to find resident information sheets. Education was also provided on facility abuse and neglect policy and potential outcomes. Quality Assurance Department designee will audit 10% of direct care staff four times per week for four weeks then two times per week for two months, to ensure staff are aware of the importance of checking resident information sheets, how to follow the information sheets and where to find the resident information sheet. Results of all audits will be reviewed at the Quality Assurance and Performance Improvement (QAPI) meetings. The Quality Assurance (QA) Committee will determine the need for additional audits and/or interventions for ongoing compliance. Review of facility Plan of Correction (POC) on July 1, 2025, revealed education titled bed mobility and the need for two-staff members initiated on June 20, 2025, and completed on July 1, 2025. The key factor was noted as fall preventions and resident safety. Review of facility POC revealed education titled Importance of Following Care Plans (Resident Information Paperwork) initiated on June 26, 2025, was completed on July 1, 2025. Key factors included the location of the care plan, what to do if not able to locate, information included on care plan and why it is important to follow the care plan. Further review of the POC education documentation titled Mechanical Lift Device Policy, initiated June 24, 2025, and completed on July 1, 2025. The purpose was noted as to provide guidance regarding enhancing residents quality of life with increased development of culture change to the best abilities possible. Review of facility POC revealed resident audits documenting 55 residents care planned for two-person assistance. Interviews conducted on July 1, 2025, confirmed nine nursing staff received the education on bed mobility, two-person assistance, care plans and mechanical lift device use. 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 211.12(c)(d)(1)(5) Nursing services

Based on observation, review of the facility's policy and procedures, facility documentation, clinical records, and staff interviews, it was determined the facility failed to ensure direct care staff were educated on the safe food heating/reheating process. This failure resulted in Immediate Jeopardy situation when it was determined a licensed nurse whom the facility failed to educate regarding safe food heating protocol failed to check the temperature of ramen soup after heating it in a microwave resulting in Resident 78 sustaining a second-degree burn to the chest. Failure of the facility to provide education to all direct care staff regarding safe food heating resulted in a situation that jeopardized the health and safety of Resident 78. This was identified as a past non-compliance situation. Findings include: Review of the facility's policy titled, Dietary Services: Food Palatability/Re-heating revision date of [DATE], revealed it is the policy of the facility, meals are prepared and readied at proper (safe and appetizing) temperature, meaning both appetizing to the resident and minimizing the risk for scalding burns. Further review of the same policy revealed food/beverages will be heated, stirred, temped (temperature taken), stirred again, and re-temped before delivery: Ensure no hot spots are in the food/beverages by stirring The temperature of the food/beverages will be taken before delivering the item to the resident; Temperatures of any hot food/beverage items, such as commercially processed and packaged ready-to-eat foods are at least 140 F and not exceed 165 F. Review of Resident 78's diagnosis list included Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), and Peripheral Vascular Disease (PVD-circulatory condition that affects blood vessels outside the heart and brain, particularly in the legs and arms). Review of Resident 78's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 5, 2025, revealed Resident 78 was cognitively intact and had no impairments of the upper extremities. Review of the Occupational Therapy (type of rehabilitation therapy that focuses on helping people perform the tasks necessary for daily life) progress notes dated [DATE], revealed Resident 78 requires set-up assistance with feeding/eating. Observation conducted on [DATE], at 10:00 a.m., revealed Resident 78 lying in bed without a shirt. A light red mark was observed on the resident's chest and abdomen. Interview with Resident 78 conducted on [DATE], at 10:00 a.m. revealed, Resident 78 reported a few weeks ago, at nighttime (unable to provide exact date and time), he/she requested staff prepare him/her a cup of instant ramen noodle soup. The staff delivered the soup overfilled with hot water, enough that when he/she grabbed the cup, the soup spilled onto his/her chest which resulted in a burn. Review of the nursing progress notes dated [DATE], at 10:08 p.m., revealed staff reported at approximately 4:30 p.m., the resident spilled soup on his/her chest area. The resident was noted with an intact reddened area measuring 12 x 15 cm. (centimeters) to the upper chest. The resident stated he/she was eating the noodle soup and some of it spilled on the chest. Review of the NP's (Nurse Practitioner) notes dated [DATE], at 10:15 a.m., revealed resident was seen for chief complaint of burn/pain. Resident indicated, yesterday, one of the girls heated up my soup and there was more water in there than I was expecting so when I went to eat it, I spilled it on my chest. The resident complained of pain immediately but indicated area no longer painful unless it was touched. The NP ordered a treatment of Silvadene (medication used to treat burns) to the burn area and wound consult. Review of the wound care consult dated [DATE], at 12:02 p.m., revealed resident was seen to assess mid chest post burn. The same consult revealed resident had a second-degree burn (damage to the outer layer of the skin and the underlying layer) measuring 12 x 12 cm field to the upper mid-chest and a 5.0 x 5.0 cm field inferior to the larger burn site. An order to continue the Silvadene to the burn area was initiated. Review of the facility's investigation, revealed a statement from licensed nurse Employee E3 indicating: At 4:30 p.m., I heated up a cup of noodles and some other food for [resident]. I brought the soup to him/her and left (room) to finish heating the rest of his/her food. When I returned to his/her room, his/her soup was all over him/her. I asked him/her what happened, (resident) said he/she spilled it on him/herself. His/her shirt was wet, and I asked him/her if I could remove it to look at his/her skin then I went to get the nurse. Review of clinical records and facility documentation failed to reveal documented evidence of food temperatures taken by Employee E3 indicating Employee E3 did not followed the facility's policy of safe food/beverages heating/reheating by not checking the soup temperature before serving the cup of ramen noodle soup to Resident 78. Interview with the Nursing Home Administrator (NHA) conducted on [DATE], at noon, confirmed Employee E3, served Resident 78 the noodle soup without checking its temperature. The Nursing Home Administrator confirmed Employee E3 did not follow the facility's policy regarding the safe heating of the food/beverages. Further interview with the NHA revealed that all direct care staff which includes nurses and nursing assistants were not educated/trained regarding the facility policy and procedure on safe food/beverages heating/reheating to prevent burns. An Immediate Jeopardy situation was identified on [DATE], at 1:36 p.m. and the Immediate Jeopardy template was presented to the NHA, regarding the facility's failure to ensure all direct staff were educated/trained on safe food/beverages heating/re-heating to prevent burns to the residents. The facility submitted and completed an immediate action plan on [DATE], and was accepted on [DATE], at 2:54 p.m. The facily's immediate action plan included the following: Education was provided to the staff (Employee E3); A whole house audit was conducted to check all microwaves in the facility had thermometers attached to it; All residents were assessed to ensure no other residents received a burn from re-heated food items; Process signage for re-heating food in the microwave were attached to the microwaves; House-wide education developed and implemented for all facility staff on re-heating process, education was implemented and presented during the new hire and agency orientation; Dietary performed audits to ensure thermometers are present and functioning on all microwaves in resident areas; Audits were completed and ongoing time a week for four weeks, then every other week times four; The outcome of audits will be reviewed at the QA meeting. The facility self identified the jeopardy at the time of the incident, [DATE]. The facility implemented a corrective action of education, whole house assessments, and monitoring audits. On [DATE], after review of audits and documentation of completed employee education as well as interviews with 20 staff members revealed the facility had completed the interventions developed for the action plan on [DATE]. The Immediate Jeopardy was lifted on [DATE], at 11:12 a.m., after confirmation the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy with Immediate Jeopardy lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on a review of job descriptions, clinical records, it was determined that the Commandant and Director of Nursing did not effectively manage the facility to make certain that all direct staff were educated and trained with facility's policy and procedure regarding safe heating/re-heating of food and beverages to prevent resident from getting burns. Findings include: A review of the job description of the Commandant revealed the following: Responsible for managing and controlling all health-related activities and management functions of the facility; Establish and maintain a safe environment for residents and staff by operating safety programs that is in conformance with agency, state, and federal standards to protect the health and safety of the residents. A review of the job description of the Director of Nursing revealed the following: Directs all nursing care activities and participates in the administration of the multidisciplinary and non-clinical aspects of the resident's extended care facility's overall operation; In conjunction with multidisciplinary team, plan, direct, administer, coordinate, monitor, and evaluate facility-wide operations affecting health services; and Maintain current knowledge of developments in the field of nursing and communicate rules and regulations, facility and department policies and procedures to nursing staff by explaining and interpreting and ensure understanding and proper implementation and observance of these matters. Analyzes and evaluates long term care nursing operations to ensure compliance with applicable regulatory agency standards and requirements. Based on the findings in this report that identified that the facility failed to ensure education and training were provided to all direct care staff regarding safe food and beverages heating which placed residents in Immediate Jeopardy. The Commandant and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medications necessary for residents with kidney disease were administered as ordered for one of the two residents reviewed (Resident 46). Findings include: A review of Resident 46 diagnosis list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own). Clinical records review revealed resident goes to Dialysis (A process of purifying the blood of a person whose kidneys are not working normally) every Monday, Wednesday, and Friday, pickup time at 9:30 a.m. A review of Resident 46 physician's order dated November 9, 2025, revealed an order for Renvela (A medication used to control phosphorus levels for people with chronic kidney disease) 800 mg two tablets three times a day. The medications were scheduled at 8:00 a.m., 12 noon and 5:00 p.m. A review of the April 2025, Medication Administration Record revealed Renvela's medication was not administered at 12 noon on the following dates: April 2, 14, 16, 21, 23, 25, 28, and 30, 2025. The MAR documentation revealed medication not administered- Resident unavailable. Clinical records review failed to reveal Resident 46's physician was notified of the missed medications. An interview conducted with the Director of Nursing (DON) on May 6, 2025, at 10:00 a.m., confirmed that Renvela medication was not administered due to the resident being out of the facility for Dialysis. The DON also confirmed that the physician was not notified of the missed medications. The facility failed to ensure that ordered medications were administered to a resident on Dialysis. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 6/14/24, 3/16/24

Based upon review of facility policy and procedure, clinical record review, and staff interview it was determined the facility failed to follow physician orders for fluid restriction and administration of medication for one of one resident reviewed (Resident 52). Findings include: Review of facility policy and procedure titled Hydration Policy revealed Residents on fluid restriction will receive fluids as per Provider Order. Review of Resident 52's diagnosis list revealed diagnoses including congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), Diabetes Mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), urinary retention (bladder does not completely empty) and chronic obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform). Review of Resident 52's physician orders dated October 16, 2024, revealed 2000 cc Fluid Restriction. Total Dietary 680 cc, Total Nursing 1340 cc, (7-3 shift: dietary 480 cc, nursing 480 cc), (3-11 shift: dietary 180 cc, nursing 480 cc), (11-7 shift: nursing 380 cc). Review of Resident 52's Medication Administration Record (MAR) and the I/O (intake and output) Chart Detail Report, revealed the facility failed to follow the 2000 cc fluid restriction ordered by the physician for the following dates: April 11, 2025 - 2220 cc; April 12, 2025 - 2960 cc; April 13, 2025 - 2530 cc; April 14, 2025 - 2120 cc; April 15, 2025 - 2240 cc; April 16, 2025 - 2720 cc; April 17, 2025 - 2960 cc; April 18. 2025 - 2240 cc; April 19, 2025 - 2340 cc; April 21, 2025 - 2840 cc; April 22, 2025 - 2530 cc; April 23, 2025 - 2120 cc; April 24, 2025 - 2960 cc; April 27, 2025 - 2560 cc; April 28, 2025 - 2090 cc and April 29, 2025 - 2388 cc. Further review of Resident 52's physician orders revealed an order for Midodrine (medication used to treat low blood pressure) 5 milligrams (mg) three times per day and to hold the medication of the systolic blood pressure is greater than 120 mmHg (millimeters of mercury). Review of April 2025 MAR revealed on April 3, 2025, at 9:00 a.m. Resident 52 received Midodrine 5 mg for a blood pressure of 130/70 and on April 5, 2025, at 9:00 p.m. Resident 52 received Midodrine 5 mg for a blood pressure of 123/72. Review of May 2025 MAR revealed on May 4, 2025, at 1:00 p.m. Resident 52 received Midodrine 5 mg for a blood pressure of 128/70 and on May 4, 2025, at 9:00 p.m. Resident 52 received Midodrine 5 mg for a blood pressure of 125/64. Interview with the Nursing Home Administrator and Director of Nursing on May 9, 2025, at 10:00 a.m. confirmed that the facility was not following physician orders for fluid restriction or medication administration for Resident 52. 28 Pa. Code 211.12(d)(1)(2) Nursing Services Previously cited 6/14/2024

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of a significant weight change for one of the 35 residents reviewed (Resident 63). Findings include: A review of the facility's policy titled Weight Policy, last revised on June 23, 2020, revealed routine weights will be done to monitor or detect any changes that would adversely affect the resident's health. A weight will be obtained upon admission and/or readmission, then weekly times four weeks. A weight loss or gain of 5% in one month will require a reweight. Dietitians will evaluate weekly weights and monthly weights to determine if additional interventions are needed. If there is a significant weight change, the Dietitian will notify the physician. A review of Resident 63's diagnosis list includes Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Chronic Kidney Disease (CKD-Gradual loss of kidney functions which can result in renal failure). A review of Resident 63's physician's order dated November 15, 2024, revealed an order to weigh the resident three times a week to monitor for weight gain due to edema. A review of the weights and vitals revealed a weight of 197 pounds on January 10, 2025, and a weight of 217 pounds on June 15, 2025, a 20 pounds (9.22%) weight gain in five days. Further review of the weights and vitals report revealed Resident 63 was not reweighed until January 20, 2025, five days after a significant weight gain was identified. Clinical records review failed to reveal that the resident was assessed upon identifying a significant weight gain. The record review also failed to reveal that the physician was notified of the significant weight gain until reported weight concerns on January 24, 2025. Interview with the Director of Nursing on May 6, 2025, at 10:00 a.m., confirmed physician was not notified of Resident 63's significant weight gain timely. The facility failed to ensure physician was notified of Resident 63's significant weight gain. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 6/14/24, 3/16/24

Based on review of facility policy and clinical record review, it was determined that the facility failed to timely assess the need for an indwelling urinary catheter for one of seven residents reviewed for urinary tract infections (UTI) (Resident 61). Findings include: Review of facility policy, Urinary Catheter Procedures, last revised December 30, 2022, revealed that A resident who enters the [facility] with an indwelling urinary catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident ' s clinical condition demonstrates that catheterization is necessary .Residents identified with an indwelling urinary catheter will be assessed by utilizing the Indwelling Catheter Observation Form in the Electronic Health Record (EHR). This observation form will be completed when the catheter is present on admission/readmission, when a catheter is inserted, and quarterly as long as the catheter remains in place .Attempts will be made to remove the catheter as soon as possible when no indications exist for its continued use. Review of Resident 61's clinical record revealed the resident was hospitalized from January 3, 2024 until January 5, 2024, for a fractured left hip with surgical repair. Review of Resident 61's physician's orders at the time of hospitalization revealed the resident did not have a foley catheter at the time. Review of Resident 61's hospital discharge summary from January 5, 2024 revealed the instructions: Continue Foley catheter for urinary retention, do void trial at skilled facility as ambulation improves. Further review of Resident 61's clinical record failed to reveal evidence that an Indwelling Catheter Observation Form was completed upon the resident's January 5, 2024 readmission. Further review of Resident 61's clinical record failed to reveal evidence that a void trial was attempted. Review of Resident 61's January 2024 Treatment Administration Record revealed the resident was documented as receiving catheter care every shift. Review of Resident 61's progress note revealed a nurse's note on January 19, 2024, at 12:06 a.m. which stated: Resident's urine observed cloudy with sediment. [supervisor] notified, VSS [vital signs stable], fluids encouraged as tolerated. Nursing will continue to monitor. Further review of Resident 61 ' s January 19, 2024 progress notes revealed a nurse's note at 2:32 p.m. which stated: Resident's foley output 120cc, cloudy and with sediment. No foul odor. VSS. Fluids encouraged. Nursing will monitor. Further review of Resident 61's January 19, 2024 progress notes revealed a nurse's note at 5:11 p.m. which stated: Resident reported to have cloudy urine with some confusion. UA/CS [(urine analysis/culture & sensitivity] order obtained. Further review of Resident 61's clinical record revealed the resident was sent to the hospital for hyponatremia (low sodium) on January 22, 2024, until January 30, 2024 and was subsequently found to have a UTI at the hospital and treated with antibiotics. Review of Resident 61's progress notes revealed a note from the CRNP (certified registered nurse practitioner) on February 16, 2024, which stated: Foley catheter not chronic despite documentation of it being chronic by ED ([Emergency Department]) . Resident returned from ED visit on 1/5/24 with foley with instructions to keep in place and do void trial at facility. Resident was sent out to ED with UTI due to catheter on 1/22/24. Plan of care: remove foley catheter now. Interview with the Assistant Director of Nursing on June 14, 2024, at 10:40 a.m. confirmed the facility failed to assess Resident 61 for the need for the foley catheter upon readmission from the hospital. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on clinical record review and staff interview, it was determined that Southeastern Pennsylvania Veterans' Center failed to ensure that one of 24 residents reviewed did not have an oncology consult timely (Resident R1). Findings include: Review of Resident R1's clnical record revealed the resident was admitted to the facility in November 2023 with a diagnosis of cancer. Review of Resident R1's clinical record revealed Certified Registered Nurse Practitioner assessed the resident on November 2, 2023 with a notation of cancer as a diagnosis. Review of Resident R1's clinical record revealed a liver biopsy was scheduled for January 31, 2024 and an oncology (physician that specializes in treatment of cancer disorders) appointment scheduled for February 23, 2024. Review of Resident R1's clinical record failed to reveal any documented evidence that the resident's cancer was assessed by an oncologist or course of treatment identified. Interview on March 14, 2024 at approximately 11:45 p.m. with the Director of Nursing, confirming the above information. Pa 28 211.12(a)(c)(d)(3)(5) Nursing Services Pa 28 211.5(f)(g)(h)Clinical Records

Based on facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to to ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist for four of five residents reviewed (Residents 23, 48, 138, and 145) and failed to act on the pharmacy recommendations in a timely way for two of five residents (Residents 23 and 132). Findings include: Review of facility policy Drug Regimen & Medical Chart Review revised June 19, 2019, indicated that at least once a month the resident's medical record will be reviewed concurrently with the drug regimen review (DRR) by a licensed pharmacist. The pharmacist will report any irregularities to the attending physician or CRNP (certified registered nurse practitioner), medical director and director of nursing for follow up with seven days. The attending physician or CRNP will document in the resident's medical record that the identified irregularity has been reviewed and acted upon. If the provider disagrees with the recommendation the provider must document in the clinical record the rationale. Review of Resident 23's Consultant Pharmacist's Medication Regimen Review (MRR) between August 24, 2023, and September 1, 2022, revealed MRR's from March 2023, February 2023, and December 2022, where the physician failed to respond to the Pharmacist's recommendations. Additional review of Residents 23's MRRs failed to find any MRRs for the months of January 2023 and November 2022. Review of Resident 48's clinical record revealed that a monthly pharmacy medication review was not completed in November and December 2022. Review of Resident 132's physician's orders revealed an order for acetaminophen 650 milligrams every six hours as needed. Review of Resident 132's MRRs from December 2022, January 2023, February 2023, March 2023, and April 2023, revealed the pharmacist recommended adding instructions to the acetaminophen order to ensure the resident did not receive more than 3 grams per day. There was no physician's response or signature on the aforementioned MRRs. Review of Resident 132's May 2023 MRR revealed the physician agreed to the recommendation at this time and the resident's acetaminophen order was updated to reflect the change on May 22, 2023. The facility's failure to respond to the pharmacist's recommendation for Resident 132 from December 2022 to May 2023 was discussed with and confirmed with the Nursing Home Administrator on August 24, 2023, at 11:20 a.m. Review of Resident 138's clinical record revealed that a monthly pharmacy medication review was not completed in November and December 2022. Review of Resident 145's Consultant Pharmacist's Medication Regimen Review (MRR) between September 1, 2022, and August 24, 2023, failed to find any MRRs for November 2022 and December 2022. Interview conducted with the Nursing Home Administrator on August 24, 2023, at approximately 10:36 a.m. confirmed the above findings. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.12(c)(d)(3)(d)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to perform wound treatment on a newly found pressure ulcer for one of 2 residents reviewed (Resident 24) Findings Include: Review of Resident 24's Progress Notes revealed a nursing entry dated August 11, 2023 at 3:30 p.m. stating New area of concern reported by CNA(certified nursing assistant) during toileting. Reported to wound team for further evaluation. Further review of Resident 24's progress notes revealed a nursing entry date August 12, 2023 at 6:19 p.m. stating Resident to start Dakin's (a diluted solution bleach and other stabilizing ingredients, traditionally used as an antiseptic) solution to wound on back in am. Review of Resident 24's physician orders revealed at order with a start date of August 13, 2023 to cleanse the lower back ulcer with Normal Saline Solution (sterile salt water), pack wound with Daikin's soaked gauze and apply foam dressing. Review of Resident 24's Medication Administration Record revealed there was no evidence a treatment was placed on the wound until August 13, 2023. Interview with the Nursing Home Administrator and the Assistant Director of Nursing on August 25, 2023 at 10:30 a.m. confirmed there was no documented evidence Resident 24 had wound care provided to the wound found on August 11, 2023 until August 13, 2023. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of Pennsylvania's Nursing Practice Act, facility policy, and clinical records, it was determined that the facility failed to provide services that met professional standards of practice regarding medication administration for one of 34 residents reviewed (Resident 20). Findings include: According to Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, section 21.145. Functions of the LPN (Licensed Practical Nurse), subsection (a), The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. Review of facility policy, Medication Administration - General, dated May 2015, revealed: Residents are identified before medication is administered. Methods of identification include: A. Checking identification band B. Checking photograph attached to medical record C. Calling resident by name d. If necessary, verifying resident identification with other facility personnel. Review of Resident 20's quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated March 22, 2023, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 05, indicating cognitive impairment. Further review of Resident 20's MDS revealed the resident did not have a diagnosis of diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment). Review of Resident 20's progress notes revealed a nurse's note from licensed nurse Employee E1 dated April 27, 2023, at 10:49 p.m. which stated: At [8:30 p.m.] this nurse was distracted and administered medication to wrong patient. This nurse called resident other name and resident replied. Administering Lantus [(long acting insulin used to lower blood sugar)] 30 unit in [right upper quadrant abdomen.] Leaving resident this nurse noticed it was the wrong patient . Supervisor informed this nurse that resident will be sent out. Resident was asymptomatic. Resident sent out with EMT (Emergency Medical Technician) to [hospital] at [9:45 p.m.]. Further review of Resident 20's clinical record revealed the resident returned from the hospital at approximately 2:00 a.m. after remaining asymptomatic and requiring no treatment. Interview with the Nursing Home Administrator on August 24, 2023, at approximately 11:25 a.m. confirmed licensed nurse Employee E1 incorrectly administered medication to Resident 20. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to correctly administer medications for two of 34 residents reviewed (Resident 20 and Resident 103). Findings include: Review of Resident 20's quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated March 22, 2023, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 05, indicating cognitive impairment. Further review of Resident 20 ' s MDS revealed the resident did not have a diagnosis of diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment). Review of Resident 20's physician's orders failed to reveal any orders for insulin (medication used to lower blood sugar). Review of Resident 20's progress notes revealed a nurse's note from licensed nurse Employee E1 dated April 27, 2023, at 10:49 p.m. which stated: At [8:30 p.m.] this nurse was distracted and administered medication to wrong patient. This nurse called resident other name and resident replied. Administering Lantus [(long acting insulin)] 30 unit in [right upper quadrant abdomen.] Leaving resident this nurse noticed it was the wrong patient . Supervisor informed this nurse that resident will be sent out. Resident was asymptomatic. Resident sent out with EMT to [hospital] at [9:45 p.m.]. Further review of Resident 20's clinical record revealed the resident returned from the hospital at approximately 2:00 a.m. after remaining asymptomatic and requiring no treatment. Interview with the Nursing Home Administrator on August 24, 2023, at approximately 11:25 a.m. confirmed that Resident 20 received the wrong medication from licensed nurse Employee E1. Review of facility policy Medication Administration-General revision date May 2025 revealed medication are administered within one (1) hour before or after regularly scheduled time, except before or after meal orders. Review of Resident 103's physician orders revealed an active order for NovoLog (NovoLog is used to manage blood sugar levels in adults and children with type 1 or type 2 diabetes) U-100 Insulin aspart: 34 units twice a day between meals at 11:00 a.m. and 4:00 p.m. with a start date of October 28, 2022. Interview conducted with Resident 103 on August 21, 2023, at approximately 10:33 a.m. stated that his insulin is administered late daily. Review of Resident 103's clinical record revealed an eMAR (electronic medication administration record) with documented NovoLog administration times for the following dates: 08/11/2023: 12:10 p.m., 05:18 p.m. 08/13/2023: 12:03 p.m., 05:08 p.m. 08/15/2023: 05:11 p.m. 08/16/2023: 05:23 p.m. 08/20/2023: 05:24 p.m. 08/21/2023: 12:13 p.m., 05:55 p.m. Interview conducted with the Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA) confirmed the above medication was administered late. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on policy and procedure, clinical record reviews, and staff interview it was determined the facility failed to provide interventions to prevent elopement for one of 2 residents reviewed. (Resident 164) Findings Include: Review of policy and procedure titled Wandering and Elopement last revised May 20, 2014 revealed a flight risk assessment will be completed upon admission, quarterly, annually, and change in condition as needed for episodes of wandering, A flight Risk Assessment score of 12 or greater indicates the need for an electronic monitoring device (EMD) to be placed on the resident's wrist or ankle. If an AMD is applied, the residents name and photo will be placed in the master photo book locate at the front desks and the nurse's station on each unit. Each resident will be reassessed as needed, and the EMD will be removed at the discretion of the interdisciplinary team following the reassessment. Further review of facility policy and procedure Wandering and Elopement defined elopement risk behavior as any behaviors including but not limited to; (1) resident is attempting to leave the home or secure unit, (2) making statement regarding leaving the home or verbalizing resistance to being placed in the home. Review of Resident 164's progress notes revealed a nursing entry dated April 21, 2023 at 12:28 p.m. stating Resident was escorted to his new room. He is settled at this time. ESD was placed on his right wrist. He said to nurse while putting the ESD on his right wrist, why are you putting that ID on my wrist, you know I won't stay. Further review of resident 164's progress notes revealed a nursing entry dated April 27, 2023 at 8:28 a.m. stating Resident is having a hard time with the adjustment to SNF (Skilled Nursing Facility) placement, as in expressing dissatisfaction to family regarding lack of activities, despite different staff members encouraging him to attend. Resident often stating he is getting out of here, Further review of resident 164's progress notes revealed a nursing entry dated April 28, 2023 at 11:24 a.m. stating Resident continues to adjust to facility often stating, I'm getting out of here. Further review of resident 164's progress notes revealed a nursing entry dated May 14, 2023 at 11:50 a.m. stating [NAME] was observed ambulating in the hall looking for the elevators with his cane in one hand and a pillowcase with laundry in the other hand. He said he was looking for the place and needed to leave. Staff were able to figure out he wanted to do his laundry. Further review of resident 164's progress notes revealed a nursing entry dated May 15, 2023 at 1:59 p.m. and 2:52 p.m. stating No elopement attempts during this monitoring period. ESD right wrist discontinued. Further review of resident 164's progress notes revealed a nursing entry dated July 20, 2023 at 10:12 p.m. Resident was very anxious and going up and down the halls in his wheelchair. Stated that he wasn't ready to go to bed yet. This nurse checked on resident at 8:55PM in his room and sitting in his w/c (wheelchair). At 9:15, security guard brought resident back to the floor. She stated that someone let resident out the front door. A resident from PC saw resident and came and told security guard that resident was outside Accutech (EMD) put on left wrist. Review of Resident 164's care plan revealed there was no care plan for wandering or elopement in place during the elopement of July 20, 2023. Resident 164 was incorrectly assessed as no longer being a wandering risk on May 15, 2023 when the EDM was removed resulting in resident 164 eloping from the facility. This information was brought to the Nursing Home Administrator on August 24, 2023 at 9:45 a,m. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility policy, clinical record, and interview; it was determined that the facility failed to ensure resident was free from significant medication error by administering heart medication outside of physician directed parameters which resulted in harm of hospitalization for one of ten residents reviewed (Resident R1). Findings include: Review of facility policy titled Medication Administration-General, with revision date of May 2015, indicated on page 2, section B(2) Medication are administered in accordance with written orders of the attending Medical provider. Review of facility policy titled Holding Medication/Treatments, with a revision date of June 2014, indicates on page 1, under Procedure Medication/treatments may not be held for any reason without a physician order. Section 2 states A physician order to hold medication or treatment may need obtained due to various factors including but not limited to: a. Blood level studies, b. Vital signs . Review of Resident R1's clinical record revealed resident's diagnoses include but are not limited to following: Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability); Hypertension (Elevated /high blood pressure); Hypothyroid (the thyroid gland can't make enough thyroid hormone); Anemia (reduction in blood cells); and Neuropathy (nerve damage). Review of Resident R1's physician orders revealed an active order for Metoprolol (used to treat high blood pressure, also known as a beta blocker) 50 mg(miligram) BID (administer twice daily)- with instructions of Hold for Systolic (BP) blood pressure less than 110 and/or a (HR) heart rate less than 60 bpm (beats per minute). Review of Resident R1's clinical record including February 2023 eMAR (electric medication administration record) revealed on February 23, 2023, that Metoprolol 50 mg was administered to the resident with a blood pressure of 93/55 and a heart rate of 38, contradictory of the prescribed parameters. Interview conducted with licensed Emplolyee E1 on March 16, 2023, at approximately 1:02 P.M. confirmed the employee administered Metoprolol outside of the physician ordered parameters. Employee E1 indicated that he/she only checked the resident's blood pressure prior to administering Metoprolol 50 mg. Employee E1 then stated after administering Metoprolol 50 mg he/she checked the resident's heart rate which was 38 bpm. Employee E1 confirmed that he/she should have held the medication and not administer Metoprolol 50 mg to the resident. Review of Resident R1's progress notes dated February 24, 2023, revealed the resident was transferred to [local] hospital's emergency room for Bradycardia (heart rate less than 60 beats per minute) and Hypotension (low blood pressure). Review of Resident R1's hospital record revealed the resident was admitted from the emergency room to the ICU (Intensive Care Unit) with a diagnosis of Bradycardia, Hypotension, and urine retention. Further review of resident's hospital records revealed the residents was admitted to the hospital on February 23, 2023, and discharged on [DATE], a total of 13 days. Interview conducted with the Director of Nursing (DON), Nursing Home Administrator (NHA), and Assistant Nursing Home Administrator (ADON) on March 16, 2023, confirmed Employee E1 administered Metoprolol 50 mg to Resident R1 contradictory of physician ordered parameters, resulting in the resident being transferred and admitted to the hospital for Bradycardia and Hypotension. 28 Pa Code 211.10(c) Resident Care Policies 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited on 08/09/22 and 3/23/22

Based on policy review, clinical record review and interviews with the staff, it was determined that the facility failed to provide supervision for one resident (Resident R1) for hot liquids sustaining a burn which is being cited as past non-compliance. Findings include: Review of the facility policy titled Food/Beverage Reheating Process revealed temperatures of any hot food/beverage items are to be at least 140 degrees F (Fahrenheit) and not exceed 165 degrees F. If the temperature is above 165 degrees F, the beverage should stand until cooling has occurred below the 165 degrees F temperature. Review of Resident 1's clinical record including quarterly MDS (periodic assessment of resident needs and capabilities) dated October 18, 2022, revealed a cognition level of 15 (cognitively intact) and a set up with supervision with meals. Review of Resident 1's clinical record revealed a nursing note dated November 22, 2022, at 6:15 a.m., resident reported scalding self with hot water on his/her right thigh. Resident requested hot water earlier to make tea approximately 10 minutes prior. Upon assessment, an open area observed on right thigh measuring 10 cm (centimeter) x 7.5 cm noted. Further review of documentation by the wound nurse dated November 22, 2022 at 11:59 a.m. revealed, Resident 1 noted with scalded area from spilling hot water to right distal thigh. Area measures 0.5cm x 3.5 cm, wound bed darker pink, moist. Edges with dry peeling skin from ruptured blister. Surrounding tissue darker pink. Resident complained of tenderness to area. Facility investigation revealed that Employee E3 was interviewed on November 22, 2022 stating\ the following: (I) was asked by the resident to get some hot water to make tea. Employee E3 provided the hot water from the coffee machine. The resident was seated in his/her wheelchair the cup was placed on the counter along with creamer. The resident came back approximately 15 minutes later and said it spilled on his/her leg. Further statements from Employee E3 revealed, the resident was given a Styrofoam cup, but it was believed to be half full. The temperature of the hot water was not taken prior to giving it to the resident. An interview with the Nursing Home Administrator on December 14, 2022, at 11:45 a.m. revealed that Employee E3, should have taken the temperature of the hot water prior to giving it to Resident 1. The facility failed to follow the policy ensuring temperatures (above 165 degrees F) of a hot liquid would not be served to resident, which resulted in a burn for one resident (Resident 1). On November 22, 2022, the facility conducted education for the updated policy Food/Beverage Reheating with all staff completing the training by December 2, 2022. Review of facility compliance audits revealed they were intiated on November 22, 2022 and completed on December 2, 2022. Review of audits for compliance were conducted and interviews with the employees demonstrated understanding of the new policy. Resident 1's care plan was reviewed and noted to have new intervention of a weighted mug with a lid to be used for hot beverages. Facility has demonstrated compliance with the regulations since December 2, 2022. During an interview with the NHA and the DON on December 14, 2022, at 1:00 p.m. and review of the facility's immediate actions, education, competencies, audits, and review of the Quality Assurance monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are supervised with hot liquids. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and staff interview, it was determined the facility failed to develop interventions to prevent falls for one of six residents reviewed causing actual harm of a [CONDITION(S)] to Resident 23. Findings include: Review of facility policy entitled Falls Prevention, dated September 2017, revealed nursing will do falls assessments with admission, quarterly, and PRN (as needed) on all residents. Any resident scoring 10 points or above is considered a high risk for falls. The interdisciplinary team (IDT) will review resident falls during every morning report, the IDT will discuss to determine root cause of fall, any needed interventions and any system changes that may be necessary to decrease falls and/or prevent serious injury from falls. An individualized, person centered nursing care plan will be initiated and updated as needed. Review of Resident 23's Quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs), dated January 28, 2021, revealed the resident could independently transfer and walk in his room and around the facility. The resident also had a BIMS (brief interview for mental status) score of 3 indicating the resident had severe cognitive decline. Review of Resident 23's care plan developed April 7, 2015, identified the resident being a high risk for falls with interventions developed to prevent falls. Review of Resident 23's progress notes revealed a nursing entry dated March 29, 2021 at 4:00 p.m. stating this nurse heard a loud noise coming from the resident's room. Resident was lying on the floor on his right side close to the bathroom door. RNS (Registered Nurse Supervisor) and physician notified. Resident c/o (complained of) right leg pain when in bed. X-ray of bilateral (both) hips to r/o (rule out) [CONDITION(S)] done as per order. Further review of Resident 23's progress notes revealed a nursing entry on March 29, 2021 at 9:05 p.m. stating x-ray result received: acute fracture at the base of the femoral neck (broken hip). MD ordered to send to ER for evaluation. Further review of Resident 23's progress notes revealed an entry dated March 30, 2021, at 12:09 a.m. stating resident will be admitted . Admitting diagnosis is acute displaced right femoral neck fracture. (broken hip) Further review of Resident 23's progress notes revealed a nursing entry dated April 1, 2021, at 7:23 p.m. that indicated the resident returned from the hospital. Resident was admitted to the hospital for right [CONDITION(S)] requiring arthroplasty (surgical repair). Review of the facility's investigative report for Resident 23's fall revealed the fall occurred at 4:00 p.m. on April 1, 2021. Review of all facility documentation revealed there was no final determination of a cause and there were no new interventions put into place after this fall as should have been completed per facility policy. Review of Resident 23's care plan revealed there was no evidence that new interventions were developed and added to the care plan after this fall. Review of Resident 23's Significant Change MDS dated [DATE] completed upon return from the hospital after the fall on March 29, 2021 resulting in hospitalization on [DATE], revealed the resident now required two people to extensively assist when resident would transfer and walk in room and limited assistance when walking in the facility. Review of Resident 23's fall risk assessment dated [DATE] revealed the resident had a score of 22 which determined the resident to be at high risk for falls. Review of Resident 23's progress notes revealed a nursing entry on April 8, 2021, at 4:10 p.m. stating this nurse saw resident lying on the floor on his back close to bed. Review of Resident 23's facility investigative report April 9, 2021 revealed the fall occurred at 4:10 p.m. on April 8, 2021. Review of a fall assessment committee note dated April 9, 2021, revealed there was a therapy screen ordered and to consider the use of signage due to poor safety awareness. Review of the Root Cause/Signature Page event Report revealed new interventions of, give resident verbal reminder not to ambulate or transfer without assistance and PT (physical therapy) will give Broda Chair (a chair that is larger and more padded then a wheelchair and can tilt back to a lying position) There was no determination of a root cause of the fall as should have been completed per facility policy. Review of Resident 23's clinical record revealed there was no documented evidence the resident received a Broda Chair. Observations of Resident 23 during all days of the survey revealed the resident was in a regular wheelchair and not a Broda chair. Interview with the Director of Nursing and Nursing Home Administrator on July 16, 2021, at 12:30 p.m. confirmed Resident 23 never received a Broda Chair. Review of Resident 23's fall care plan revealed there was no evidence of new interventions developed after the fall of April 8, 2021. Review of Resident 23's progress notes revealed a nursing entry dated May 6, 2021, at 4:11 p.m. stating the resident was sitting in the dining room on A side and had an unwitnessed fall. when this writer arrived at the scene the resident was laying on his left side on the floor. Resident stated no injuries Review of the facility's investigative report for the May 6, 2021 fall revealed there was no evidence of an investigation to determine the cause of the fall and no evidence of new interventions developed to prevent falls as should have been completed per facility policy. Review of Resident 23's care plan revealed there was no evidence of new care plan interventions developed after the fall of May 6, 2021. Review of Resident 23's progress notes revealed a nursing entry dated May 29, 2021, at 5:42 p.m. stated resident found on the floor after using the restroom. Resident has complaints of pain in his left hip and left wrist. STAT (immediate) x-ray orders obtained. Review of Resident 23's progress notes revealed a nursing entry dated May 30, 2021 at 3:45 a/.m. stating resident off the unit at 11:40 p.m. to the emergency room for evaluation and treatment Further review of Resident 23's progress notes revealed a nursing entry on May 30, 2021, stating received call back from hospital. Resident is awaiting orthopedic consult and will probably wait until Tuesday 6/1/21 for ORIF (Open Reduction Internal Fixation- surgical repair of [CONDITION(S)]). Interview with the Nursing Home Administrator and the Director of Nursing on July 16, 2021, at 12:30 p.m. confirmed there were no new interventions developed and care planned for Resident 23 after the falls of March 29, April 8, and May 6, 2021. The facility failed to thoroughly review, determine cause, or develop new or effective fall prevention interventions after the fall with fracture on March 29, 2021. This facility failure resulted in a decrease in transfer and walking ability but with increased fall risk resulting in subsequent non injury falls on April 8, and May 6, 2021. Resident 23 suffered actual harm during a fall on May 29, 2021 resulting in another [CONDITION(S)] requiring surgical repair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) (e)(1) Management 28 Pa. Code 207.2(a) Administrator ' s responsibility 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical records, and facility documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that policies and procedure were in place to trace and investigate COVID-19 presumptive positive and positive residents and staff to mitigate or potentially control the spread of the coronavirus, failed to follow CDC (Center for Disease Control) guidelines, CMS (Center for Medicare/Medicaid Services) guidelines and Pennsylvania Department of Health (DOH) guidelines to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 24 of 34 residents reviewed (4A, 6A, 7A, 8A, 13A, 14A, 15A, 16A, 17A, 18A, 19A, 20A, 21A, 22A, 23A, 24A, 25A, 26A, 27A, 28A, 29A, 30A, 31A, 32A) on five of six units (CLC 2, CLC 3, CLC 4, Coates Hall 2E/2W, Coates Hall 3E. These failures placed the residents 128 of 154 residents at the facility in an Immediate Jeopardy situation. The Acting Commandant and Acting Director of Nursing (DON), both having started at the facility on May 28, 2020, were made aware the Immediate Jeopardy existed for the 128 of 154 total residents in the facility on June 2, 2020, at 3:15 p.m. and a corrective action plan an was requested. An acceptable corrective action plan was received from the Commandant on June 2, 2020, at 7:30 p.m. The Immediate Jeopardy was removed on June 9, 2020, at 4:30 p.m., after onsite verification that the corrective action plan was implemented. Findings include: The CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Updated May 16, 2020, revealed, Upon Arrival and During the Visit Limit and monitor points of entry to the facility. Advise patients and visitors entering the facility, regardless of symptoms, to put on a cloth face covering or facemask before entering the building and await screening for fever and symptoms of COVID-19. Take steps to ensure everyone adheres to respiratory hygiene and cough etiquette, hand hygiene, and all patients follow triage procedures throughout the duration of the visit. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about hand hygiene and respiratory hygiene and cough etiquette. Instructions should include wearing a cloth face covering or facemask for source control, and how and when to perform hand hygiene. Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins. Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients. Consider establishing triage stations outside the facility to screen individuals before they enter. Triage personnel should have a supply of facemasks or cloth face coverings; these should be provided to all patients who are not wearing their own cloth face covering at check-in, assuming a sufficient supply exists. Ensure that, at the time of patient check-in, all patients are asked about the presence of fever, symptoms of COVID-19, or contact with patients with possible COVID-19. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. Incorporate questions about new onset of COVID-19 symptoms into daily assessments of all admitted patients. Monitor for and evaluate all new fevers and symptoms consistent with COVID-19 among patients. The DOH 2020 - PA-HAN - 492 - 4-3-ALT Alert: Universal Masking of Healthcare Workers and Staff in Congregate Care Settings, dated April 3, 2020, revealed that minimizing transmission of COVID-19 into and within health care facilities and congregate care facilities is critical. Consider the utility of creating a designated COVID-19 unit, creating a separate area of the building or a designated unit with the plan to move COVID-19 positive residents there upon diagnosis, may be an option in some facilities. If employed, this strategy must be used in conjunction with maintaining the original unit under all precautions; many residents of that unit might already be COVID-positive. The DOH 2020 - PA-HAN - 496 - 4-14-ALT Advisory: Universal Message Regarding Cohorting of Residents in Skilled Nursing Facilities, dated April 14, 2020, revealed that cohorting of residents with COVID-19 in dedicated units within skilled nursing facilities can be an effective transmission prevention strategy, but it must be done deliberately to be effective. Once COVID-19 is identified in a nursing care facility, there are three types of residents to consider: Cases: Those with confirmed or probable COVID-19. This includes residents who were exposed to COVID-19 and are exhibiting symptoms consistent with COVID-19 but have not yet been tested or will not be tested , Exposed: Those who have been exposed to COVID-19 but are not yet exhibiting symptoms, and Unexposed: Those who are not known to have not been exposed to COVID-19. Cohorting decisions should consider all three groups of residents, with the priority being to restrict the mixing of residents who are cases or are exposed with those who are thought to be unexposed. Cohorting decisions should consider all three groups of residents. The primary goal of cohorting is to restrict mixing of residents who are cases or are exposed with those who are thought to be unexposed. Separating cases from exposed residents is a secondary goal of cohorting. Older adults with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. With regard to moving residents and cohorting residents, it is imperative that facilities follow the guidance in PA-HAN 492. Consider all residents in units with COVID-19 cases as exposed and potentially infectious. Recent information about COVID-19 spread in Long Term Care Facilities (LTCF) shows about half of residents testing positive for COVID-19 are not symptomatic. Spread of [MEDICAL CONDITION] could have been occurring undetected long before a positive test is reported. The first positive COVID-19 resident is identified in a unit where there are also other residents with possible symptoms, or several positive residents are identified in the same unit within a few days. This suggests transmission has likely occurred to many others in the unit. Moving the positive residents to a dedicated unit, even a unit that already has several positive COVID-19 residents, has minimal benefit. All residents in the original unit must be treated as infectious and cared for using full personal protective equipment (PPE - gown, gloves, mask, and eye protection) per PA-HAN 492. In most facilities using this process, newly identified symptomatic residents present over the following week, and moving residents becomes no longer feasible. Urgent room changes may negatively impact the health and well-being of the residents and should occur when benefits outweigh the risk. The facility's policy regarding caring for residents with suspected and confirmed COVID-19, dated March 27, 2020, revealed that the facility will follow the Centers for Disease Control (CDC) guidance for a combination of Standard Precautions (a set of infection control practices used to prevent transmission of diseases) and Transmission-Based Precautions (used when standard precautions alone are not sufficient to prevent the spread of an infectious agent) when caring for residents that may be suspected of having COVID-19 and have known COVID-19. Resident placement: Isolate the unit/wing to limit intermingling of staff and residents between other units/wings. CDC guidelines for collecting, handling and testing clinical specimens for COVID-19, dated May 22, 2020, revealed that proper collection of specimens is the most important step in the laboratory [DIAGNOSES REDACTED]. Using a flocked or spun polyester swab, insert the swab at least 1 cm (0.5 inch) inside the nostril (naris) and firmly sample the nasal membrane by rotating the swab and leaving in place for 10 to 15 seconds. Review on the instructions for use of Coronavirus Screening Questionnaire dated March 15, 2020, provided by the Southeastern Pennsylvania Veterans Center revealed for staff, volunteers, and contracted personnel (hereafter referred to as staff). All staff will receive an initial screening upon implementation of this process. The screening must occur prior to the employee beginning their shift. Any staff person answering yes to any of the screening questions will have their temperature taken and recorded on the screening form (temperature over 100 degrees Fahrenheit will be classified as a fever). Any staff member who is currently showing active symptoms of the coronavirus (fever, dry cough, sore throat, difficulty breathing) or who have answered yes to two or more of the screening questions 1 thru 3 and have an active temperature (temperature over 100 degrees Fahrenheit will be classified as a fever) will be sent home and highly encouraged to contact their Primary Care Provider and will not be permitted to return to work until asymptomatic or released by a physician. (With a written release from their Medical Provider). Upon return such members of staff will be prescreened. Any staff member who has answered yes to questions 5 thru 7 will undergo further screening and questioning to determine appropriate actions. Upon return from sick or annual leave of three or more days staff members will be screened in the manner described above for initial screening. They will assign personnel to maintain a list of staff members who are not permitted to return to work and the duration of their exclusion from the workplace. The commandant will provide an immediate SITREP (Situation Report) to the Director, Chief Medical Officer, Chief of Operations, and Chief Nursing Officer when any staff member fails a screening. An observation on June 1, 2020, at 8:10 a.m. of the screening process revealed no social distancing at the entrance to the building and no screening questionnaire form was used by the security guard at the entrance to the building. Interview on June 1, 2020, at 9:55 a.m. with the Infection Preventionist (Employee 2) revealed that not all of the staff had been fit tested (A process in which people who are required to wear negative-pressure respirators (i.e. N95) are examined with a rigorous protocol in which the tester challenges the face-to-face piece seal with a chemical agent). The Infection Preventionist was requested to provide the facility's trending and tracking for the last six months, COVID-19 plan binders and COVID-19 policy and procedures. The Infection Preventionist also revealed that on rare occasions people who are not working on positive units are pulled to work on positive units. During an additional interview June 1, 2020, at 12:10 p.m. with the Infection Preventionist, she was asked about a timeline of events since the Coronavirus pandemic started and what was put in place? Responses included: January 25, 2020, she spoke with County Employee 1 from the local county health department about getting testing swabs and was told not sure. March 5, 2020, Signage was put out regarding [MEDICAL CONDITION]. March 10, 2020, Family and visitors were limited, and screening began. March 11, 2020, Guidance was received on cohorting residents. March 12, 2020, Possible exposure of an employee who had worked at another facility. This employee was not tested by Southeastern Pennsylvania Veterans Center but was sent home and instructed to see their primary care physician. March 16, 2020, Visitation was stopped for families, visiting angels and senior helpers. March 25, 2020, Protective Personal Equipment (PPE)-Update on re-use of COVID-19 equipment. A resident on 2 West unit presented with respiratory illness. Protocol on resident assessments was increased from once a shift to every shift (same thing). March 31, 2020, Employee tests positive. Facility continued to test staff, but not residents. No instructions received about resident testing. April 2, 2020, Resident testing began, but there was no one specifically trained to do nasopharyngeal or oropharyngeal COVID testing with swabs. The Infection Preventionist got CDC guidelines for testing from the county website. She explained the test procedure and stated, I swab for 2-3 seconds. They (residents) won't last ten seconds. The Infection Preventionist also stated that she was off work from April 3, 2020, to April 15, 2020. Review of the line sheets for COVID-19 testing at the facility revealed that she developed symptoms for COVID-19 on April 3, 2020 and was tested COVID-19 negative with symptoms resolving on April 17, 2020. April 4, 2020, Droplet precautions started on residents who were symptomatic. Refrain from resident moving about. The Infection Preventionist Nurse (Employee 2) and the Director of Nursing were to create protocols. April 13 and 14, 2020, resident deaths started occurring. April 21, 2020, Infection Preventionist spoke with an employee from the local county health department about containing [MEDICAL CONDITION]. Recommended to stay the course and not move the residents about. Two more deaths occurred. The Infection Preventionist did not answer any questions about cohorting. April 22, 2020, Three more deaths. In addition, the Infection Preventionist was asked, did anyone try to determine how the COVID-19 was getting through and did you look at any residents to determine or track? She responded with, not sure why residents were moved, I don't know what was done, I can't answer. Observations on nursing unit 2 CLC-A side on June 1, 2020, at 10:50 a.m. revealed that Resident 34A was propelling himself in a wheelchair and saw Nurse Aide (NA) 6. Resident 34A put his arms out and NA 6 bent over and hugged him. Resident 34A was not wearing a mask. Interview with Registered Nurse (RN) 2 on June 1, 2020, at 10:51 a.m. confirmed that due to social distancing guidance the NA should not have hugged the resident. Interview with NA 7 on June 1, 2020, at 11:10 a.m. revealed that she was fit tested (a test that is done to confirm that a N95 respirator/mask correctly fits the user) for the N95 mask and failed which meant that she was unable to wear a N95 mask. She revealed that she has been pulled to COVID-19 positive units on several occasions since the pandemic began, even though she had failed the fit test. Resident 6A was readmitted to the facility on [DATE], at 3:00 p.m. Physician's orders for Resident 6A, dated May 20, 2020 included an order for [REDACTED]. Interview with RN 3 at that time confirmed that the thermometer was to be used on Resident 6A only and that it should have been stored inside the isolation cart and not on top. Observations of Laundry Aide (LA)1 on June 1, 2020, at 11:55 a.m. revealed that she was in Resident 6A's room putting away his laundry and socializing with the resident. The laundry aide exited Resident 6A's room and was wearing a surgical mask. She was not wearing the required N95 mask, gloves, gown or eye protection. Interview with (LA) 1 on June 1, 2020, at 11:55 a.m. revealed that she has been going in and out of all resident rooms (both COVID positive and negative) to deliver laundry and has never been told to wear the correct protective equipment. The LA 1 also stated that she has some medical conditions and her doctor told her to wear a N95 mask at all times when at work. June 2, 2020, at 8:20 a.m. interview with the Acting Commandant revealed CDC guidelines where not followed when residents who were tested positive and after timeline (14 days) were left on a positive unit. There was no tracing or tracking in place. An interview on June 2, 2020, at 8:38 a.m. with Screener 1 revealed that she started working at the facility on April 13, 2020 and works 7:00 a.m.-7:00 p.m. She's been instructed to sanitize her hands, then ask 4 questions, to each person who is entering. If they answer no to the questions, she takes their temperature. If it registers low, she has them sit and wait a few minutes until they warm up and retakes it. If the temperature registers high (100 degrees Fahrenheit) she contacts nursing to come down and ask more questions. If a person leaves the building and comes back, they are required, to have their temperature re-checked. One other security guard is at the Community Living Center (CLC) entrance. Other than today there was only one day that she was told to do a questionnaire and it was two weeks ago on a Wednesday. She asked a couple of questions then recorded temperature at the bottom of the form. During an interview on June 2, 2020, at 9:35 a.m. with Housekeeper 1 on 3CLC was asked, have you been instructed on what to do and he replied no. Housekeeper 1 revealed that in rooms with PPE (Personal Protective Equipment) he puts his mop in a bag and wipes the handle off. When ask if he was fit tested , measured specifically for the N95 mask and he replied No. An interview on June 2, 2020, 9:45 a.m. with RN 1, revealed that she has been at the facility for 5 weeks and was fit tested at VA. Further it was revealed that today was the first day with screening forms completed at the door. Interview with NA 5 on June 2, 2020, at 9:55 a.m. revealed that April 2020, was when the quarantine started, and the residents were isolated if they had signs and symptoms of COVID 19. NA 5 stated, I was on the positive floor for 3 weeks 2 East (2E). Was not allowed to leave for breaks or meals. Was occasionally pulled to another COVID floor. It was all new with changes every day. Interview with NA 3 on June 2, 2020, at 10:15 a.m. confirmed that staff have been pulled from positive to negative units and back the same day. NA 3 stated, Sometimes when I come in there isn't any PPE. I know they have it, but why do we have to beg for stuff that we have to wear, or we get PDC'd (Preliminary Disciplinary Committee). We had to take care of positive residents without being fit tested . The fit testing just started a week ago. During an interview with LPN 2 on June 2, 2020, at 10:25 a.m. it was stated, that we will be fired for talking to you. Watching people die was awful. We were told to wrap the residents in a body bag and meet the undertaker at the elevator. NA 3 went on to say no one from administration came on the floor because they didn't want to put gear on. What makes them better than us? There was a girl who was positive and worked the entire time. They also kept the residents in the dining rooms too long. We had problems, we knew some residents had something, but no one would do anything. We weren't allowed to wear PPE, or we would get written up. We were told it would scare the residents. On June 2, 2020, at 10:35 a.m. an interview with NA 4 revealed that she observed Employee 2 enter a positive room with no gown and mask on. Then was off for two weeks. On June 2, 2020, at 10:50 a.m. an interview with NA 2 revealed that no testing was done before April 5, 2020, because of arrogance. Resident 4A and Resident 13A were first tested . I tested positive on April 10, 2020, but back at work on April 12, 2020. Never had fever, I had what I thought was a sinus infection, but it was COVID-19. Resident 4A got sick March 31, 2020, we were given surgical masks, no gowns or N95 masks. Resident 14A never tested but put in a room with another man and woman (Resident 4A and 13A). Communal dining was stopped April 1, 2020, when the first employee was positive. An interview with Chief Medical Director on June 3, 2020, at 9:00 a.m. revealed that County Employee 4, told the former Commandant he no longer wanted to speak with Chief Medical Director at Southeastern Pennsylvania Veterans Center because he was confusing him. Was not comfortable with the Chief Medical Director having the link followed. The Chief Medical Director stated, I think I got myself in a little trouble because I may have put on the record that I wanted all staff and residents tested in April. An interview with County Employee 4 on June 4, 2020, at 10:00 a.m. revealed that the main person communicated with at Southeastern Pennsylvania Veterans Center was the Infection Preventionist and he kept telling her that the County was only the local department and that she needed to call the Pennsylvania Department of Health. An observation on June 5, 2020, at 7:55 a.m. of the screening process revealed Employee 1 was stationed behind a folding table on the sidewalk outside of the entrance to the facility. He had a surgical mask covering his nose and mouth and was not wearing any gloves on his hand. On the table was a container of disinfecting wipes, several pens, a digital thermometer, and two clip boards, which contained the screening forms. Employee 1 was calling the persons waiting in line to come to the table two at a time. This writer refused, stating social distancing, which he responded, you have a mask on. When this writer was screened, Employee 1 stated read the form, sign and date. This writer requested the employee to disinfect the pen prior to this writer picking up the pen. Employee 1 stated he didn't have any wipes, while at the same time, he removed the top of the container, placed his bare hand into the container (contaminating the entire container) and proceeded to wipe a pen. This writer asked the employee to place the pen down. At that time, Employee 1 said, I guess I should put gloves on and pulled gloves from his right pants pocket. This observation was confirmed at the time by the Director of Safety, who was social distancing in line behind this surveyor. On June 2, 2020, at 3:15 p.m. the Acting Commandant was notified of Immediate Jeopardy related to absence of a procedure for contract tracing and investigation of residents/staff suspected or confirmed positive for COVID-19. An action plan was requested to remove the Immediate Jeopardy. On June 2, 2020, at 7:30 p.m. an action plan was submitted and accepted. The action plan included: Resident 1A has been placed on isolation precautions since May 31, 2020, his COVID-19 testing swab pending results. All residents in facility are reviewed daily for temperature monitoring. No other residents are currently exhibiting signs/symptoms of COVID-19. Contact tracing will begin with Resident 1's caregivers and other staff members June 2, 2020, to be completed by June 5, 2020. The following measures will be implemented for residents with known or suspected COVID-19: In the event a resident is suspected or confirmed positive of COVID-19 the resident would be started on isolation precautions in accordance with the current CDC guidelines and contract tracing will begin. In the event a staff person acquires or is suspected of being positive for COVID-19 they will be restricted from providing direct care or services to residents and contact tracing would be initiated. Process for contact tracing in the case of resident: Implement log of all staff entering presumptive positive room. Minimize the number of staff entering room of presumptive positive or positive room. Only essential personnel are to enter the room of presumptive positive or positive resident. Record COVID-19 presumptive positive or positive residents' demographics and exposure data in the Respiratory Tracking Line List. Identify the first day of symptoms for the resident. If the resident's symptoms onset is unclear, use the earliest suspected date of symptoms. Obtain consent and order for COVID -19 swab. For each day the resident was symptomatic, identify all locations the resident visited or if the resident was hospitalized or in another facility (e.g. [MEDICAL TREATMENT] facility). For each location, make notes about each person or types of people that could have been in contact with the resident including visitors, other residents, staff and volunteers. Identify contacts, type and duration of exposure at each location/person during the symptomatic period. The time tracing that should be used for contact tracing after exposure to asymptomatic individuals who test positive for [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2) is currently 2 days. Any duration of exposure should be considered prolonged if the exposure occurred during performance of an aerosol-generating procedure. For each person exposed, investigate the interaction between the resident and the exposed contact. Was the resident wearing a mask? Was the resident able to wear a mask consistently? Was the resident coughing? What was the nature of the interaction? How long was the interaction? How close was the resident and exposed person? For staff what PPE were they wearing? Close contact is defined as: Being within approximately 6 feet distancing of a COVID-19 positive or presumptive positive case for a prolonged period of time. Close contact can occur while caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 positive case. Having direct contact with infectious secretions of COVID-19. Prolonged contact is defined as 15 minutes or longer. Process for contact tracing if case is a staff person: Record COVID-19 presumptive positive or positive staff demographics and exposure data in the Respiratory Tracking Line List. Identify the first day of symptoms for the employee. If the employee's symptoms onset is unclear, use the earliest suspected date of symptoms onset. Obtain consent and order for COVID-19 swab. For each day the staff member (employee) was in the facility, identify the staff's resident assignment and all locations the staff person visited within the facility. For each location, make notes about each person or types of people that could have been in contact with the employee including visitors, other residents, staff and volunteers. Inquire if staff maintained social distancing aside from direct resident care and where unavoidable within job duties. Identify contact types and duration of exposure at each location/person during symptomatic period. The time period that should be used for contact tracing after exposure to asymptomatic individual who tested positive for [DIAGNOSES REDACTED]-CoV-2 is currently 2 days. Any duration of exposure should be considered prolonged if the exposure occurred during performance of an aerosol-generating procedure. For each person exposed, investigate the interaction between the staff person and the exposed contact. Was the staff person wearing a mask? Was the staff person able to wear a mask consistently? Was the staff person coughing? What was the nature of the interaction? What was the duration of the interaction? How close was the case person and exposed person? Close contact is defined as: Being within approximately 6 feet of a COVID-19 positive or presumptive positive case for a prolonged period of time. Close contact can occur while caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 positive case. Having direct contact with infectious secretions of COVID-19 case. Prolonged contact is defined as 15 minutes or longer for any of the interactions, was exposed person wearing a mask or other PPE. The Infection Preventionist, Assistant Directors of Nursing, Quality Assurance Coordinator, Registered Nurse Supervisors and Unit Managers will be educated on contact Tracing Plan by the Director of Nursing Services/Designee by June 5, 2020. The Infection Preventionist will be responsible for ensuring contact tracing is completed for all presumptive or positive COVID-19 residents and staff. Spreadsheet tool will be utilized for tracking purposes. All staff will be completed with 100% of COVID-19 testing by June 19, 2020. The facility currently has 21% of staff tested since May 28, 2020, when mandatory testing was implemented. The facility will continue with 20% of employee testing weekly through the duration of the pandemic category of COVID-19. Audits of contact tracing of presumptive or positive residents will be completed by the Quality Assurance Coordinator/designee, daily times 7, weekly times 4 and monthly times 3 or through duration of pandemic. The results of all audits will be reviewed at the monthly Quality Assurance Committee meeting. The Quality Assurance Committee will determine the need for additional audits/interventions to ensure ongoing compliance. A review of the facility policy titled, Laundry Services states, all clean linen should be stored and transported in carts; all soiled linen should be bagged or put into carts at the location used; soiled linen should be removed from patient care areas a least daily and may need to be removed more frequently depending on the amount of soiled linen that is generated. During the entrance screening (questionnaire completion, temperature check) for Coronavirus COVID-19 on June 6, 2020, at 7:40 a.m. Screener 1 was observed not wearing gloves and using her bare hands to reach into the sanitizer bucket after touching contaminated pens and papers touched by individuals that were screened. Screener 1 was asked if she should be wearing gloves and she stated, I have them to wear but I was not told I had to wear them all the time. A box of gloves was present on the table. During entrance screening on June 6, 2020, at 10:40 a.m. Screener 2 had two persons complete the questionnaire at the same time at the same table, not [MEDICATION NAME] social distancing. During an interview with the Acting Commandant and the Acting Director of Nursing on June 6, 2020, at approximately 1:00 p.m. they confirmed that screeners were informed to wear gloves, that social distancing is required and will re-educate screeners on the process. Onsite tour was conducted on June 6, 2020, for implementing of the action plan, observations during a tour of 3 CLC on June 6, 2020, at 8:45 a.m., revealed a clean storage linen cart was uncovered. There were also clean linens exposed on top of the cart. Observations of 3 CLC on June 6, 2020, at 8:55 a.m. revealed a linen container/hamper overflowing with exposed soiled linen and a clear plastic bag with linen laying on the floor outside of room [ROOM NUMBER] CLC (214). During a tour of the 4 CLC B unit on June 6, 2020, at 9:10 a.m., NA 2 was observed without her mask. During an interview with NA 2, she was asked, are you to be wearing a mask? NA 1's response was I was hot, so I took it off. I just masked up and I can't breathe. The 4 CLC B is a COVID-19 positive unit. Observation on 2 East on June 6, 2020, at 9:45 a.m. revealed a covered linen cart with clean linen exposed on top of the cart. A review of the facility's policy titled, Water Pass, last revised October 2017, states fresh water and ice will be passed out on each shift in 16-ounce disposable cups with lids and straws. During a tour of 2 East on June 6, 2020, at 9:40 a.m., NA 1 was observed with the ice scoop placed in the storage ice container as she was delivering ice room to room on a positive COVID-19 unit. During an interview with NA 1 on June 6, 2020, at 9:42 a.m., she was asked, should the ice container be uncovered, and the ice scoop stored in the container? There was no comment from NA 1. NA 1 was delivering ice room to room and filing the cups outside each resident room, rather than filling the cups in a clean location and delivering the already filled cups to the resident rooms. This was a (TRUNCATED)

Based on review of clinical records, observation and review of facility documentation, it was determined that the facility failed to ensure that adequate monitoring, supervision and implementation of interventions were provided to prevent falls and injuries for five of 33 residents reviewed (Residents A10, A12, B1, B7 and O11) which resulted in a fall with a fracture and actual harm to Residents A12 and O11, and the facilty failed to safeguard medications on one of six nursing units (Coates Hall 2 West). Findings include: Review of Resident A12's [DIAGNOSES REDACTED]. Review of Resident A12's Quarterly Minimum Data Set assessment (MDS - periodic assessment of a resident's needs) dated March 8, 2017, revealed Resident A12's Brief Interview for Mental Status score was 6, indicating severe cognitive impairment and the resident required supervision for walking in the resident's room and corridor and ambulating on and off the unit. Review of Resident A12's plan of care dated July 6, 2016, revealed that Resident A12 used a rollator walker throughout with supervision for directions and orientation. Review of Resident A12's resident progress notes dated February 28, 2017, revealed that on February 28, 2017, Resident A12 was transferred from Coates Hall to a room on the memory support unit on first floor of Community Living Center building (CLC). Further review of Resident A12's resident progress notes dated March 1, 2017, revealed a physical therapy screen note which revealed resident seen for screen upon move to new room in CLC. She remains able to transfer and ambulate using rolling walker (RW) on carpeting with staff supervision and safety/directional cueing. Resident has no retention of safety measures and has impaired safety awareness due to impaired cognition. Review of Resident A12's resident progress notes dated March 8, 2017, at 9:15 a.m. revealed nurse was passing medication around 9:15 when this nurse heard resident shouting for help. Nurse immediately rush to resident who was lying on her back on the floor; walker on her side. Resident was alert even though she was in serious pain on left hip. Resident was not able to extend her left leg without serious pain. Resident was transferred off the floor by emergency personnel. The resident was subsequently transferred to the local hospital for evaluation. Further review of Resident A12's resident progress notes dated March 8, 2017, at 10:10 a.m. revealed resident was sent to the ER (emergency room ) . for evaluation related to s/p (status [REDACTED]. Further review of Resident A12's resident progress notes dated March 8, 2017, at 2:09 p.m. confirmed that the resident was admitted to the hospital with [REDACTED]. Review of facility documentation revealed that Resident A12's fall in the hallway was unwitnessed by any staff member. Resident A12 was ambulating unassisted and with no supervision which resulted in a fall and a subsequent hip fracture which caused actual harm to Resident A12. The above information was relayed to the Director of Nursing on October 11, 2017, at approximately 11:00 a.m. Review of Resident O11's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident O11's Quarterly MDS assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status score was 99, indicating that the resident was unable to complete the interview. Staff assessment of the resident's cognition revealed the resident had short and long term memory problems and was severely cognitively impaired. Review of Resident O11's Fall Risk Assessment completed on January 18, 2017, revealed the resident scored 17, with a score of 10 or above indicating a risk for falls. Review of Resident O11's plan of care for falls revealed an intervention developed on October 22, 2015, stated the resident was to be given verbal reminders not to ambulate or transfer without assistance. Another intervention added March 3, 2016, stated that the staff were to toilet the resident immediately after the resident gets up from meals. Review of Resident O11's progress notes revealed the resident had unwitnessed falls in the dining room on January 5, 2017, at 5:40 p.m. and January 18, 2017, at 5:24 p.m. Review of Resident O11's progress notes revealed a nurse's note on January 25, 2017, which stated that throughout the shift, the resident required a lot of redirection. The nurse wrote after multiple ineffective redirects from (nursing assistants) and myself, I sat with resident and provided 1:1 care until supper. At 5:45 p.m. I walked resident over from TV room to dinning room for supper. The note further indicated that the licensed nurse felt that the resident required more redirection during the evening and the licensed nurse chose to sit and feed the resident. Further review of the nursing note revealed that I was able to get the resident to sit back after multiple attempts at 1818 (6:18 p.m.) after feeding resident, I noted another resident nearby needed my assistance, therefore I got up to assist the other resident. Prior to the licensed nurse getting up she made sure resident was up and walking steady. At 6:20 p.m. the licensed nurse heard a loud noise, she turned around and noted the resident lying on the floor next to the table in the dinning room floor facing the window. The nursing note indicated that the licensed nurse assessed the resident and noted resident was initially unresponsive. I also noted blood on the floor . at 6:23 p.m. 911 ( Emergency Medical Services) was called. The resident's physcian was notified of the fall incident and orders were obtained to transfer the resident to the emergency room for evaluation. At 6:35 p.m. EMT (emergency medical technician) arrived at the facility to the take the resident to the emergency room . Review of a nursing note dated January 25, 2017, at 10:06 p.m. confirmed that the resident was admitted to the hospital with [REDACTED].) Resident O11's three unwitnessed falls in the dining room at dinner time and the resident being left to ambulate without assitance following a display of unsafe behaviors throughout the shift were discussed with the Nursing Home Administrator and Director of Nursing on October 11, 2017, at approximately 1:55 p.m. The facility failed to ensure that the resident was toileted immediately after the resident completed her meal as indicated on the resident's care plan. The licensed staff failed to follow the resident's plan of care which stated that the resident was not to ambulate without assistance which resutled in actual harm to resident O11 sustaining a fall, requiring transfer via emergency medical services and [DIAGNOSES REDACTED]. Review of Resident B1's clinical record revealed the resident had [DIAGNOSES REDACTED].) Review of Resident B1's Quarterly MDS assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status score was 4, indicating severe cognitive impairment and the resident required supervision of one staff member for transfers and walking in the resident's room. The MDS further revealed that the resident was to utilize a walker while ambulating. Review of Resident B1's progress notes revealed that on September 5, 2017, at approximately 4:45 a.m. the resident was found screaming on the floor by her bed with no walker around. The resident was subsequently sent to the hospital for evaluation. Review of the facility investigation witness statements revealed that the nursing assistant assigned to the first floor of the CLC building on B wing, was on break at the time of the fall. A review of Question 12 on the witness statement which asked the assigned nursing assistant Who covered for your resident when you were off of the unit? was left blank. Further review of the facility investigation revealed that the nursing assistant on first floor of the CLC building on A wing, was on the A wing doing rounds at the time of the fall and the nurse assigned to the first floor of the CLC building was in the nurse's station at the time of the fall. Resident B1's fall and the lack of supervision on the first floor of the CLC building on B wing, at the time of the resident's fall was discussed with the Nursing Home Administrator and Director of Nursing on October 11, 2017, at approximately 1:45 p.m. Review of Resident A10's [DIAGNOSES REDACTED]. Review of Resident A10's Quarterly Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 4 which indicated severe cognitive impairment. Further review of this MDS revealed that Resident A10 required limited assistance of one staff person for ambulation on and off the unit. Review of Resident A10's plan of care dated November 21, 2016, revealed Resident A10 required supervision with ambulation and cue for safety and direction. Review of Resident A10's resident progress notes revealed that on January 22, 2017, Resident A10 was found with a 2.5-centimeter (cm) laceration (cut) to the back of the head. Further review of Resident A10's resident progress notes revealed that Resident A10 stated, I slipped. Review of Resident A10's Physical Therapy Screen note dated January 25, 2017, revealed use RW (rolling walker) all the time. Review of Resident A10's resident progress notes revealed that on May 30, 2017, at 6:56 p.m. Resident A10 was found on the floor of the resident's room with an abrasion on the back of the resident's head. Review of Resident A10's resident progress notes revealed that on August 17, 2017, at 7:15 p.m. Resident A10 was found on the floor of the resident's room stating he climbed on the desk top to get to the television set. Review of Resident A10's resident progress notes revealed that on August 24, 2017, at 7:11 p.m. the resident was found lying on the floor of the common television room. Review of Resident A10's Physical Therapy Screen note dated August 26, 2017, revealed recommend to provide appropriate redirection and assistance with resident wearing appropriate shoe and on navigating crowded areas for safety. He has impaired safety awareness and not able to retain safety education measures. Review of Resident A10's Physical Therapy Screen note dated October 4, 2017, revealed due to anxiety it is felt resident will be safest with RW and ongoing staff supervision/cueing for safety measures. Interview with the Director of Nursing on October 11, 2017, at approximately 11:00 a.m. confirmed that Resident A10 should be supervised during ambulation. The facility failed to provide Resident A10 with appropriate supervision during ambulation to prevent falls, which resulted in Resident A10 sustaining falls on January 26, 2017, May 30, 2017, August 17, 2017, and August 24, 2017. Review of Resident B7's [DIAGNOSES REDACTED]. Review of Resident B7's Admission MDS assessment dated [DATE], revealed that Resident B7 required supervision assistance of one staff member for ambulation in the hallway of the nursing unit. Further review of Resident B7's Admission MDS revealed a Brief Interview for Mental Status score of 3 which indicated severe cognitive impairment. Review of Resident B7's admission plan of care dated March 9, 2017, revealed ambulate throughout using wheeled walker, supervised for safety and for directions/orientation to her new environment. Review of Resident B7's resident progress notes dated April 28, 2017, revealed Resident B7 was found on the floor at the entrance to the bathroom. Review of Resident B7's resident progress notes dated May 18, 2017, revealed that Resident B7 was found on the floor in the dining room and Resident B7 reported hitting head on the floor. Further review of Resident B7's resident progress note revealed a 2.5 centimeter round bump located on the back of Resident B7's head. Review of Resident B7's resident progress notes dated July 15, 2017, revealed at 6:08 p.m. Resident B7 was found lying on the common television room floor and had complained of hitting head again during the fall. Review of Resident B7's Physical Therapy Screen note dated July 17, 2017, revealed remains needing supervision for directions/orientation. Recommend to provide appropriate assistance as needed especially on crowded areas. Review of Resident B7's resident progress notes dated September 3, 2017, at 4:45 p.m. revealed Resident B7 was found in the back hallway of the unit lying on the resident's right side with the rolling walker approximately 10 feet away. Resident B7 stated I tripped. Review of Resident B7's resident progress notes dated October 8, 2017, revealed that Resident B7 was found on the floor in the resident's room lying on the left side with the resident's head against the night stand and stated, She was holding a sandwich and salad. Review of facility documentation provided by the facility revealed that on October 8, 2017, the staff witnessed the resident walk down to her room unattended after dinner. Further review of facility documentation revealed that the nurse, on the unit at the time of the fall on October 8, 2017, was in the nurses' station putting notes in computer. Interview with the Director of Nursing on October 11, 2017, at approximately 11:00 a.m. confirmed that Resident B7 had no supervision during ambulation on the nursing unit. The facility failed to provide Resident B7 with appropriate supervision during ambulation to prevent falls, which resulted in Resident B7 sustaining falls on April 28, 2017, May 18, 2017, July 15, 2017, September 3, 2017, and October 8, 2017. During an observation of the medication administration on the second floor of Coates Building West Wing on the on October 5, 2017, at 4:05 a.m. revealed a Licensed Nurse, Employee E4, proceeded to administer crushed medications in pudding to Resident J4. Employee E4 was able to administer one teaspoon of medication mixed in pudding to Resident J4, who then refused the rest of the medication. Employee E4 then set the medication on top of the medication cart and proceeded to continue the medication administration pass. At 4:20 p.m., a pharmacy technician approached Employee E4 at the medication cart and delivered a tote full of eighteen medications, which were taken out of the tote and placed on top of the medication cart. Further observation of the medication administration pass on October 5, 2017, at 4:35 p.m. revealed Employee E4 proceeded to leave Resident J4's medication cup containing medication and pudding, a plastic bag containing a vial of Novolog (fast-acting mealtime insulin that works quickly to help control blood sugar spikes that happen when you eat), four plastic bags containing individual bottles of eyedrops, a box of ocusoft eyelid scrubs, two one pound (454g) jars of Hydrocerin Cream (hydrate dry, scaly skin), four 4.23 ounce (120g) jars of Hydrocerin Cream and two tubes of ointment on top of the medication cart which was sitting in front the second floor West Wing nurses' station. Employee E4 then left the medication cart unattended and out of site, while she walked down the hall, around the corner to the door of Resident I1's room and administered medication. Resident I1's room was approximately 40 to 50 feet away from the medication cart and out of Employee E4's site. Interview with Employee E4 on October 5, 2017, at 4:40 p.m. during the medication administration pass confirmed that the medications should have been put away and locked up, prior to leaving the medication cart out of site and unattended. The aforementioned findings were reported to the Director of Nursing on October 11, 2017, at approximately 10:45 a.m. The facility staff failed to ensure that medications were safely secured and stored to prevent access of the medications by unauthorized persons or residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 10/29/15 28 Pa. code 211.5(g) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 10/29/15 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/29/15

Based on observations, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the serving areas of each of the two Country Kitchens located on four of four floors (the 1st, 2nd, 3rd, and 4th floors) for a total of eight Country Kitchens, were adequately secured to restrict access to potential hazards and to ensure the safety and supervision of dementia residents living in the Community Living Center. Additionally, the facility failed to properly supervise residents from wandering into two of two Country Kitchens in the secured 1st floor Dementia A and B Nursing Units, thereby placing the health and safety of the residents in an Immediate Jeopardy situation on the 1st floor A & B Nursing Units of the Community Living Center. The facility also failed to ensure that the treatment carts were secured on one of 10 units (1st floor Dementia Unit A side). Findings include: Observation of the Community Living Center 1st Floor Secured Dementia Unit, 2nd Floor, 3rd Floor and 4th Floor revealed that the facility has a homelike environment with Country Kitchens in the dining areas. These Country Kitchens allow for the serving of food in the dining area with the serving area secured by a retractable seat belt device that extends across the front of the serving counter through the opening into the serving area to the other side of the opening. Observations conducted on August 13, 2014, at 9:48 a.m., on the 1st Floor Secured Dementia Unit, revealed that Resident E11 freely entered the Country Kitchen A side serving area and opened one of the two freezers and retrieved a 4 ounce cup of vanilla ice cream. The resident opened the lid of the ice cream and proceeded to eat the ice cream using the lid as a spoon while walking down the hallway towards his room. At the time of the observation, there were no facility staff present or nearby to provide supervision to this resident. On August 13, 2014, at 9:51 a. m., (3 minutes later) Dietary Staff, Employee E5, arrived to the 1st Floor/Secured Dementia Unit and enclosed the serving area on the A side of the Country Kitchen with a retractable seat belt strap, which started at a post and went around the counter and the opening of the kitchen. Employee E5 left the kitchen area at 9:55 a.m. At 10:00 a.m., Resident E11 was observed going around the retractable seat belt post which was placed around the counter and entered the serving area of the Country Kitchen. The resident opened the same freezer again but did not retrieve any food articles at the time. Resident E11 went around the post and proceeded to exit the Country Kitchen serving area without restrictions. On August 13, 2014, at 10:05 a.m., Employee E5 returned to the Country Kitchen and was interviewed by the surveyor. During the interview, Employee E5 confirmed that the residents were not allowed to access the kitchen area to get food. Observation conducted on August 13, 2014, at 10:20 a.m., with Employee E5, of the Country Kitchen on the 1st Floor A side, revealed that the serving area contained a steam table with four steam wells, a stove, a full size refrigerator, a small freezer, and a dishwasher next to the steam table. At the time of the observation, the right side cabinet underneath the steam table was unlocked with easy access to the on/off switch that controlled the steam table wells. The switch was in the 'on' position as confirmed by Employee E5. All four steam wells on the steam tables were able to be easily turned to the heated 'on' position. Employee E5 indicated that the cabinet should remain locked at all times but when Employee E5 went to lock it, the key must have "slipped" from the lock which caused the cabinet to remain unlocked. Employee E5 confirmed that the on/off switch would remain in the 'on' position until the end of the shift at 2:30 p.m., when the switch to the steam wells is then turned off by the employee. In addition, items stored underneath the cabinet were a bottle of hand soup and a large bottle of commercial dishwasher soap with a hose to supply the soap to the dishwasher. The dishwasher soap bottle label indicated, "keep out of reach of children." Employee E5 proceeded to lock the cabinet and the switch to the steam table remained in the 'on' position allowing for all of the steam wells to be turned on. Employee E5 was then observed to have exited the Country Kitchen area. Observation conducted on August 13, 2014, at 11:00 a.m., revealed that Resident E3 proceeded to enter the Country Kitchen serving area on the 1st Floor A side by going under the retractable seatbelt enclosing the opening to the kitchen in his wheelchair. Resident E3 took off his shoes and left them in the serving area of the Country Kitchen and again went under the seatbelt extended between two poles to exit the serving are of the Country Kitchen. The retractable seatbelt was observed to retract while Resident E3 went under it to exit the kitchen serving area. The opening to the Country Kitchen serving area between the cabinets on the left side and the counter was observed to be freely accessible to the residents. The steam table remained with the switch in the 'on' heated position and no facility staff were observed supervising the Country Kitchen, allowing residents to have full access to the steam table. Observations conducted on August 13, 2014, at 11:10 a.m., revealed that Employee E5 returned to the 1st Floor Country Kitchen, on the A side, for a period of 4 minutes then proceeded to leave the Country Kitchen. No other facility staff was observed to be available to provide supervision of the 1st Floor Country Kitchen A side. An observation conducted on August 13, 2014, at 11:15 a.m., revealed that Resident E11 returned to the Country Kitchen serving area for the third time and proceeded to go around the retractable seat belt placed around the counter and opening into the serving area of the kitchen and retrieved another 4 ounce cup of vanilla ice cream. The resident again opened the lid of the ice cream and proceeded to eat the ice cream using the lid as a spoon while walking down the hallway towards his room. Review of Resident E11's August 2014 physician's orders [REDACTED]. Resident E11 was ordered to receive a diabetic carbohydrate control diet with a physician's orders [REDACTED]. There were no facility staff available in the Country Kitchen on the 1st floor A side or in the surrounding areas to provide adequate supervision to Resident E11, who had a [DIAGNOSES REDACTED]. Observations conducted on the 1st Floor/Dementia Unit B side revealed that on August 13, 2014, at 10:20 a.m., the cabinet underneath the steam table was unlocked with the steam table switch in the 'on' position. Underneath the cabinet was a stored bottle of hand soap 1/3 full with a label that indicated, "keep out of reach of children and call poison control." An interview conducted with Employee E5 on August 13, 2014, at 10:35 a.m., confirmed that the cabinet underneath the steam table was unlocked with the steam table switch in the 'on' position and hand soap was stored in this cabinet. Review of facility documentation revealed that there were 11 residents identified with a [DIAGNOSES REDACTED]. Observations conducted of the 4th Floor Country Kitchen, A side serving area, on August 13, 2014, at 11:45 a.m., with dietary Employee E7 revealed that the left side cabinet underneath the steam table was unlocked. An interview with Employee E7 at the time of the observation confirmed that the lock was broken and Employee E7 proceeded to demonstrate that the lock was able to turn 360 degrees from the inside of the door confirming that it did not properly secure the cabinet. Under the cabinet Employee E7 confirmed that the switch to heat the steam table was in the 'on' position and that a bottle of glass cleaner was also stored in this cabinet. The glass cleaner label indicated, "low risk for skin, eye and respiratory irritation." Further interview with Employee E7 on August 13, 2014, at 11:45 a.m., indicated that after she completed the noon meal dining service on the 4th floor A side she proceeded to assist in serving the meal on the B side. Observations conducted on August 13, 2014, at 12:55 p.m., confirmed that at the completion of the noon meal, Employee E7 left the Country Kitchen on the A side and went to the Country Kitchen on the B side to begin the lunch service. The left side cabinet underneath the steam table remained unlocked, the steam table switch remained in the 'on' position and the glass cleaner remained stored in the cabinet. There was no facility staff available supervising this area which allowed for residents to have unsupervised access to the steam table with four heated steam wells. Review of facility documentation revealed that 9 residents were identified with a [DIAGNOSES REDACTED]. Observations conducted of the 2nd Floor Country Kitchen A side serving area on August 13, 2014, in the company of dietary staff, Employee E10, at 11:50 a.m., revealed that the steam table was heated and covered with a hard plastic cover and it was hot to the touch around the metal edges of the four steam wells of the steam table. Employee E10 indicated that the steam table was turned on at 11:00 a.m., and that it was checked every 10 minutes to ensure the water contained in the metal well, "would not boil away." Observation conducted of the 2nd Floor Country Kitchen B side serving area on August 13, 2014, at 12:05 p.m., revealed that Resident G7 accessed the serving area without restriction and poured himself a cup of coffee, heated the cup in the microwave, retrieved the cup and sat in the dining area. There was no staff supervision provided in the kitchen area while Resident G7 heated the coffee. An interview conducted with Dietary Staff, Employee E10, on August 13, 2014, at 12:05 p.m., confirmed that the kitchen area was safeguarded at times from resident access by utilizing a movable two-tier metal cart which was placed across the opening of the kitchen serving area between the cabinets and the counter space. A total of 18 residents on the 2nd floor had a [DIAGNOSES REDACTED]. Although the 3rd Floor Country Kitchen A and B sides were not observed during meal service, these serving areas were also secured by retractable seat belt closures to stop access into the serving areas of the Country Kitchen. Review of facility documentation revealed that nine residents were identified with a [DIAGNOSES REDACTED]. An interview conducted with the Director of Dietetic Services on August 13, 2014, at 4:20 p.m., revealed that the steam wells in the steam tables in each Country Kitchen on the 1st, 2nd, 3rd and 4th floors are turned on to be heated in the morning, 30 to 45 minutes before the food is brought up from the main kitchen to the Country Kitchen, and each steam well should be covered with a plastic cover. The cabinet underneath the steam table was to be locked at all times. The Director of Dietetic Services confirmed that after the steam tables were turned on, the dietary staff left the Country Kitchen and returned to the main kitchen to obtain the food carts with the food to be served for the designated meal. At the completion of the meal, the dietary staff were to turn off the steam tables and drain the hot water before proceeding to begin the meal service on the second unit of their designated floor. The facility was not able to provide evidence that during the time the dietary staff left the Country Kitchen areas to return to the main kitchen to obtain the food carts, there was facility staff designated to supervise the Country Kitchens on all floors of the Community Living Center while the dietary staff were not present. An interview with the Director of Dietetic Services on August 13, 2014, at 5:40 p.m., after the completion of the dinner meal on the 1st Floor/ Dementia Unit A side, revealed that the temperature of the water remaining in the wells of the steam table was tested at 140 degrees Fahrenheit. Interview conducted with Licensed Nurse, Employee E15, on August 13, 2014, at 5:10 p.m., confirmed the residents were not allowed to be in the serving area of the Country Kitchen at any time on the 1st Floor /Dementia Unit A and B sides. Immediate Jeopardy was identified to the Nursing Home Administrator on August 13, 2014, at 4:00 p.m., for failing to ensure that four Country Kitchen serving areas in the Community Living Center, were safely secured and restricted from resident access to safeguard the residents from accidents and failed to provide adequate supervision of the residents with dementia on the 1st Floor Dementia Unit, which placed the health and safety of residents in Immediate Jeopardy. An action plan was requested on August 13, 2014, at 4:00 p.m., to immediately put systems in place to provide adequate supervision and security of the Country Kitchens, in the Community Living Center, to ensure the safety of the residents. The IJ was removed on August 13, 2014 at 6:00 p.m., when the plan of action was implemented. Immediate supervision was put in place in all of the Country Kitchens and temporary gates were installed until permanent ones were located. Further observations conducted of the 1st Floor Secure Dementia Unit on August 13, 2014, at 10:25 a.m., revealed that the treatment cart was placed in front of Room 122. The door to the room was closed and the treatment cart was observed to be unlocked for approximately 4 minutes. Licensed Nurse, Employee E16, opened the door to the room and then proceeded to lock the treatment cart. Employee E16 had no view of the treatment cart, during the period of time that the staff was in Room 122, to ensure the residents did not have access to the contents in the treatment cart. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/06/2012, 12/19/2012, 09/23/2013, 05/21/2014. 28 Pa. Code 201.18(b)(3) Management. Previously cited 09/23/2013. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 12/06/2012, 09/23/2013, 05/21/2014. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/06/2012, 12/19/2012, 09/23/2013, 05/21/2014. 28 Pa. Code 211.12(c) Nursing services. Previously cited 09/23/2013. 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/06/2012, 06/25/2013, 09/23/2013. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/06/2012, 12/19/2012, 06/25/2013, 09/23/2013, 05/21/2014.

Based on clinical record review, facility policy and procedure and staff interview, it was determined that the facility failed to correctly administer medication in accordance with the physician order [REDACTED]. Findings include: Review of facility's policy titled "Medication: Long Term Care" revised August 2012 indicated that all medications must be written on the physician's orders [REDACTED]. The policy indicated for staff read the medication administration sheets carefully, be sure to understand them and if in doubt to check them with the physician's orders [REDACTED]. The policy also indicated that stat (immediately) medications must be charted in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The policy stated that PRN medications (as needed) are charted under date and column with the time the medications are given and staff initials. Review of the facility's policy titled " Medication Insulin Administration" updated July 2011 revealed that all residents who have physician's orders [REDACTED]. It indicated that the nurse would read the label on the insulin vail and compare it with the medication administration record and would withdraw the correct amount of insulin. Review of the facility's policy titled " Hypoglycemic - Treatment" dated December 2011 included glucometer reading less than 60 as sign and symptom of low blood glucose. The policy indicated that if the resident was symptomatic and unconscious and an accu check reading (test of blood sugar level) is less than 60, to immediately administer [MEDICATION NAME] IM, Activate EMS- call 911 and then notify physician and family. If no response in 5 minutes repeat [MEDICATION NAME] 1 milligram IM remain with resident, and monitor vital signs until EMS has arrived. Review of the facility's policy titled " list of Emergency Drugs" updated December 2011 included the following Oral Glucose Gel ( used for low blood sugar) and [MEDICATION NAME] Hypokit (given to increase blood sugar level). Review of Resident R1's physician orders [REDACTED]. The physician's orders [REDACTED]. revealed an order for [REDACTED]. Facility documentation dated December 17,2012 revealed that the Resident R1 was scheduled to received [MEDICATION NAME] 100unit/ml, 7unit SQ (subcutaneously) Bid (twice daily), was given [MEDICATION NAME] 100 units/ml, 100 units SQ (subcutaneously) by LPN. Review of nursing notes dated December 17, 2012 revealed that the resident was Diaphoretic (excessive sweating associated with medical emergency conditions) and unresponsive and the resident's accu check (blood sugar) at 11:30a.m. was 36, then rechecked and the accu check was 31. There was no documentation in the clinical record when the recheck was done. Nurses' notes dated December 17, 2012 indicated that the physician and nurse practitioner were notified and present on the unit and orders were received to transfer resident to the hospital via 911. Nurses notes dated December 17, 2012 stated to administer [MEDICATION NAME] 1 milligram/milliliter SQ to the abdomen x 4- 11:50a.m.-11:55a.m. and Glucotose oral gel x 2 doses. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s policy. There was also no clear documentation to indicate when blood sugars and blood pressures were taken. The nurses notes indicated that the resident 's blood pressure dropped from 112/60 to 90/60 and that it was monitored closely by the nurse practitioner, that the resident's blood sugar was 51 then 76 prior to his departure to the hospital. Review of the facility's documentation for the incident licensed nursing Employee E4 indicated that at approximately 11:30 a.m. on December 17, 2012, licensed nursing Employee E 3 approached her and stated that Resident R1's blood sugar was 36 milligrams per deciliter ( normal-70 mg/dl) and that the resident was unresponsive and diaphoretic (excessive sweating associated with medical emergency conditions). Licensed nursing Employee E4 then saw licensed nursing Employee E5 who indicated she would recheck the accu check. Review of Licensed Employee E5's statement revealed that she was notified at approximately 11:25a.m. on December 17, 2012 that Resident R1's blood sugar was 31 milligrams per deciliter Employee E4's statement indicated that the resident's blood sugar was rechecked and it was now 31. There was no documentation that licensed nursing Employee E 3 administered [MEDICATION NAME] immediately after she identified that the resident was unresponsive or that EMS was activated immediately as indicated in the facility's policy for this emergent situation.(before notifying the physician or finding another nurse). Review of the physician's orders [REDACTED]. The order included [MEDICATION NAME] 1 ampoule x 4 doses and Glucosegel be administered by mouth x two doses total. Interviewed with the Director of Nursing on December 19, 2012 revealed that the Emergency medications are located in the emergency box in the medication room on each unit. Review of the hospital documentation dated December 17, 2012 revealed that the resident was admitted with a [DIAGNOSES REDACTED]. The facility failed to ensure that physician insulin order was administered correctly and failed to ensure consistent accurate documentation regarding the timeliness of care. 28 PA Code 201.18(b)(1)(e)(1) Management Previously cited 12/6/12, 7/18/2012; 6/30/2011; 9/15/2011 28 Pa Code: 211.5(f) Clinical records Previously cited 10/17/2012; 8/27/2012; 7/18/2012, 12/6/12 28 Pa Code: 211.10(d) Resident care policies Previously cited 8/27/2012, 12/6/12 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 7/23/2010; 10/1/2010; 6/30/2011; 9/15/2011; 6/18/2012; 7/18/2012; 8/27/2012, 12/6/12

Based on a review of facility policy and procedure, family and staff interviews, and review of facility documentation, it was determined that the facility failed to implement their policy for reporting and investigating abuse and neglect for five out of 35 residents reviewed (Residents A13, A8, A10, A4 and K12), resulting in actual harm to one resident (Resident A13). Findings include: A review of the current facility policy entitled, "Prevention of Resident Abuse Policy " revised May 20, 2009, revealed that abuse included: "The willful deprivation of goods or services which are necessary to maintain physical, mental and psychosocial well being or mental health. Intimidation or punishment with resulting physical harm, pain or anguish. Any act by an employee with residents that does not have as its legitimate goal the healthful, proper and humane care and treatment of [REDACTED]. The policy revealed that "all employees, regardless of classification, bargain unit or seniority have the same obligations regarding the fulfillment of the Prevention of Resident Abuse Policy. All employees are required to immediately report any knowledge of possible resident abuse to a supervisor (or directly to the Assistant Director of Nursing, Director of Nursing, Assistant Commandant or Commandant). All supervisors are responsible for ensuring that management/administrative personnel are notified immediately and appropriate action is initiated. Immediate reporting of cases of alleged abuse is extremely important and at times it may be necessary to bypass the normal supervisory chain and report directly to a higher-level management official." Further review of this policy revealed that during the time of the investigation, the suspected employee(s) will be removed from the area in which the resident(s) who may have been abused reside. The investigation team will then decide whether or not to remove the employee(s) to a different department, unit, or from the building based on their investigative findings. Review of Resident A13's June 2012 physician's orders [REDACTED]. Review of the facility investigation into abuse dated July 11, 2012, indicated that Resident A13 was completely oriented to person, place, and time. Further review of the facility investigation into abuse indicated that on July 11, 2012, the resident had reported to Employee E5, a social worker, that Employee E15, a Registered Nurse, had been forcefully administering medications and water to him. The resident further reported that Employee E15 was demanding, and embarrassed him by, "treating him like a boy." A psychology note completed on July 11, 2012, indicated that Resident A13 had reported that Employee E15 gives the resident his medications in a forceful manner, and that Employee E15 is harsh. The psychology note further documented that the resident appeared to be intimidated by Employee E15. Review of a staff statement by a nursing assistant obtained as a result of the investigation dated July 14, 2012, indicated that the employee had seen Employee E15, "force medication into resident's mouths by pushing the cup against their lips and push medication into the resident's mouth." The employee did not give specific dates but stated, "It is consistent reoccurrences on the unit." Another staff statement obtained on July 14, 2012, indicated that another nurse aide had responded to the resident the prior week when he rang his call bell. This employee's statement indicated that the resident reported that he was very upset with the accused nurse, Employee E15, because he had forcefully administered pills down the resident's throat. Interview with the Director of Nursing on July 17, 2012, at 12:30 p.m., indicated that neither employee had ever reported this resident's concerns as per facility policy and procedure. Interview with Resident A13 on July 18, 2012, at 1:40 p.m., indicated that Employee E15, on his first day in the facility tried to disguise his medications in applesauce. The resident stated he had confronted the employee, Employee E15, and explained that he liked to see what pills he was getting, and that he was oriented enough to know what pills he should be getting. The resident further stated that Employee E15 continued, on multiple occasions after this incident, to put pills on a spoon and shove them in his mouth. The resident reported he had little time to swallow the pills before the nurse shoved a cup of water into his mouth. Resident A13 also stated that Employee E15 was very short with him, demanding and intimidating, and causing him to frequently accept his pills in this manner. The facility staff failed to report the resident's concerns regarding the forceful administration of medications by Employee E15, causing Resident A13 harm in the form of being repeatedly intimidated by the accused nurse. Review of Resident A8's current physician's orders [REDACTED]. The resident's Significant Change in Status Minimum Data Set (MDS - a periodic assessment of care needs) assessment dated [DATE], revealed that the resident was moderately cognitively impaired. Interview on July 11, 2012, at 12:15 p.m., with a family member of Resident A8, revealed that she was concerned about an incident that she had witnessed while visiting Resident A8 on July 8, 2012, at noontime. The family member reported this incident to staff, specifically Employee E4, a licensed nurse, via e-mail on July 9, 2012. She stated that Employee E15 was forceful in giving the resident his medications on a spoon, pushing the spoon forcefully into his mouth. She stated that Employee E15 did not attempt to engage the resident in taking the medicine but rather forced him. When questioned by the survey team on July 12, 2012, at 9:00 a.m., about reporting and investigating the incident involving Resident A8 that was witnessed by a family member, Employee E5 provided an e-mail that was sent to Employee E4, from the family member on July 9, 2012, at 9:36 a.m., reporting the incident. The information was forwarded to social service Employee E5 on July 9, 2012, at 9:41 a.m., who made out a concern form dated July 10, 2012, 10:59 a.m. Both of these employees, Employee E4 and Employee E5, did not identify Employee E15's action as possible abuse and did not timely report the allegation through the chain of command so that an investigation could be initiated immediately. In addition, because the incident was not immediately reported, Employee E15 continued to work and have contact with the resident on the unit throughout the day on July 9, 2012, and July 10, 2012. The Director of Nursing confirmed on July 12, 2012, at 2:00 p.m., that the abuse policy was not followed regarding the reporting and investigation of abuse. Review of a quarterly MDS assessment completed on Resident A10 on May 15, 2012, indicated that the resident was completely unable to make decisions for himself. The review of Resident A10's June 2012, physician orders [REDACTED]. Further review of one out of several statements, indicated that Employee E15, was not [MEDICATION NAME] with many of the residents on the unit. During an interview with the Director of Nursing on July 17, 2012, at 12:30 p.m., it was confirmed that staff had never initially reported their observations of Employee E15 forcing fluids and medications on Resident A10. She further confirmed that they could give no justifiable reason as to why they did not report their concerns initially as dictated in facility policy and procedure, but they did admit that Employee E15 had been acting unprofessionally for the last few weeks. The lack of staff reporting the alleged abuse resulted in the resident being given medications and fluids in a forced manner for a prolonged period of time. Review of a quarterly MDS assessment completed on Resident A4, on May 29, 2012, indicated that the resident was completely alert and oriented, and capable of eating independently. Review of an Abuse Investigation initiated on July 15, 2012, concerning Resident A4, indicated that employees were reporting that Employee E15 was not allowing staff to deliver food trays to the resident when he refused to eat in the dining room. Further review of statements obtained from the nursing staff, including one licensed practical nurse, and three nursing assistants, confirmed that they were directed by Employee E15 not to take food trays to the resident's room on multiple occasions. Further review of the Licensed Practical Nurse's statement indicated that Employee E15 stated, "that the resident will come out of his room when he is hungry enough." Review of Resident A4's meal percentage records from May 20, 2012, until July 17, 2012, indicated that the resident refused breakfast on 39 out of 57 occasions. Interview with the Director of Nursing on July 17, 2012, at 2:00 p.m., indicated that the staff had never initially reported that they were directed by Employee E15 to withhold the resident's food trays. The Director of Nursing further reported that it was only during the investigation of another allegation of abuse that staff reported this concern, and it was identified that meals were being denied to this resident. The Director of Nursing could not justify why the staff had been witness to this abuse did not initially report their concerns per facility policy and procedure. Interview with Resident A4 on July 18, 2012, at 2:30 p.m., indicated that until today (July 18, 2012) if he did not go to the dining room, staff did not provide him with a meal or ask if he was hungry and wanted something to eat. The lack of staff reporting, as dictated in the abuse policy and procedure, resulted in Resident A4 being denied access to a meal on multiple occasions over a prolonged period of time. Review of Resident K12's psychology progress notes revealed that the resident was oriented to person, place and time. Review of the resident's concern form dated April 9, 2012, revealed that the resident communicated to Employee E12, a licensed nurse, that he felt that a specific certified nursing assistant was treating him in an unprofessional manner by making the following comments in a sarcastic or loud tone, "why don't you eat in your room?" and "you ought to get yourself a phone" and "get your own water." Interview with Employee 12 on July 19, 2012, at 2:20 p.m., confirmed that Resident K12 had alleged the concerns on April 9, 2012. Employee E12 communicated the resident's concerns to the social worker on this date. Employee E12 confirmed that the resident's concerns against an identified nursing assistant were of a verbal abuse nature; however, Employee E12 was not able to confirm that this allegation of possible verbal abuse was reported immediately to the person in charge of the shift or to a higher-level management official as stated in the facility's abuse policy. 483.13(c) Development/Implement Abuse/Neglect, Etc Policies Previously cited 7/23/2010 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 6/30/2011 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 6/30/2011, 9/15/2011 28 Pa. Code 211.5(f) Clinical records Previously cited 7/23/2010, 6/30/2011, 6/18/2012 28 Pa. Code 211.10(d) Resident care policies Previously cited 6/30/2011 28 Pa. Code 211.12(c) Nursing services Previously cited 6/30/2011, 9/15/2011, 6/18/2012 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/23/2010, 10/1/2010, 6/30/2011, 9/15/2011, 6/18/2012

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of one of two residents identified at risk for falls, resulting in actual harm to Resident A1. Findings include: Review of Resident A1's May 2012 physician's orders [REDACTED]. Review of the resident's quarterly assessment completed on April 24, 2012 revealed that the resident was identified with short term and long term memory impairment, inattention and disorganized thinking. The resident required extensive assistance with transfer, ambulation and toilet use with the support of two staff persons. Review of the resident's current plan of care, identified the resident at risk for injury related to falls due to the [DIAGNOSES REDACTED]. Review of June 2012 physician's orders [REDACTED]. Review of facility incident documentation revealed that Resident A1 had sustained a total of 31 falls from February 1, 2012 to June 13, 2012. Twenty-three of these falls occurred during the 7-3 tour of duty. Review of a fall incident documentation dated May 28, 2012 revealed that at 2:30 p.m. the nursing assistant found the resident lying face up in the bathroom floor. The resident sustained [REDACTED]. There was no documented evidence that the resident was wearing the helmet ordered by the physician and no evidence that the sensor alarms above the bathroom door was activated when the resident entered the bathroom. Further review of two statements obtained from nursing aides in relation to the fall noted that the chair alarm was turned off. Interview with Employee E1 and E2 on June 18, 2012 at 11:45 p.m. confirmed that there was no documented evidence that the interventions of a helmet and a sensor alarm on the bathroom door were in placed at the time of the fall. Observation conducted on June 18, 2012 at 10:30 in the company of Employee E3 revealed that Resident A1 was in the bedroom seated on chair next to the bathroom door. Observation of the sensor alarm above the bathroom door revealed that the switch was on the off position and the alarm did not activate upon entering the bathroom. Employee E3 confirmed this observations. The facility failed to ensure that all intervention to prevent falls to safeguard Resident A1 from injury were implemented and failed to increase measures to adequately supervise and monitor this resident, resulting in actual harm to Resident A1. 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.10(c) Resident care policies 28 Pa Code: 211.11(d) Resident care plan 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services