Every finding on record at Spring Creek Rehabilitation and Nursing Center

Based on clinical record review, observations, facility document review, resident and staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 334). This failure resulted in an immediate jeopardy situation for Resident 334 as evidenced by an elopement from the facility to the airport. Findings include: Review of facility policy, titled Emergency Procedure - Missing Resident, revised March 21, 2025, read, in part; 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Review of Resident 334's clinical record revealed diagnoses that included aphasia (a neurological disorder caused by brain damage that impairs a person's ability to speak, write, and understand language, while leaving their intelligence entirely intact), and chronic atrial fibrillation (a continuous, sustained arrhythmia where the heart's upper chambers beat irregularly). Review of Resident 334's clinical record revealed a psychiatry progress note written on October 21, 2025, noted that the Resident had previously left AMA (against medical advice) from another facility and ended up at the airport attempting to board a plane. The note further stated the Resident had reported confusion and altered mental status and was taken to the ER (Emergency room) for further evaluation. Further review of Resident 334's clinical record revealed a social worker (SW) note written on January 27, 2026, that read, in part; SW met with resident in SW office. Resident is aphasic and has difficulty verbalizing/articulating thoughts and feelings. Resident wrote on a piece of paper '9:00' and made an airplane sound with his mouth while pretending his arm was an airplane. SW asked resident if he was planning on booking a flight at this time. Resident answered in the affirmative and stated that he was planning on discharging next Tuesday (February 3, 2026). SW discussed unsafe discharge with resident along with AMA procedure and asked if resident had a plan for after he arrives at his destination. The resident offered no post discharge plan. Review of Resident 334's clinical record revealed a progress note on January 29, 2026, that the Resident had a BIMS (brief interview for mental status) of 6, which indicates severe impairment. Further review of Resident 334's clinical record revealed a nursing progress note on February 2, 2026, at 3:09 PM, that the Resident tried to leave the facility and was placed on 15-minute checks until a wander guard was in place. Another nursing note was documented at 4:38 PM as a late entry that read, in part, At approximately 2:00 PM, this writer received a call from the receptionist stating the resident had managed to get out of the front door after she opened the door for a visitor to leave. The receptionist immediately followed the resident. The resident was brought back inside the facility within less than a minute. Review of Resident 334's physician's orders revealed an order for an alarming security bracelet wander guard on his wheel chair, with a start date of February 3, 2026. Review of Resident 334's elopement risk evaluation completed on February 3, 2026, revealed that the Resident was at risk for elopement with an intervention to have a wander guard/alarming security bracelet placed on the Resident's chair. Review of Resident 334's comprehensive care plan revealed the Resident was an elopement risk related to cognitive impairment, with an intervention for a wander bracelet in place, initiated on February 2, 2026. Review of Resident 334's psychiatry progress note on March 9, 2026, revealed the Resident expressed wanting his wander guard removed so he can go off of the unit. Review of Resident 334s' psychiatry progress note on March 16, 2026, revealed the Resident was fixated on wanting his wander guard removed so he can go to activities. Review of Resident 334's clinical record revealed a care plan/IDT note on March 19, 2026, that read, Residents wander guard removed, no longer an elopement risk. Review of Resident 334's physician's orders revealed the order for alarming security bracelet wander guard on chair was discontinued on March 19, 2026. Review of Resident 334's elopement risk evaluation completed on March 20, 2026, revealed the Resident is no longer at risk for elopement. Further review of the evaluation read, in part, 4. Does the patient have a history of leaving facility with out needed supervision? 5. Does the patient have a history of leaving facility without notifying staff? Both answers were documented as No despite him leaving the facility the previous month. Review of Resident 334's clinical record revealed a progress note on May 6, 2026, that the Resident had a BIMS of 8, which indicates moderate impairment. Review of the facility provided incident report for Resident 334 indicated that on May 9, 2026, at 5:57 PM, Resident was observed self-propelling in wheel chair throughout the facility. Resident was alert and in pleasant mood. Resident was dressed for the day, and with rubber soled shoes on bilateral feet. Resident was last seen on unit at 1:30 PM at which lunch time was provided by the assigned certified nurse aid in his room. Resident was observed by the operator, sitting in the lobby in his wheelchair turning pages of a magazine while sitting in his wheelchair. This writer was alerted at 5:57 PM by an airport dispatcher, 'We have one of your residents here at the ticket gate wanting to purchase a ticket to fly to St. [NAME]. He is here in a wheelchair and doesn't have the means to purchase a plane ticket, and he seems to be confused. He is very adamantly and refusing to go back to your facility.' The resident was transported to the hospital to be further evaluated at 8:26 PM. Under the section Actions taken as a result revealed, in part, Resident taken to hospital from the airport and is currently being evaluated as per registered nurse. At 10:27 PM writer contacted daughter and made her aware of the above findings. Daughter shared concerns that she is unable to care for him and that St. [NAME] does not have the infostructure to take care of him medically and 'he doesn't understand that.' Review of Resident 334's clinical record revealed a nursing note on May 10, 2026, at 10:30 AM, that he returned to the facility and was placed under close observations 1:1 and a head-to-toe assessment was performed. Review of employee witness statements revealed that Resident 334 was last seen by staff at 3:00 PM on May 9, 2026, sitting in a wheelchair in the lobby, reading a magazine. The employee did not see where the Resident went. During an interview with Resident 334 on May 11, 2026, at 1:33 PM, he confirmed that he left the facility, called an Uber and went to the airport and was going to buy a plane ticket to go to St. [NAME]. Resident 334 said that he lived in St. [NAME] for 20 years and was going back to see a friend, however, the cops came and figured out he was a Resident at this facility and ended up back here. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 11, 2026, at 2:25 PM, it revealed that the facility was first made aware Resident 334 had eloped when they received a call from the airport. NHA revealed that video footage was reviewed and it was determined that the receptionist opened the door for a gentleman that was leaving carrying big boxes and the Resident just left with him. The receptionist did not see the Resident leave the facility. Further interview conducted with the NHA and DON on May 13, 2026, at 1:55 PM, revealed that after they removed Resident 334's wander guard on March 19, 2026, there were no other elopement interventions put in place and that it was an error to have his wander guard removed. During an interview with Employee 3 (Licensed Practical Nurse/Unit Manager) on May 14, 2026, at 9:40 AM, it was confirmed that they were the nurse who completed Resident 334's elopement risk evaluations in February 2026 and March 2026 and answered the questions in March by here say. Employee 3 confirmed it was an error in documentation and received education. Employee 3 revealed that after Resident 334's wander guard was removed in March 2026, the Resident would go sit in the courtyard for the majority of the day and would leave the floor to do his own laundry. Employee 3 revealed the Resident would sign himself out whenever he left the unit. Employee 3 revealed that residents who have a wander guard are able to leave the unit with staff assistance and supervision, however, the facility does not have enough staff to accompany every resident who wants to go off the unit. During an interview conducted with Employee 4 (Assistant Director of Nursing) on May 13, 2026, at 1:28 PM, revealed that residents who are not an elopement risk are able to leave their units and sign out off the floor at the nurse's station. Employee 4 revealed that if a resident has a wander guard on, someone has to be with them to leave the unit. Employee 4 stated that residents are not confined to their units because of a wander guard and that they make sure the resident has the supervision needed to leave the unit. The facility is adjacent to a main road, thus, the Resident could have entered onto main road and suffered a serious adverse outcome. The Resident was found at the airport trying to buy a plane ticket out of the country. The airport is 8.5 miles from the facility. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement. The NHA was provided with the immediate jeopardy template on May 12, 2026, at 12:34 PM, and an immediate action plan was requested. The facility initiated immediate interventions on May 9, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included the following: The receptionist was immediately re-educated on May 9, 2026, on visualizing every person that exits the facility and not leaving a resident out of the building and disciplinary action taken. Education was completed for receptionist currently working. One receptionist was on vacation, and another was per diem and will be educated before they work their next shift. Education was initiated to facility residents who leave the unit to go around the facility on the process of signing out when leaving the unit. A review was completed of residents who were previously considered an elopement risk and had their code alert bracelet removed in the last year. No concerns were identified. Completion date May 10, 2026. An audit was conducted to determine like residents completed on May 10, 2026. Residents with exit seeking behaviors were reviewed to confirm that facility procedures regarding facility elopement policies are followed. An exit seeking audit to include a review of elopement risk, will be completed daily for one week and weekly for three weeks for new admissions and resident with a change in condition to determine if they are at risk for elopement. Any Residents identified at risk in an audit will have a code alert bracelet applied, and care plan initiated. The daily audit was completed on May 10 and continued on May 11, and 12, 2026, and will continue daily for one week. The Medical Director was notified on May 9, 2026. Review of Resident 334's care plan revealed it was revised to include that Resident 334 was an elopement risk with the following interventions: 1:1 observation every shift, accompany to meals and scheduled activities due to risk of elopement attempts, allowed to vent feeling and/or frustration as needed, encourage socialization with others to provide recreational programming as tolerated, engage in activities/tasks to keep occupied, wander bracelet in place, when exhibiting exit seeking behavior, redirect to an appropriate area and provide supervision. Review of Resident 334's clinical record revealed orders to check placement of code alert (wander guard) per protocol of facility every shift, with a start date of May 10, 2026. Review of Resident 334's elopement risk evaluation conducted on May 10, 2026, revealed that the Resident was at risk for elopement, and has a wander guard/alarming security bracelet in place. The facility demonstrated past non-compliance by initiating immediate interventions by May 10, 2026, following the incident. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed and no concerns were identified. Audits were reviewed to ensure residents with exit seeking behaviors were reviewed and confirmed the facility's procedures regarding facility elopement policies are followed. Audits were reviewed for exit seeking residents with an elopement risk for new admissions and residents with a change in condition and there have been no other elopements that have occurred since this incident. The receptionist working during the day of the incident has been educated. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of the education. Observations made during the on-site survey on May 12, 2026, revealed there were no additional resident elopements that occurred out of the facility. The Immediate Jeopardy was lifted on May 12, 2026, at 4:26 PM, after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that a discharge summary was completed in a timely manner for one of three closed record charts reviewed (Resident 375). Findings include: Review of facility policy, titled Discharge Summary and Plan, last reviewed March 2026, it stated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed. Review of the facility check list for closed record, titled Discharge/Death Checklist, it stated for the Physician Planned/Unplanned D/C Summary Completed and Signed. Review of Resident 375's clinical record revealed a diagnoses that included End-Stage Renal Disease (ESRD-kidneys can no longer filter waste and excess fluid from the blood). Resident 375 required hemodialysis (a life-sustaining treatment for kidney failure that uses a machine to remove waste products and excess fluid from the blood). Review of Resident 375's clinical record revealed a transfer to the hospital on March 30, 2026. Review of Resident 375's clinical record revealed the Resident passed away at the hospital on March 31, 2026. Review of Resident 375's clinical record on May 12, 2026, revealed no discharge summary for March 2026 hospital transfer. Review of Resident 375's clinical record on May 13, 2026, revealed a discharge summary for March 31, 2026, that was put into the clinical record on May 13, 2026, at 1:29 PM. During an interview with the Nursing Home Administrator on May 14, 2026, at 11:09 AM, he confirmed that the discharge summary should be completed on schedule, which is 30 days after discharge. 28 Pa. Code 211.5(d) Medical records

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, for one of 35 residents reviewed (Resident 379).Findings include: Review of the facility policy, titled Wound Care last reviewed March 31, 2026, read, in part, Verify the physician's order for this procedure. The following information should be recorded in the resident's medical record: How the resident tolerated the procedure. If the resident refused the treatment and the reason why. Report other information in accordance with facility policy and professional standards of practice. Review of Resident 379's clinical record revealed diagnoses that included acquired absence of eye, schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior), and dysphagia (difficulty chewing and/or swallowing). Review of Resident 379's physician orders revealed an order for Cleanse right eyelid with NSS, pat dry, cover with 4x4 gauze, and secure with tape every day and as needed every night shift, with a start date of May 8, 2026. Observations of Resident 379 on May 11, 2026, at 12:03 PM; May 12, 2026, at 9:16 AM and 1:13 PM; and May 13, 2026, at 9:14 AM; revealed she did not have any gauze covering over her right eyelid. Interview with Resident 379 on May 13, 2026, at 9:14 AM, revealed the gauze covering was not over her eyelid because it does not stay in place. Review of Resident 379's May Treatment Administration Record revealed the order for the gauze was signed as completed on May 10, 11, and 12, 2026, on night shift. During an interview with Employee 1 (Registered Nurse) on May 13, 2026, at 9:18 AM, she revealed the gauze should be in place at all times, and she did not see anything in nursing report between shifts that the gauze was not in place. During an interview with Employee 2 (Licensed Practical Nurse) on May 13, 2026, at 9:19 AM, she revealed Resident 379 has behaviors of self-removing the gauze, but she had not yet noted anything in the clinical record. Review of Resident 379's behaviors nurse aide task failed to note any behaviors since her admission on [DATE]. Review of Resident 379's care plan failed to reveal behaviors of refusing treatment of self- removing the gauze to her eyelid. During an interview with the Director of Nursing on May 13, 2026, at 1:47 PM, the surveyor revealed the concern with the lack of Resident 379's treatment in place during observations and failure of any notation in the clinical record as to why it was not in place. No further information was provided. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record reviews, review of facility investigation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate assistance devices during a transfer, which resulted in harm as evidenced by a dislocated shoulder requiring surgical repair for one of five residents reviewed (Resident 1).Findings include: Review of Resident 1's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) with hemiplegia (paralysis of one side of body) to left non-dominant side, muscle weakness, and need for assistance with personal care. Review of Resident 1's care plan revealed a care plan focus for self-care deficit related to physical limitations, with an initiated date of June 10, 2025. Interventions included, but were not limited to: transfers - dependent of two with Hoyer lift (a mechanical device designed to safely transfer individuals with limited mobility). Further review of Resident 1's care plan revealed that she had been a dependent of two with a Hoyer lift for transfers since November 10, 2025. Review of Resident 1's Kardex (nurse aide care reference) also revealed that she was care planned for transfer with assist of two using a Hoyer lift. Review of the facility investigation report revealed that on March 26, 2026 at 2:00 PM, Resident 1 was transferred from the bed to the chair using a two person assist. In the afternoon, the wound team requested that the resident be put back into bed. Resident 1 did not have a lift pad underneath her, which is required to use the Hoyer lift. Using a stand pivot method, three staff members assisted the resident back to bed. Following the transfer, the resident complained of increased pain to the left arm. Review of the witness statement from Employee 4 (Nurse Aide [NA]) who was Resident 1's assigned NA that day, which indicated that Resident 1 was transferred out of bed to her chair on the morning on March 26, 2026, with two-person assist without using Hoyer lift, and that when Resident 1 got into the chair, she was pulled up by holding underneath shoulder lightly with no problem. The witness statement further indicated that when the wound team came to see Resident 1 they could not transfer her. Employee 4 stated she then went and checked Resident 1's Kardex, which indicated that Resident 1 was a Hoyer lift. Employee 4 confirmed in her witness statement that Resident 1 did not have a lift pad under her to use to transfer her back to bed. Employee 4 stated that she and wound team, Employee 5 (NA) and Employee 6 (RN) transferred Resident 1 back to bed by holding underneath her arm lightly and holding both brief and pants with no problem. Further review of the witness statement from Employee 5, which indicated that when the wound team entered Resident 1's room, she was sitting in her chair and that Resident 1 said that she had been working with therapy on standing. Employee 5 said that she asked Resident 1's nurse (Employee 7 [Licensed Practical Nurse]) about Resident 1's transfer status. Employee 7 also indicated that Resident 1 was a Hoyer transfer. Employee 5 said that Employee 4 entered Resident 1's room to help, and Employee 5 told Employee 4 that there was no lift pad. Employee 5 said that Employee 4 then said she had lifted Resident 1 all by herself and that Resident 1 was a slide board transfer. Employee 5 said she asked Employee 4 where the slide board was, and Employee 4 said she did not know. Employee 5 said that since there was no lift pad or slide board, they did a three-person lift to transfer Resident 1 back to bed: Employee 4 and Employee 7 held under Resident 1's arms, Employee 5 held legs, and Employee 8 (Wound Care Nurse Practitioner) stood on the opposite side of the bed. Employee 5 indicated that they carefully transferred Resident 1 to a sitting position on the side of bed first, then maneuvered Resident 1 into her bed, and pulled her up in bed using the drawsheet that was present on the bed. Employee 5 indicated Resident 1 told Employee 4 you hurt my arm. Review of Resident 1's progress notes revealed a nurse's note completed by Employee 3 (Registered Nurse [RN]) dated March 26, 2026, at 11:56 AM, which indicated Resident 1 reported that she had chronic pain to her left upper extremity, but that she felt like the pain had been worse since she transferred back to bed. Review of Resident 1's x-ray results dated March 26, 2026, revealed left shoulder mild degenerative changes with a shoulder prosthesis in place but there may be subluxation slight separation at the shoulder joint proper. No fracture is noted. Clinical correlation is needed; and left elbow degenerative chronic appearance with an effusion and a fracture of the proximal ulnar region with separation exact age of this is difficult to ascertain no prior studies are available for comparison at this institution and close clinical correlation with a short interval follow-up series for comparison is recommended. Review of Resident 1 clinical record progress notes revealed a progress note dated March 26, 2026, at 4:00 PM, that her provider was made aware of the x-ray results and an order was given for an orthopedic consultation. Review of a Nurse Practitioner note dated March 27, 2026, at 2:22 PM, revealed that Resident 1 was seen and that she reported her arm was pulled by staff when getting in and out of bed. The note also indicated that Resident 1 stated the pain in her left shoulder was worse and that her range of motion had also worsened. The note further indicated that Resident 1 experienced pain when her left shoulder was touched by the Nurse Practitioner. Review of Resident 1's clinical record progress notes revealed a nurse's note dated March 31, 2026, at 3:34 PM, that indicated she had returned from her orthopedic appointment and that the consultation report indicated left shoulder dislocation. Send to emergency room as soon as possible for reduction. The note further indicated that Resident 1's provider was made aware and that she was transferred to the emergency room. Review of Resident 1's hospital records revealed that x-rays obtained on March 31, 2026, at the hospital indicated a dislocation of the left shoulder prosthesis with no acute fractures noted, which was a noted change from x-rays obtained on February 24, 2026, while hospitalized . Review of Resident 1's hospital history and physical dated March 31, 2026, indicated that she was too high a risk for bedside reduction of the left shoulder dislocation and that orthopedics evaluated and will complete reduction of the dislocation surgically. Review of Resident 1's hospital discharge summary revealed that she had the dislocation surgically repaired on April 1, 2026, and was discharged back to the facility on April 5, 2026. During staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 8, 2026, at 2:45 PM, the DON said Resident 1 was alert and oriented and was telling staff that she could stand and pivot to transfer and that Resident 1 was not a Hoyer transfer prior to going to the hospital. She said that she returned to the facility from a hospital stay on March 24, 2026. During a resident interview with Resident 1 on April 8, 2026, at 4:05 PM, Resident 1 indicated that on March 26, 2026, she was assisted out of bed in the morning by one nurse aide and that she was assisted back to bed by two aides and two wound care staff. She indicated that one of the aides pulled on her left shoulder causing it to hurt more. She said that she was not aware that she was to be a lift transfer until all this occurred. Review of facility provided plan to correct the identified issue revealed the following:1) The facility Quality Assurance and Performance Improvement committee met on March 27, 2026, to review the incident and formulate a plan for improvement.2) Staff involved with the transfer were suspended pending the outcome of the investigation.3) Education was immediately initiated with nursing staff on abuse/neglect and following the plan of care and reviewing Resident's Kardex for care required.4) Education and disciplinary were completed with staff involved.5) An initial audit was completed for alert and oriented residents requiring a mechanical lift for transfers to ensure resident knowledge of transfer status and that transfers are completed per care plan.6) The DON or designee will complete an audit of 15 residents weekly for four weeks to ensure that the residents are being transferred as per their care plan. 7) Audit results will be forwarded to the QAPI committee for further review and recommendations. The next QAPI meeting is scheduled for April 22, 2026. Date of compliance was April 3, 2026. Further review revealed that the initial audit was completed on April 1, 2026, with no additional concerns identified. Employee 4 was issued her Final Written Discipline on April 1, 2026. Education sign-in sheets reviewed, which included Employees 4, 5, and 6. Random interviews with two nurses and four nurse aides on April 8, 2026, revealed they did review and sign the education. Observation of transfer for Resident 8 on April 8, 2026, at 11:47 AM, revealed the care plan was followed. During a final staff interview with the NHA and DON on April 9, 2026, at 3:15 PM, the DON confirmed that after further review, Resident 1 had been a Hoyer transfer for quite some time and that it did not just change with her most recent hospitalization. She indicated that there were two nurse aides who got Resident 1 out of bed in the morning, but the facility had no statement to provide as the other nurse aide was terminated for an unrelated incident. She confirmed that Resident 1 refused to give the facility any names because she did not want to get anyone in trouble. She confirmed that she would expect staff to follow a resident's care plan to provide the necessary treatments and interventions to prevent accidents and injuries. The DON confirmed that Employee 4 was given a written disciplinary action for failing to follow Resident 1's care plan for the initial transfer out of bed, which caused Employees 4, 5, and 6 to have to transfer her the same way. Facility staff failed to follow Resident 1's care plan for a two person assist using a Hoyer lift, which resulted in the Resident experiencing actual harm as evidenced by a dislocated shoulder requiring surgical repair. 201.4(a) Responsibility of licensee.201.18(b)(1) Management.211.10(d) Resident care policies.211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident received care, consistent with professional standards of practice, to treat pressure ulcers for one of five residents reviewed (Resident 1). Findings Include:Review of Resident 1's clinical record revealed diagnoses that included unstageable sacral pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Unstageable-obscured full-thickness skin and tissue loss) and stroke. Review of Resident 1's wound assessment report, dated November 4, 2025, revealed treatment recommendations to cleanse the wound (pressure ulcer) with normal saline, apply medical grade honey to the base of the wound, and secure with silicone bordered super-absorb. Review of Resident 1's wound assessment report, dated November 11, 2025, revealed treatment recommendations to cleanse the wound with normal saline, apply Santyl (ointment that removes dead tissue from wounds for healing) to the base of the wound, and secure with silicone bordered super-absorb. Review of Resident 1's wound assessment report, dated November 18, 2025, revealed treatment recommendations to cleanse the wound with normal saline, apply Santyl and Dakins (wound cleanser) moistened fluffed gauze to the base of the wound, and secure with silicone bordered super-absorb. Review of Resident 1's TAR (treatment administration record), dated November 2025, revealed that on November 12-19, nursing staff were signing off that both treatments were administered. The honey was being signed off as being the treatment and Santyl was also being signed off as being the treatment administered. On November 20, 2025, the honey treatment was discontinued. On December 17, 2025, at 12:30 PM, the Director of Nursing (DON) stated that when the wound team changed the treatment to Santyl on November 11, 2025, the honey order was not yet removed because they were waiting on the Santyl to arrive from the pharmacy. She stated that on November 12, 2025, honey was used because the Santyl did not arrive from the pharmacy until 8:00 PM. She further stated that she confirmed with each nurse, who stated that on November 13-17, 2025, they used the Santyl because they knew the treatment order was changed. On November 18, 2025, she stated that the wound team performed the treatment. Nursing staff continued to sign off that the honey was administered on November 12-19, 2025, in addition to signing off that the Santyl was administered November 12-19, 2025.On December 17, 2025, at 2:53 PM, the DON stated that was an oversight by nursing and that they were aware of the correct treatment that was to be done, per the wound team recommendations. In a follow up interview with the Nursing Home Administrator and DON on December 17, 2025, at 3:09 PM, the DON stated that nursing staff should have clarified the treatment order and not sign off that both treatments were administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records, hospital records, facility documents, and staff interviews, it was determined the facility failed to monitor residents and provide care and services during elevated temperatures in resident care areas, resulting in actual harm as evidenced by hyperthermia and respiratory distress for one of eight residents reviewed (Resident 1). Findings include: Hyperthermia is defined as a medical condition characterized by an abnormally high body temperature. Respiratory distress is defined as a condition where a person has difficulty breathing, characterized by increased effort or difficulty taking in enough oxygen. Review of facility provided documentation, dated June 23, 2025, revealed at midnight the rooftop HVAC (Heating, Ventilation, Air Conditioning) unit on the building had a bad compressor and condensing coil. The rooftop HVAC unit was not able to be provided sufficient air conditioning to the common areas, especially on M4 ([NAME] unit 4) and M3 units. Further review of facility documentation revealed, On 6/23/2025, the facility rented 13 one-ton portable air conditioning .to be installed on the unit hallways and dining rooms. The units arrived around 0800 [8:00 AM]. The nursing team assessed residents for symptoms of heat exhaustion. Residents were offered extra fluids. Residents in areas where temperatures were high were moved to another room on the South building. The maintenance team took random temperatures on the unit. The temperature ranges from 82-85 [degrees Fahrenheit (F)]. In the late afternoon, the temperature on M4 and M3 dining rooms rose to 90 degrees. On 6/23/25, clinical services was notified that temperatures were rising on [NAME] units 3 and 4. Temperatures completed for all rooms and common areas. Extra fluids and popsicles were distributed to the residents on M 3 and 4. Vital signs were obtained on M4, and residents assessed. Residents affected by the temperatures were moved to other units. Review of Resident 1's physician's orders revealed diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), traumatic brain injury, vascular dementia with behaviors, and Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of Resident 1's progress note titled Late Entry, dated June 23, 2025, at 10:54 PM, read Nursing Note Late Entry: Resident Alert and Oriented assessment completed, no s/s of acute distressed noted. Resident encouraged to continue to stay hydrated. The Late Entry progress note was created on June 25, 2025, at 10:56 AM. Review of Resident 1's progress note titled Late Entry, dated June 23, 2025, at 11:12 PM, read, Late Entry: Note Text: Evaluation of resident completed. Resident shows no s/s of pain or distress. [He/She] denies needs or concerns at this time. The Late Entry progress note was created on June 25, 2025, at 11:19 AM. Review of Resident 1's progress notes revealed a Late Entry dated June 24, 2025, at 8:19 PM, that read Late Entry: Note Text: Resident offered room change; however, resident declined room change at this time. Resident shows no s/s of discomfort or distress and verbalizes understanding to contact staff for any needs or concerns. The Late Entry progress note was created on June 25, 2025, at 11:20 AM. Review of Resident 1's progress note on June 24, 2025, at 6:00 PM, revealed a new order for Acetaminophen (Tylenol) 650 mg by mouth every six hours as needed for Elevated Temperature. A progress note on June 24, 2025, at 7:58 PM, nursing documented Prior to Writer's arrival resident was assisted from [his/her] room, then placed into [his/her] wheelchair and provided a different location X2 and encouraged fluids. After much encouragement. Resident was found back in [his/her] in bed. Upon entering resident's room, call light was not on. Room temperature 87 F (Fahrenheit), personal fan oscillating nearby resident. A progress note date June 24, 2025, at 8:00 PM, revealed the charge nurse documented Writer was alerted by assigned nurse that resident was under respiratory distress. Writer assessed; Resident had medium sized emesis. Increased temperature (Tylenol was administered). Skin warm and intact. Resident is lethargic, Resident has shortness of breath, lung sounds clear, and no cough present, pulse oxygen 90% at room air. Unable to follow simple commands, increased restlessness (reaching into the air and involuntary extremity movements), and no verbal responses. Vital signs as noted in PCC [Point Click Care- documentation system]. Writer obtained a verbal order from [Certified Registered Nurse Practitioner] to send to hospital for eval (evaluation) and treat. An additional progress note on June 24, 2025, at 8:25 PM, read Resident ask to me get out bed and this write put on [his/her] chair, room so hot. Resident stayed on [his/her] wheelchair about 15 minutes and put [himself/herself] in bed. I get up again to stay in hallway because room too hot and after a while [he/she] put [himself/herself] again in bed. I put my persona fan in [his/her] room and take [his/her] temp (temperature), and it was 103.3 and I put ice pack and administered Tylenol 650 mg, and it was effective and with normal range. Then resident mental status was changed and vomit twice and [his/her] temp went up again about 103.4. I call supervisor for further action to be taken. I was with resident all times until the EMS [Emergency Medical Services] arrived because resident was at risk of fall. Additional review of Resident 1's clinical record failed to reveal assessments specific to the risk of hyperthermia or documentation of Resident 1's vital signs, including temperature, pulse (heart rate), respiratory rate, blood pressure and oxygen saturation when the facility was aware of the elevated temperatures. Review of Resident 1's hospital emergency department admission documentation revealed, per EMTs [Emergency Medical Technicians] patient is coming from [facility] where [he/she] was found to be altered for the past 2 hours. [He/She] is in acute respiratory distress on arrival. Patient is critically ill. Unable to provide a history. Patient is very ill appearing. [He/She] is extremely hot to the touch. Even the urine in [his/her] Foley bag that we inserted on arrival feels very warm to the touch. Also, Patient was critically ill on arrival. [He/she] is blood pressure was 80/34 [normal is 120/80] with a temperature of 107.1 Fahrenheit. [He/She] was clearly in acute respiratory distress. During Resident 1's assessment in the emergency department, Resident 1 was intubated (medical procedure where a tube is inserted into the body, most commonly through the mouth or nose and into the trachea [windpipe] to maintain an open airway. This is often done to assist breathing, deliver medication, or provide anesthesia. The tube can be connected to a ventilator to help the patient breathe, especially in cases of respiratory failure or during surgery). Resident 1 was subsequently admitted to the Intensive Care Unit (ICU). Review of the emergency department's clinical impressions dated June 25, 2025, at 12:24 AM, revealed the following diagnoses to include Hyperthermia and Acute respiratory failure. According to additional hospital record review, staff consulted with Resident 1's court-appointed guardian, and The decision was made to transition the patient to comfort care with compassionate extubation (removing an endotracheal tube (ETT), which is the last step in liberating a patient from the mechanical ventilator. Comfort measures orders (actions taken to alleviate pain, suffering, and discomfort in a person who is seriously ill or nearing the end of their life. These measures focus on providing physical, emotional, and spiritual support to ensure a peaceful and dignified passing) were placed after discussing with the whole team. Interviews conducted with the Nursing Home Administrator (NHA) on June 26, 2025, at approximately 10:00 AM, revealed the facility to be experiencing a breakdown of its heating and cooling system. Review of Resident 1's progress notes for June 2025 revealed no evidence of a decline in Resident 1's clinical status, including any abnormal vital signs or respiratory distress prior to the elevated temperatures. Vital signs documented during an assessment on June 17, 2025, revealed vital signs as follows: Temperature: 97.9 °F, Blood Pressure: 128/67, Pulse: 68 bpm, O2 Saturation: 97 and Respiratory Rate: 18 Breaths/min. An interview with the Director of Nursing on June 26, 2025, at 2:00 PM, revealed that staff were instructed to document late entries in the clinical record to capture all assistance provided to the residents during the emergent situation regarding the hot temperatures in the building. The interview also revealed the possibility Resident 1 was already ill and the elevated building temperatures did not help his/her current condition. Interview conducted with the NHA on July 7, 2025, at 1:42 PM, provided no additional information related to Resident 1's hospitalization and status. The facility was unable to provide documentation of vital signs for Resident 1 when the faciity noted the elevated temperature on the nursing unit. The progress notes entered for Resident 1 prior to the change in condition were entered after the Resident was sent to the hospital. There was no evidence that the facility monitored and assessed Resident 1 for hyperthermia after becoming aware of the elevated temperatures on the nursing unit. The facility failed to provide care and services in accordance with professional standards, resulting in a significant decline in Resident 1's health status, as evidenced by hyperthermia and acute respiratory failure, leading to emergency treatment, hospitalization admission, and subsequent comfort care. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (3) (5) Nursing Services

Based on observations, facility policy review, clinical record review, Center for Disease Control (CDC) guidelines, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection for three of six residents on transmission based precautions reviewed (Residents 212, 277, and 554) and one of five residents observed for medication administration (Resident 171). Findings Include: Facility policy, Isolation precautions, revised September 2022, read, in part, when a resident is placed on Transmission-Based Precautions (TBP), appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and type of precaution. The signage informs the staff of the type of Center for Disease Control (CDC) precaution, instructions for use of Personnel Protective Equipment (PPE) and/or instructions to see a nurse before entering the room. When TBP are in effect, non-critical resident-care equipment items such as a stethoscope will be dedicated to a single resident when possible. Contact precautions are implemented for a resident suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to wear: gloves when entering the room and gloves are removed and hand hygiene is performed before leaving the room; and a disposable gown upon entering the room and remove before leaving the room. Facility policy, Enhanced Barrier Precautions (EBPs), April 2024, read, in part, EBPs are utilized to prevent the spread of multi-drug-resistant organisms to residents. A gown and gloves are used during high contact resident care activities when contact precautions do not otherwise apply. Signs are posted on the door indicating the type of precautions and PPE required. Facility policy, Clostridium Difficile (CDI-inflammation of the colon caused by the bacteria clostridium difficile), revised October 2018, read, in part, the primary reservoirs for CDI are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. Residents with diarrhea associated with CDI are placed on Contact Precautions. When caring for residents with CDI, staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior for the mechanical removal of CDI spores from hands. Review of Resident 212's clinical record revealed diagnoses that include Clostridium difficile (C. diff-a bacterium that can cause infections, primarily diarrhea and colitis) and Lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks its own tissues, causing inflammation and damage). Review of the clinical record for Resident 212 revealed the Resident had loose stools (diarrhea) and a positive culture that confirmed C. diff infection (CDI) on April 2, 2025. Based on policy review the facility references Centers for Disease Control Guidelines for infection control, The CDC provides comprehensive guidelines for preventing and managing CDI that included isolate patients with possible C. diff immediately, even if you only suspect CDI. Wear gloves and gown when treating patients, even during short visits. When CDI is confirmed, continue isolation and contact precautions. Clean room surfaces daily with an EPA-approved spore-killing disinfectant while treating a C. diff patient. Observations on April 14, 2025, and April 15, 2025, revealed Resident 212 with EBP signage instead of contact precautions. Resident 212's care plan failed to include wearing a gown during care and touching surface areas, and the enhanced barrier precautions limits the use of a gown. During an interview on April 17, 2025, at 10:15 AM, with Employee 2 (ICP-Infection Control Preventionist) the ICP confirmed that Resident 212 should have signage indicating contact precautions instead of EBP. During an interview with the Director of Nursing (DON) on April 17, 2025, at 11:00 AM the DON confirmed that Resident 212 should have signage indicating contact precautions. Observation of Resident 277 on April 15, 2025, at 11:30 AM, revealed Employee 10 (Nurse Aide) entering Resident 277's room, walk up next to the Resident's bed, asked Resident 277 what he needed, and turned the call bell light off before exiting the room. At no time did Employee 10 apply any personal protective equipment (PPE). Observation of Resident 277 on April 16, 2025, at 10:42 AM, revealed Employee 11 (Nurse Aide) entering Resident 277's room without putting on any PPE and shut the door behind her. Observation of Resident 277 on April 16, 2025, at 11:37 AM, revealed Employee 12 (Activities Aide) entering Resident 277's room, walked up next to the Resident's bed, handed Resident 277 a bag of snacks from the gift shop, and then exited Resident 277's room. At no time did Employee 12 apply any PPE. Review of Resident 277's clinical record revealed diagnoses that included Klebsiella (a type of bacteria normally found in human feces that can cause healthcare-associated infections) and benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland). Review of Resident 277's current physician orders revealed an order for Resident 277 to be on contact precautions due to Klebsiella in his urine from April 8, 2025, until April 17, 2025, at 11:59 PM. Review of Resident 277's care plan revealed a care plan for, infection of Klebsiella in urine, with a revision date of April 8, 2025, with an intervention of Isolation-contact precaution. Interview of the DON on April 17, 2025, at 12;15 PM, revealed the expectation that the employees would have used the appropriate PPE. Observations on April 15th, 16th, and 17th, 2025, on the wall to the right of Residents' 554 and 555 room, were two signs. The top sign documented Enhanced Barrier Precautions; wear gloves and gown upon entering room and complete hand hygiene prior to leaving the room; and a letter D in the top left corner. Under the aforementioned sign was another sign containing a red stop sign with handwriting documenting to see the nurse; without notation of window W or door bed D. Interview with Employee 15 (Occupational Therapist) on April 15, 2025, at 10:05 AM, revealed he wasn't sure of the what the infection/concern was in Residents' 554 and 555 room. However, when the sign is present, you must wear the PPE that is stated when providing direct care. Interview with Employee 16 (Registered Nurse) on April 17, 2025, at 9:37 AM, revealed the aforementioned signs on the wall outside of Residents' 554 and 555 room pertained to Resident 554, who has CDI. Review of Resident 554's clinical record revealed diagnoses that included enterocolitis (inflammation of the colon) due to clostridium difficile. Review of Resident 554's physical chart on April 17, 2025, at 9:39 AM, it failed to contain documentation on the outside of the chart the Resident was on contact precautions. Review of Resident 554's current physician orders included: isolation precautions-contact due to clostridium difficile, start date April 2, 2025; Vancomycin 125 milligrams (mg) 1 capsule every 6 hours related to clostridium difficile for 10 Days then, one capsule every 8 hours for 7 days, then one capsule every 12 hours for 7 days, then one capsule one time a day for 7 days, then one capsule every other day for 7 days, then one capsule one time a day every 3 days for 7 days, with a start date of April 2, 2025. Review of Resident 554's care plan included: Infection of clostridium difficile, date-initiated April 2, 2025, revised April 3, 2025. Interventions included: isolation- contact precautions: wash hands with antimicrobial soap upon leaving room taking care not to touch environmental surfaces, date initiated April 2, 2025; and isolation- contact precautions: wear gloves during care, date initiated April 2, 2025; proper handwashing after each contact, date initiated April 2, 2025. Review of Resident 554's bowel tracking documentation revealed loose, watery stool documented for April 2nd through 16th, 2025. Review of Resident 555's (Resident 554's roommate) clinical record documented diagnoses that included a wound on the left lower extremity with use of a wound vacuum. Review of Resident 555's care plan included: at risk for infection related to wound date-initiated April 14, 2025, with an intervention for enhanced barrier precautions, date initiated April 14, 2025. Interview with DON on April 17, 2025, at 10:35 AM, revealed the enhanced barrier precaution pertained to Resident 555, and the transmission-based contact precaution noted by the stop sign pertained to Resident 554. Electronic communication with the DON on April 17, 2025, at 11:23 AM, it was confirmed that Resident 555 doesn't get out of bed or utilize the restroom. The facility failed to delineate the specific infection control practice (enhanced barrier precaution/transmission base precaution) for Residents 554 and 555 per the signage posted outside of the Resident's room. The signage lacked clarity as to which precaution pertained to each Resident. Although gloves and a gown must be worn for both Residents. The transmission-based contact precaution differed in the hand hygiene procedure (hand washing not use of a hand sanitizer) and always use PPE, to include potential contact with surfaces in the room vice just for direct care. Review of Facility policy, titled Administrating Medications, last revised April 2019, revealed that subsection 25 stated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During medication administration observation on April 17, 2025, at approximately 9:18 AM, Employee 14 (Licensed Practical Nurse) was observed preparing medications for administration for Resident 171. Observation revealed one of the medication tablets did not go into the medication cup where Employee 14 was dispensing medication tablets. The medication tablet was observed on the medication cart computer's mouse pad. Once identified by Employee 14, Employee 14 used her bare hand to pick up them medication and place it in the medicine cup. Employee 14 was then observed crushing Resident 171's medications and subsequently administered them at approximately 9:23 AM. During a staff interview on April 17, 2025, at approximately 10:35 PM, the DON revealed that staff should not handle medications with their bare hands and that Employee 14 should have discarded the medication tablet that fell on to the mouse pad. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, resident and staff interviews, and observations, it was determined that the facility failed to provide residents access to grievance forms for three of eight areas identified ([NAME] 2, [NAME] 3, and [NAME] 4). Findings Include: Review of the facility policy, titled Grievance Process Procedure with a last review date of March 2025, revealed 1. All concerns and questions may be presented to any staff member. Concern forms/boxes are available on South 1, South 2, South 3, South 4, [NAME] 1, [NAME] 2, [NAME] 3, [NAME] 4. During the resident group meeting conducted on April 15, 2025, at 11:00 AM, with eight residents (Residents 48, 59, 77, 94, 215, 230, 244, and 337) revealed that residents are not able to file grievances anonymously due to having to ask staff to get them a blank grievance form behind the nurse's station. Residents revealed the grievance forms are not within reach if they are wheelchair bound and have to ask for assistance retrieving one. Observation conducted on April 16, 2025, at 10:40 AM, on [NAME] 2, revealed a locked grievance box in the hallway by the nurses' station with no grievance forms beside it. There were no grievance forms observed in prominent locations on [NAME] 2. Interview conducted with a staff member who was sitting behind the nurses' station on [NAME] 2 on April 16, 2025, at 10:43 AM, when asked where the blank grievance forms were located, revealed they were in a folder behind the nurses' station, out of reach for residents who are wheel chair bound and inaccessible for residents as they are behind the nurses' station. Observation conducted on April 16, 2025, at 10:56 AM, on [NAME] 3, revealed a locked grievance box in the hallway by the nurses' station, with no grievance forms beside it. Interview conducted with a staff member who was sitting behind the nurses' station on [NAME] 3 on April 16, 2025, at 10:58 AM, revealed that the grievance bin was on the wall beside the locked box, however, a resident with behaviors ripped the bin off, so they have to put it back on the wall. Staff member revealed there were blank grievance forms sitting on top of the counter in the nurses' station, however, there was a medical cart sitting in front of them. Observation conducted on April 16, 2025, at 11:07 AM, on [NAME] 4, revealed a locked grievance box in the hallway by the nurses' station, with no grievance forms beside it. Further observation revealed blank grievance forms located in in a folder behind the nurses' station, in a bin attached to the top part of a door, out of reach for residents who are wheelchair bound an inaccessible for residents as they are behind the nurses' station. Interview conducted with the Nursing Home Administrator on April 17, 2025, at 10:46 AM, revealed that the grievance bins were placed in the hallway at resident height on [NAME] 2, 3, and 4, and that he would expect them to be within resident reach, however, some resident behavior issues result in ripping the bins off of the hallway wall. Further, he stated the facility would need to come up with a solution to keep them in prominent locations to be accessible to residents. 28 Pa code 201.18(b)(2)(3) Management 28 Pa code 201.29(a) Resident rights

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for two of 38 residents reviewed (Residents 148 and 290). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person Centered, with a last revised date of March 2022, and a last review date of March 2025, revealed, in part, 11. Assessments of resident's are ongoing, and care plans are revised as information about the residents and the residents' conditions change; and 12d. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required . assessments Review of the clinical record for Resident 148 revealed diagnoses that include dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and type 2 diabetes mellitus (body has trouble controlling blood sugar). Resident 148 was admitted to the facility on [DATE], and a dementia diagnoses was was effective July 30, 2021. A review of Resident 148's current care plan was never revised to include a dementia care plan. During a staff interview with the Director of Nursing (DON) on April 17, 2025, at 11:00 AM, the DON revealed the care plan should have been revised to include a dementia care plan. Review of Resident 290's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. Review of Resident 290's current physician orders revealed an order for olanzapine (an antipsychotic medication) 5 milligrams, give one tablet at bedtime, dated January 6, 2025. Review of Resident 290's care plan failed to reveal any documentation an antipsychotic medication. Further review of the care plan revealed that he was care planned for receiving an antianxiety medication. Review of Resident 290's physician order history revealed that his antianxiety medication was discontinued on December 24, 2024. During a staff interview with the Nursing Home Administrator and DON on April 17, 2025, at 10:46 AM, the DON confirmed that she would have expected Resident 290's care plan to have been revised when the medication orders changed. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on a group meeting with residents, observations, review of facility documentation, and staff interviews, it was determined that the facility failed to provide for an ongoing program of activities designed to meet the interests and physical, mental and psychosocial well-being of the residents for four of eight resident areas (South 2, 3, 4, and [NAME] 4). Findings include: During the resident group meeting conducted on April 15, 2025, at 11:00 AM, with eight residents (Residents 48, 59, 77, 94, 215, 230, 244, and 337) revealed that the facility is short staffed and that activities do not always occur as scheduled. Review of the facility's activity calendar for April 2025 revealed that there was an activity scheduled for 1:00 PM on April 16, 2025, with the activity being activity on unit. Observation conducted on April 16, 2025, at 1:17 PM, on South 2, revealed there were no activities occurring on the unit at that time. Observation conducted on April 16, 2025, at 1:19 PM, on South 3, revealed there were no activities occurring on the unit at that time. Observation conducted on April 16, 2025, at 1:21 PM, on South 4, revealed there were no activities occurring on the unit at that time. Observation conducted on April 16, 2025, at 1:09 PM, on [NAME] 4, revealed there were no activities occurring on the unit at that time. Interview conducted with the Nursing Home Administrator (NHA) on April 16, 2025, at 1:40 PM, revealed that if an activity is scheduled, he would expect it to occur. NHA was unable to provide a description what the activity on unit would consist of on resident units. 28 Pa. code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on review of the clinical record and staff and resident interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for one of 38 residents reviewed (Resident 333). Findings include: Review of Resident 333's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Interview with Resident 333 on April 14, 2025, at 1:19 PM, revealed that he receives insulin and that his blood sugars (the amount of glucose in your blood) have been running high, although he is on a medication that does elevate blood sugar. Review of Resident 333's physician orders included: NovoLog (Insulin Aspart- rapid acting insulin) Flex-Pen (disposable dial a dose insulin pen) Inject as per sliding scale: if 0 - 200 = 0 units/ml; 201 - 250 = 2 units/ml; 251 - 300 = 4 units/ml; 301 - 350 = 6 units/ml; 351 - 400 = 8 units/ml ; 401 - 450 = 10 units/ml; 451 - 999 = 12 units/ml and notify provider, subcutaneously (under the skin) before meals, with a start date March 29, 2025. Review of Resident 333's March 2025, Medication Administration Record (MAR - documentation of medications that were administered) failed to document NovoLog administration or blood sugar monitoring on March 30th and 31st. Review of Resident 333's vitals monitoring for blood sugar documented 235 ml/dl on March 30th, 2025, at 5:08 AM, and 155 ml/dl on March 31st, 2025, at 7:06 AM. Per the physician's order, Resident should've received 2 units/ml on March 30th and shouldn't have received any insulin on March 31st. During an interview with the Director of Nursing (DON) on April 17, 2025, at 12:13 PM, it was revealed that the expectation is that documentation would be completed on the MAR. It was also revealed that March 30th the Novolog was administered per DON's conversation with the nurse on duty at that time, and on the 31st the Novolog didn't need to be administered. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment to maintain vision abilities for one of 38 residents reviewed (Resident 290). Findings include: Review of Resident 290's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and glaucoma (a group of eye diseases that can lead to damage of the optic nerve which transmits visual information from the eye to the brain that may cause vision loss if left untreated). Review of Resident 290's clinical record progress notes revealed a note dated August 29, 2024, at 7:30 PM, written by the facility psychology consultant, that indicated that the Resident reported he had vision problems and that his vision problems have negatively impacted his ability to engage in recreational activities. Review of Resident 290's clinical record progress notes revealed a nurse's note dated August 30, 2024, at 7:24 AM, that indicated that his physician had placed orders for consults for resident. Review of Resident 290's clinical record progress notes revealed a physician's progress note dated March 6, 2025, at 9:31 AM, that stated Resident 290 had indicated that he was experiencing acute vision loss. Review of Resident 290's clinical record progress notes revealed a nurse's note dated March 7, 2025, at 2:06 PM, that indicated that the facility eye doctor would not be on site until the end of the month, and that Resident 290's provider was called for guidance. A follow-up nurse's note dated March 7, 2025, at 3:10 PM, indicated that the Resident was complaining of loss of eyesight and to send to the emergency room for evaluation. Review of Resident 290's clinical record progress notes revealed a nurse's note dated March 7, 2025, at 11:50 PM, that indicated the Resident had returned to the facility with a diagnosis of cataracts in both eyes. Review of Resident 290's clinical record progress notes revealed a nurse's note dated April 8, 2025, at 2:34 PM, that indicated he had returned from his eye surgeon appointment and that the office would call to set up cataract surgery and no new orders were given. Review of Resident 290's physician order history revealed an order for optometry consult for bilateral cataract complaint dated August 30, 2024, with a discontinuation date of March 6, 2025. Review of Resident 290's clinical record failed to reveal any optometry consult appointments between August 3, 2024, and his emergency room visit on March 7, 2025. Email communication received from the Director of Nursing (DON) on April 17, 2025, at 12:00 PM, she indicated that she had no additional information to provide for Resident 209's vision concern. In a follow-up email communication received from the DON on April 17, 2025, at 12:06 PM, she indicated that she would have expected nursing staff to have set up an optometry appointment for Resident 290's vision concerns when the consult order was given on August 30, 2024. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility incident report review, and staff interviews, it was determined that the facility failed to ensure the resident receives adequate supervision to prevent accidents for one of 38 residents reviewed (Resident 339). Findings include: Review of Resident 339's clinical record revealed diagnoses that included repeated falls, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), adjustment disorder with anxiety (a mental health condition characterized by emotional or behavioral responses to a significant life change or stressor), and urinary retention (incomplete emptying of the bladder or inability to urinate) with the use of an indwelling foley catheter. Review of Resident 339's care plan revealed a care plan focus for falls that included an intervention for 1:1 (one-to-one observation-one staff member to always be with resident). Review of Resident 339's clinical record progress notes revealed an occurrence note written by a nurse dated February 7, 2025, at 9:45 PM, which indicated that Resident 339 was on the floor in front of his dresser, laying on his left side. He was undressed, his anti-skid socks were not in place, and his foley catheter was dislodged and located on his bed with the balloon still inflated. The note further indicated that the nurse was unable to reinsert a foley catheter and that Resident 339 was sent to the emergency room to have his indwelling foley catheter placed. He had no other injuries at the time of the fall. Review of Resident 339's facility provided incident report investigation revealed that education was provided to staff member to not leave a 1:1 resident unattended. Review of Employee 13's witness statement revealed the following information: she had finished giving care to Resident 339 and he was sleeping; she went to the nursing office to talk to someone; she took only 5 minutes to put the trash outside; when she came back staff were going to Resident 339's room because he had fallen; and that she did not imagine that he could fall that quick. During a staff interview with the Director of Nursing (DON) and the Assistant Nursing Home Administrator on April 17, 2025, at 9:10 AM, the DON confirmed that Employee 13 had just stepped outside of room to speak to nurse. She indicated that staff said Resident 339 was sound asleep and had been for a while. The DON indicated that Employee 13 was only away for a couple of minutes and when she returned, he was on floor. The DON indicated that facility practice for 1:1 supervision was usually only for when residents are awake, but that Resident 339 could be fast in his actions and was to be under 1:1 supervision at all times for his safety. During a follow-up staff interview with the Nursing Home Administrator and DON on April 17, 2025, at 10:54 AM, the DON indicated that she did not feel that leaving the room to remove soiled linens and trash after providing care while the Resident was sleeping was inappropriate. She said that it was truly an accident, and that Employee 13 was educated, and no other incidents have occurred while 1:1 supervision at all times has been provided. 201.4(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure residents are assessed and receive appropriate treatment and services for removal of a foley catheter as soon as possible for one of nine residents reviewed (Resident 339). Findings include: Review of Resident 339's clinical record revealed diagnoses that included repeated falls, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), and urinary retention (incomplete emptying of the bladder or inability to urinate) with the use of an indwelling foley catheter. Review of Resident 339's clinical record progress notes revealed an orders administration note dated February 18, 2025, at 8:14 AM, that indicated his foley catheter was not removed as ordered. Further review of Resident 339's clinical record progress notes revealed a nurse's note dated February 18, 2025, at 10:02 AM, that indicated the urology office was called to reschedule Resident 339's foley catheter removal and office visit appointment for that date. The appointment was rescheduled for February 25, 2025. During a staff interview with Employee 17 (Registered Nurse) on April 16, 2025, at 2:18 PM, she indicated that Resident 339 had an order for staff to remove his foley catheter on February 17, 2025. She indicated that this was entered as an order to be completed by the night shift nurse. The order also included that nursing staff were to complete a bladder scan intermittently and, if urinary retention was noted, the urology office would see him at 10:00 AM, on February 18, 2025. If retention was too extreme before the office visit time, the facility was to send him to the emergency room . Employee 17 indicated that the appointment had to be rescheduled because the night shift nurse did remove Resident 339's foley catheter as ordered. She said that the nurse said she didn't feel it was good for the Resident to go that long without catheter. Employee 17 said that the facility contacted urology office and had to reschedule the appointment for February 25, 2025, for the same process. Employee 17 confirmed that the assigned nurse should have followed the physician's orders for Resident 339. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on April 17, 2025, at 10:52 AM, the DON confirmed that she would have expected the nurse to follow Resident 339's physician's order for removing the catheter. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on review of select food service committee meeting minutes, observation, one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed. Findings include: Resident interviews with Residents 81, 331, and, 347, obtained April 14, 2025, between 10:30 AM and 11:57 AM, revealed concerns with the temperature of hot food. A test tray completed on South 3rd floor on April 16, 2025, at 12:47 PM, revealed adequate portions size and the food was palatable for taste and texture for a puree diet; however, the temperature of the puree barbecue chicken and puree lima beans weren't palatable for temperature. The test tray was placed on a meal cart and delivered to South 3 unit with other trays being delivered at that time. 18 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 3 (Food Service Manager) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: puree barbecue chicken- 129.9 degrees Fahrenheit (F) mashed potato w/gravy - 136 degrees F puree lima beans- 120 degrees F puree peanut butter cookie - room temp milk- 43 degrees F During an interview with the Nursing Home Administrator on April 16, 2025, at 2:30 PM, the surveyor revealed concern regarding food temperature of the puree barbecue chicken and puree lima beans. No further information was provided. 28 Pa. Code 201.14. Responsibility of licensee 28 Pa code 211.6 - Dietary Services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of 10 residents reviewed (Resident 2). Findings include: Review of facility policy, titled Administering Medications last revised December 2012, read, in part, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Review of Resident 2's clinical record revealed diagnoses that included pancreatitis (inflammation of the pancreas that can cause swelling, pain, and changes in how an organ or tissues work), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and hypertension (high blood pressure). Review of Resident 2's physician orders revealed an order for Creon Oral Capsule (a medication that contains digestive enzymes to aid in the breakdown of food), give four capsules by mouth three times a day with meals. The administration times for the medication were noted as 7:30 AM, 11:30 AM, and 5:30 PM daily, consistent with the mealtimes on the nursing unit. Review of Resident 2's care plan revealed a focus area Nutritional Care Plan: at risk for malnutrition related to chronic disease and increased metabolic needs, with a start date of March 13, 2025, with an intervention for administer medications and obtain labs as ordered, with a start date of March 13, 2025. Observation on the South 1 Nursing Unit on March 20, 2025, at 9:30 AM, revealed Resident 2's call light was on above his room. During an interview with Resident 2 on March 20, 2025, between 9:33 AM and 9:44 AM, he revealed that he had stomach issues, and he required a medication called Creon with meals. He further revealed he had his call light on because he still hasn't received the medication, despite that it should have been served with his breakfast meal around 7:30 AM. He stated that he was requesting to have his medication, as well as a lactose free milk to have the medication with some cereal. During an interview with Employee 1 (Registered Nurse Unit Manager) on March 20, 2025, at 9:46 AM, the surveyor revealed the concern with Resident 2 not receiving his Creon with his breakfast meal, and that his call bell had been on for an extended period. Employee 1 revealed the Creon should have been given with his breakfast meal. Observation of the call light system at the nurse's station on March 20, 2025, at 9:46 AM, revealed Resident 2's call light had been on for 24 minutes. The surveyor and Employee 1 went to find Employee 2 (Licensed Practical Nurse) who was found on a different part of the unit passing medications. Employee 1 then went to answer Resident 2's call bell. During an interview with Employee 2 on March 20, 2025, at 9:47 AM, she revealed she had a late start passing medications that morning, because there was a resident on the unit that was having behaviors, and she needed to spend time calming him down. Follow-up interview with Employee 2 on March 20, 2025, at 10:07 AM, revealed she had just administered Resident 2's Creon and made sure he had some milk and cereal while he consumed the medication. She further revealed she was late passing medications as she was overseeing 22 residents, many of which need blood sugar checks in addition to morning medications, and reiterated that she spent extra time calming the resident with behaviors. She stated that she also helped a dependent resident get dressed to go out for a funeral, and that the nurse aide staff was too busy that morning passing meal trays and doing their rounds to help with other tasks. Follow-up interview with Employee 1 on March 20, 2025, at 10:13 AM, revealed she would have helped assist Employee 2 with her duties since she was behind, or call to another unit for assistance, but she got caught up on a phone call with a resident's family member for an extended period of time. She further revealed that there was typically another Registered Nurse Unit Manager assigned to the unit during day shift, but that she was on vacation. Review of Resident 2's clinical record revealed his meal completion for breakfast on March 19, 2025, was documented as 75-100% of the meal eaten at 9:00 AM. Review of Resident 2's Administration History Report noted that on March 19, 2025, he did not receive his Creon medication that should have been served with breakfast until 10:37 AM. During an interview with the Director of Nursing (DON) on March 20, 2025, at 3:25 PM, she revealed that medications should be given timely and per physician order, call bells should be answered timely, and she would expect that staff not report that they are too busy to pass medications on time or answer call bells timely, due to other basic care needs on the unit. She revealed that staff is aware that they could call for assistance from nursing staff on other units, and that Employee 1 should have called Employee 6 (Registered Nurse Unit Manager) for help. She further revealed the incident of the late medication and the long call bell wait time would not have occurred if they were staffed with the other unit manager that was on vacation; however, they had not designated a staff member to replace her that week. Follow-up email correspondence with the DON on March 20, 2025, at 4:21 PM, revealed she was unable to provide information as to why Resident 2 received his Creon late on March 19, 2025. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of select facility grievances, review of the menu and select facility recipes, observation, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed. Findings include: Review of facility grievance log from January 2025, revealed a grievance filed on January 16, 2025, that stated, Resident stated meals are frequently cold. Chicken noodle soup last evening was cold, and bowl was only half full. Also stated tomato soup Monday evening was cold and watery. Review of facility grievance log from January 2025, revealed another grievance filed on January 16, 2025, on behalf of another resident, that states, French toast and bacon was cold when received this morning. Resident stated food is frequently cold. Review of facility menu on March 11, 2025, revealed the lunch menu consisted of Chicken with Lemon Pepper, Fluffy Steamed Rice, Peas & Carrots, and Fruit Jello & Topping. Review of the recipe that was provided for Lemon Pepper Chicken, read, in part, Place chicken in a roasting pan, brush with oil and rub well with seasoning, bake at 350 [degrees Fahrenheit - F] for 45-60 minutes until chicken begins to brown. Review of the recipe that was provided for Steamed Rice, read, in part, Place rice in stock pot or kettle, add water. Bring water to a boil, reduce heat, cover pot & simmer rice 20-25 minutes until done, rice tender, water absorbed & internal temperature of 140 [degrees Fahrenheit]. Fluff rice with service fork, add margarine & season with salt & pepper. The recipe also contained an alternate steamer method for the cooking process. A test tray was completed on March 11, 2025, at 1:17 PM, with Employee 10 (Food Service Director) that included the Chicken with Lemon Pepper, Fluffy Steamed Rice, Peas &Carrots, Fruit Jello (without topping), Milk, and Coffee. The test tray was placed on a meal cart and delivered to [NAME] 3 unit with other trays being delivered at that time; 18 minutes had elapsed between with the test tray was prepared from the service line and presented for evaluation. Employee 10 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the chicken had a recorded highest temperature of 121.4 degrees F and the rice had a recorded highest temperature of 114.7 F; both the chicken and rice were not at appetizing temperatures. In addition, the chicken was opaque white in color, not browned, and tasted and appeared under seasoned. The rice tasted and appeared under seasoned, as well as undercooked. The surveyor discussed the results of the test tray with Employee 10. During an interview with Resident 2 on March 11, 2024, at 1:20 PM, he revealed his lunch lacked flavor and wasn't warm enough. He further revealed that his food is never warm enough. During an interview with the Nursing Home Administrator and the Director of Nursing on March 11, 2025, at 2:18 PM, the surveyor revealed the concern with food palatability and the test tray results. No further information was provided. 28 Pa. Code 201.14. Responsibility of licensee

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Food Receiving and Storage, last revised March 2023, read, in part, Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observation of the walk-in freezer in the main kitchen on February 26, 2025, at 9:13 AM, revealed one box of mix vegetables on a lower shelf that was left open to air; one bag of open fish patties not dated; one pan of biscuits not dated, the foil covering the pan was ripped and the biscuits were open to air; one pan of lasagna with the foil covering the pan ripped and the lasagna was exposed to air; one tub of prepared rigatoni pasta not labeled or dated, the lid was not properly sealed and the rigatoni appeared to be freezer burned; one pan of french fries not dated; two bags of hash brown potatoes not dated; and one pan of garlic bread with the foil covering the pan ripped open and exposing the garlic bread to air. Interview with Employee 1 (Food Service Director) on February 26, 2025, at 9:15 AM, revealed the box of mixed vegetables should be closed and not left open to air, and the other food storage containers should be properly sealed. Observation of the dry storage area in the main kitchen on February 26, 2025, at 9:16 AM, revealed a bin of breadcrumbs not labeled or dated; a bin of white rice with a scoop stored inside the bin; and a box of hashbrown potatoes not sealed and left open to air. Interview with Employee 1 on February 26, 2025, at 9:17 AM, revealed bins should be labeled and dated, and scoops should not be stored inside of bins. Observation of the walk-in refrigerator in the main kitchen on February 26, 2025, at 9:18 AM, revealed one open bag of parmesan cheese without an open date or use by date once opened. Interview with Employee 1 on February 26, 2025, at 9:19 AM, revealed he is working on routine education with staff to ensure proper food storage and labeling. During a follow-up interview with the Director of Nursing on February 26, 2025, at 11:23 AM, she revealed her expectation that foods items are labeled and dated per facility policy, and food items are stored in accordance with professional standards. 28 Pa. Code 201.18.(b)(1)(3) Management

Based on clinical record review, review of facility investigation, observations and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision to prevent elopement, which resulted in harm, as evidenced by a fall and knee abrasion for one of four resident's reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things) and generalized muscle weakness. Review of select facility report detailing an elopement that occurred on October 6, 2024, stated, Resident 1 walked to the front door and asked the receptionist to let him out of the door. The receptionist thought he was a visitor, so she opened the door to let him exit and he left the facility at 3:45 AM. At 4:38 AM, a passerby heard him calling for help and noted him lying in the grass. He assisted him to his feet and brought him into the facility. Resident 1 stated he got confused and thought he was dreaming he was at work and left work to go home. Further review of the facility report revealed a RN (Registered Nurse) Assessment was completed and noted an abrasion to the left knee that required first aide. The physician was made aware and ordered lab work and a urinalysis due to new onset confusion. Psychiatric consult was made and Resident 1 was placed on 15-minute checks and was in agreement to move rooms. Resident 1 was moved to a different building and unit due to elevator monitor being in place on the ground floor. Review of Resident 1's physician orders revealed the following treatment orders: Wound Care: Left Knee, one time a day for Wound Care: Left Knee for 3 Days Cleanse Normal Saline (NS) every dressing change. Pat area dry using sterile gauze. Apply Skin Prep to surrounding intact skin to protect from moisture. Monitor for signs of infection (increased redness, warmth, drainage, swelling), with a start date of October 6, 2024, and discontinued on October 7, 2024. Wound Care: Left Knee, every evening shift for Wound Care: Left Knee for 3 Days Cleanse Normal Saline (NS) every dressing change. Pat area dry using sterile gauze. Apply Skin Prep to surrounding intact skin to protect from moisture. Monitor for signs of infection, with a start date of October 8, 2024, and completed on October 11, 2024. During an abbreviated survey on October 15, 2024, , the NHA and DON provided information and documentation of a plan of correction put into place after Resident 1's elopement. Review of the facility's plan of correction revealed that an investigation was initiated, interviews were conducted with staff on the unit and the receptionist, and the receptionist was immediately re-educated and disciplinary action was taken. Resident 1 was moved to the building where monitor was in place to prevent elopements. Resident's POA and physician were notified, and new orders were received. Physician review to be conducted for recent medication changes, the residents care plan was updated for elopement risk, and his information was added to the risk of elopement book. An audit was conducted to determine like residents with elopement risk. Residents with exit seeking behaviors were reviewed to confirm that facility procedures are followed. Review of statement provided by Employee 8 (Receptionist) on October 6, 2024, revealed the following, Front desk, I was sitting here, and resident walked up to the counter around 3:45 AM. He startled me by tapping on the glass window saying let me out. So, I did not pay attention that he was a resident. Around 4:38 AM, a good Samaritan was getting off work and heard [Resident 1] screaming for help. He came in to let me know that he fell and helped him off of the ground and back into the facility. Front desk then called up to nursing supervisor around 4:41 AM, they came down to help [Resident 1] get back to his room. Review of document titled Spring Creek Employee Discipline Report dated October 6, 2024, revealed Employee 8 had received written disciplinary action at a level II offense of a violation related to resident safety. The document was signed by Employee 8. Review of document titled Spring Creek Unit Training Form dated October 6, 2024, revealed Resident access in and out of facility, ex LOA policies, visitor's procedures. Supervisor to be notified of as soon as possible as any situation occurs. Maintain all individuals associated with occurrence until interviewed by on duty RN supervisor. The document was signed by Employee 8. Review of document titled Receptionist Competency Checklist dated April 6, 2024, revealed Competency Trained: Door Alarm and Front Door and Independent Resident's with Badges and LOAs, who can come and go, process for signing out and signing in. The competencies were signed off by Employee 8. Review of facility education titled Spring Creek Unit Training Form dated October 7 and 8, 2024, revealed education detailing that process of LOAs including the form that should be used, these education sheets were signed by all nursing staff members. Review of Resident 1's clinical record revealed he was signed off as receiving 15 minute checks on all shifts since the elopement incident. Review of email correspondence provided revealed an email from the Assistant Director of Nursing to Unit Managers that read, in part, Unit Managers, please review all of your residents for change in condition and possible elopement risks. Any resident that has had a recent change in condition needs to be reviewed for a possible elopement risk. Please complete an elopement risk form. Notify myself of the audit results so corrective action can be taken to ensure resident safety. Review of select facility audit documentation titled Exit Seeking revealed risk forms had been completed for all units. Interview with Employee 3 (Receptionist) on October 15, 2024, at 1:19 PM, revealed the ability for resident LOA is determined by therapy and the doctor. If a resident is determined to go LOA, there needs to be a form completed by the unit and a copy is given to the receptionist. She has paper documentation of which residents are allowed to go out, and they are signed out in a book. Independent LOA residents carry a badge and sign themselves in and out at the reception desk. Visitors are required to sign in and out on a kiosk, and the front door remains locked at all times. Interview with Nursing Home Administrator (NHA) and the Director of Nursing (DON), on October 15, 2024, at 2:18 PM, revealed the precautions they put in place to prevent an incident from occurring again was re-education and disciplinary action for Employee 8. The NHA further revealed Employee 8 was a per-diem employee and the facility currently has a full-time receptionist hired for all three shifts. During a follow-up interview with the NHA and DON on October 15, 2024, at approximately 2:30 PM, the surveyor revealed the concern with the lack of proper supervision to prevent accidents that occurred on October 6, 2024. No further information was provided. During the abbreviated survey, the facility's audits and education were reviewed. Resident 1's clinical record was reviewed and revealed updated precautions. Observations were made of residents and the visitor sign-in/out process. Staff were interviewed about the LOA and visitor sign-in and out process and there were no concerns identified. 28 Pa. Code 201.4(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services.

Based on facility policy review, clinical record review, facility provided documentation review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to properly secure controlled medications which resulted in missing controlled medications prescribed to Resident 6. Findings include: Review of facility policy titled Controlled Substances, with a revised date of September 2022, revealed [in part] Only authorized licensed nursing and/or pharmacy personnel have access to . controlled substances maintained on premises and controlled substances are separately locked in permanently affixed compartments. Review of Resident 5's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), and narcolepsy (a chronic neurological disorder that impairs the ability to regulate sleep-wake cycles). Review of Resident 5's progress notes revealed a note dated October 8, 2024, at 2:20 PM that indicated Called to unit for resident having Ativan [a controlled medication used to treat anxiety] found in room. Resident was AOX3 (alert and oriented to person, time, and place), PERRLA (pupils equal, round, reactive to light, and accommodate or the ability to see things near and far) and in NAD [no acute distress]. No c/o [complaints of] pain or discomfort. Resident in no respiratory distress. Resident noted to be drowsy, and does have a narcolepsy diagnosis. Resident denies taking the Ativan, and said someone else did it. He did not know how the pills (18) in the clear plastic container sitting on his nightstand got in his room. Room searched w/ resident present and another Ativan pill found in the glove box on his bedside table. No other pills found. Empty pill pack found in residents bathroom garbage can torn into 4 pieces. No pills found in garbage can. Total found 19. Provider notified and ordered neuro checks [which assess an individual's neurological functions, motor and sensory response, and level of consciousness and allows medical specialists to determine whether a patient ' s neurological functions are working and reacting correctly] q [every] 2 hours for 24 hours and to notify immediately if any change in mental status. Administrator notified. Review of Resident 5's progress notes revealed a note dated October 8, 2024, at 4:46 PM, that indicated Resident refused to go to the hospital. Resident was talked to by two EMT's [Emergency Medical Technician] and charge nurse, and still declined to go to the ED [emergency department]. Review of Resident 5's progress notes revealed a note dated October 8, 2024, at 8:15 PM, that indicated No decreased respirations as resident engaging in conversations with Writer with his eyes closed. Continues with frequent neurological assessments. Self-propels in wheelchair on unit. Room search and shower search was conducted by writer, and no evidence of nonprescribed medications. Plan of care ongoing. Review of Resident 5's physician services progress notes revealed a note by psychiatric services on October 10, 2024, at 7:52 PM, with recommendations for medication changes. Review of Resident 5's physician services progress notes also revealed a note by their primary physician services dated October 10, 2024, at 8:45 PM, that indicated [in part] Resident 5 was seen due to increased behaviors. Per nursing, pt took another resident's Ativan off nursing cart. He was found to have medication at bedside and 11 pills were missing. Per nursing, pt was monitored closely and his own narcotics were held. No adverse reactions noted. Pt seen sitting in room. He adamantly denies taking medication off nursing cart. He is alert and orient x 3. He denies CP [chest pain], SOB [shortness of breath]. The note further indicated that approval was given for the psychiatry recommended medication changes. Review of Resident 5's clinical record progress notes from October 8, 2024, through October 15, 2024, failed to reveal that Resident 5 had experienced any negative outcome from the possible ingestion of the 11 missing Ativan tablets. Review of a facility provided document titled Neurological Record revealed that Resident 5's neuro checks were completed every two hours beginning on October 8, 2024, at 2:00 PM and ending on October 10, 2024, at 6:00 AM, with no changes noted in their neurological status. Review of facility provided documentation revealed a statement from Employee 5 (Licensed Practical Nurse) dated October 8, 2024, that indicated around 8:00 AM that date a pharmacy driver delivered Resident 6's Ativan 1 mg (milligram) tablets in the quantity of 30. Employee 5 indicated another nurse had originally signed for this medication but Resident 6 had now moved to another nursing unit. Employee 5 further checked the card and ensured it matched the narcotic count sheet with it for 30 tablets. Employee 5 then signed for the medication and placed the card in the lock box of their medication cart until Employee 4 was available for direct hand off. Employee 5 indicated that she gave the medication card to Employee 4 at 12:00 PM. Review of facility provided documentation revealed a statement from Employee 4 (Licensed Practical Nurse) dated October 8, 2024, that indicated a coworker gave her Resident 6's medication card at 12:00 PM. Employee 4 indicated that she became distracted when a resident asked for water and ice. Employee 4 indicated that she placed the medication card containing the lorazepam in the narcotic logbook and when she came back the card was gone. Employee 4 indicated that they started a search and located the medication in a resident's room. Review of facility provided documentation revealed a statement from Employee 10 (Nurse Aide) dated October 8, 2024, that indicated they observed Resident 5 in their wheelchair going down the hall. Employee 10 indicated that when they arrived at the nurse's desk, they overheard the nurse's discussing a blister pack of Ativan was missing. Employee 10 indicated that they went to Resident 5's room and found a small clear container of pills, they removed them from the room, and gave them to the unit manager. Employee 10 said that they went back to the room to see if they could find the blister pack and that when they went into the bathroom, they saw that there were a bunch of unused paper towels in the trash can and when they looked underneath them the blister pack was there and that she gave this to the unit manager. Employee 10's statement further indicated that she assisted the Assistant Director of Nursing and another RN search the room again and that was when another tablet was found in a box of gloves sitting on the bedside stand. Review of facility provided documentation revealed that the Nursing Home Administrator (NHA) had called a meeting of the facility Quality Assurance Performance Improvement Committee on October 8, 2024, to review and resolve this incident. This documentation indicated the following plan of correction: 1) the police were notified, and that Resident 5 was interviewed, but continued to deny involvement; 2) Resident 5's legal guardian was also notified and spoke with Resident 5 but was unable to obtain any additional information; 3) additional searches were performed of all common areas on the unit and no additional pills were located; 4) due to being unable to locate the additional eleven missing pills, other residents that are independently mobile on the unit had their vital signs completed and were monitored for changes in condition; 5) Employee 4 was immediately educated, and disciplinary action rendered; 6) counts were completed for controlled medications for every medication cart in the facility and all controlled substances were accounted for with no discrepancies noted; 7) education on the facility Controlled Substances policy was immediately initiated with the licensed nurses and would continue every shift until all licensed nurses were educated; 8) an audit of all medication carts with controlled substances in the facility will be completed daily for one week to ensure no discrepancies arise; and 9) the medical Director was made aware of the Ativan issue and the plan to address the concern. This facility provided documentation indicated that the above plan and findings were reviewed at another Quality Assurance Performance Improvement Committee on October 9, 2024. During a staff interview with the Director of Nursing (DON) on October 15, 2024, at approximately 12:45 PM, she indicated that the police had come to the facility to investigate and provided their business card but said that they could not take any action as there was no evidence that Resident 5 stole the medication. She indicated that Resident 5 nor any of the other residents being monitored had experienced any noted changes in condition. She also confirmed that they could not prove that Resident 5 stole the medication, nor that Resident 5 had ingested the eleven missing tablets. The DON also shared that Employee 10 (Nurse Aide) was a regular staff member on that unit and very familiar with the residents and when they heard the package was missing and noticed Resident 5 was acting out of character they went in Resident 5's room and found the pills immediately bringing them to the nurse. Review of facility audits on October 15, 2024, revealed that the audits were completed daily on each medication cart from October 8-14, 2024, with no discrepancies noted. Review of education sign-in sheets on October 15, 2024, revealed that a total of 65 nurses had received education. During a staff interview with Employee 6 (Licensed Practical Nurse) on October 15, 2024, at 1:20 PM, Employee 6 indicated that when medications are delivered to the unit, the carrier will present the medications to a nurse who would complete a count of the medications and verifies this with the delivery receipt and then signs for the delivery. The nurse is then responsible to put the controlled medications into the lock box and place the reconciliation sheet into the controlled medication logbook. Employee 6 indicated that all non-controlled medication gets placed into the other drawers of the medication cart. During a staff interview with Employee 5 (Licensed Practical Nurse) on October 15, 2024, at 1:26 PM, Employee 5 indicated that when medications are delivered to the unit, the medication nurse checks the actual medications being received against the packing slip to make sure they match and if accurate they sign for the medication receipt. Employee 5 then indicated that uncontrolled medications go into the regular drawers of the cart and that controlled medications go into the narcotic lock box. During a staff interview with Employee 7 (Licensed Practical Nurse) on October 15, 2024, at 1:29 PM, Employee 7 indicated that when medications are delivered to the unit, the nurse checks the paperwork to reconcile the medication counts are correct. Employee 7 indicated that once the counts are completed and noted to be correct medications are then placed in the drawers of the medication cart with controlled medications going into the lock box. Employee 7 indicated that this would be the same process that would be followed if a resident were to transfer from one unit to another. During a final staff interview with the NHA and DON, on October 15, 2024, at approximately 1:45 PM, the DON confirmed that all licensed staff had received the education on the facility Controlled Substances policy. The NHA and DON both confirmed Employee 4 failed to store the medication properly which resulted in the theft of the medication card. They further confirmed they were unable to locate the additional 11 Ativan tablets, they were unable to prove that Resident 5 had stolen the medication card, and they were unable to prove that Resident 5 had ingested the 11 missing Ativan tablets. During the abbreviated survey, the facility's audits and education were reviewed. Observations were made of medication storage and medication carts and nursing staff were interviewed regarding the controlled substances policy. There were no concerns identified. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2) Nursing services.

Based on interviews, record review, and policy review, the facility failed to follow physician orders to administer medications, failed to have medications available, and failed to notify hospice resulting in unnecessary labored and rapid breathing (struggling and unable to breathe easily, breathing rate above normal 12-16 breaths per minute), restlessness (unable to relax), and no pain management for one of eight residents reviewed (Resident 7). Findings include: A review of the facility provider pharmacy policy titled, Emergency Pharmacy Services and Emergency Kits, last revised August 2020, states the following; The pharmacy supplies emergency or STAT medications according to the pharmacy provider agreement. The ordered medication is obtained either from the emergency box or electronic interim box (Omnicell) from the provider pharmacy, or from a back-up pharmacy that is determined by the provider pharmacy. For Schedule II (CII) medications [MEDICATION(S)] (an [MEDICATION(S)] and narcotic drug obtained from [MEDICATION(S)] and used medically for pain and decrease respiratory efforts), the prescriber prepares and sends a written, Authorization for Emergency Dispensing, to the pharmacy within seven (7) days or as required by state regulations. An authorization code may be obtained 24 hours a day to access medications from the Omnicell. A written statement from the provider pharmacy provided two options for local emergency pharmacies. One of the options is available 24 hours a day, and is located 4.61 miles the facility. The pharmacy received a verbal authorization for emergency dispensing on 1/22/2021, approximately 5:49 PM. A review of the facility policy titled, Hospice Program, last reviewed July 2017, states, Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. A review of Resident 7's interdisciplinary care plan, dated January 22, 2021, stated the facility would keep the resident comfortable at all times and would notify hospice with any changes in the plan of care. A review of the clinical record for Resident 7 on January 25, 2021, revealed the resident was admitted to the facility on [DATE], and was transferred to the hospital on January 16, 2021, due to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted back to the facility on [DATE]. On January 20, 2021, it was determined that his condition declined, and his responsible party changed his code status from a full code to a do not resuscitate status. The responsible party also agreed to a hospice consult for Resident 7. On January 21, 2021, a physician order was placed for a consult with hospice. The resident was assessed and admitted to hospice on January 22, 2021, at 2:32 PM. Hospice Nurse 2 recommended Resident 7 receive [MEDICATION(S)] every 4 hours routinely due to labored respirations. Physician orders included: [MEDICATION(S)] sulfate solution 20 milligrams/milliliter (an opioid that relieves the sense of breathlessness and relieves pain), give 5 milligrams by mouth every 4 (four) hours related to acute respiratory failure with [CONDITION(S)], and acute pain, start January 22, 2021, at 1600, and give 5 milligrams [MEDICATION(S)] sulfate by mouth every 2 hours as needed for pain; shortness of breath, start January 22, 2021 at 3:30 PM; and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide the [MEDICATION(S)] or [MEDICATION(S)] to the resident until January 23, 2021, at 11:00 AM, 19 and ½ hours after the [MEDICATION(S)] was ordered to be administered every 4 hours routinely, and every 2 hours as needed. The facility stated that from 3:30 PM until approximately 11:00 PM, on January 22, 2021, they were unable to obtain an authorization code, to retrieve the medication from the medication unit, and when they received the authorization code at 11:00 PM, the medication was not available in the medication unit. There was one dose of [MEDICATION(S)] administered on January 23, 2021, at 1:56 PM. A written statement from LPN 1 received on January 26, 2021, revealed that on January 22, 2021, LPN 1 was unable to locate the physician to sign the prescriptions for [MEDICATION(S)] and [MEDICATION(S)] (antianxiety medication) prior to the end of her shift. LPN 1 informed the oncoming Supervisor regarding the need for the physician to sign the prescriptions. When LPN 1 returned on January 23, 2021, at 7:00 AM, she was informed the medication was never received or administered because the Omnicell did not contain the concentration of [MEDICATION(S)] ordered by the physician. A written statement from RN Supervisor 1, received from the Director of Nursing on January 26, 2021, reveals that on January 2, 2021, at approximately 10:50 PM, LPN 2 went with the Supervisor nurse to the medication storage units to obtain [MEDICATION(S)]. She stated there was a higher concentration (100 mg/5ml) of [MEDICATION(S)] available but not the concentration the doctor ordered (20mg/1ml). A review of a progress note dated January 22, 2021 at 10:50 PM states, medication not available, pharmacy called and stated medication will be delivered overnight. MD aware. There was no documentation informing the physician of the resident's status, or that the physician was informed [MEDICATION(S)] was available in another concentration. A review of the medication unit inventory sheet dated January 22, 2021, at 1:00 AM revealed 1 (one) vial of [MEDICATION(S)] was available (100mg/5 milliliters) and that 10 (ten) 5 milligram [MEDICATION(S)] tablets were available. During an interview with the Director of Nursing on January 28, 2021, at 3:49 PM, she stated that staff would not be able to use that concentration of [MEDICATION(S)] without a new physician order. During a telephone interview with the Hospice Nurse 1 on January 26, 2021, at 12:35 PM she stated that when she arrived at the facility on January 23, 2021, at 11:00 AM, she observed the resident extremely agitated. She stated respirations were 48 breaths per minute, and he was lying in a very poor position, unclothed, and uncovered. She stated, the responsible party was also present, and informed the hospice nurse that comfort medications were never provided to the resident. She said the responsible party was very upset to see the Resident 7 still suffering. The responsible party informed the hospice nurse that he expected comfort medications would be provided the evening before and was informed by staff they would administer as soon as they received the authorization code from pharmacy. Hospice Nurse 1 stated that she immediately went to the medication nurse to inquire about the [MEDICATION(S)] and [MEDICATION(S)], and was informed by LPN 1 that she has attempted to page the supervisor for the [MEDICATION(S)], but she hasn't brought it to the floor. The Hospice Nurse 1 said that she requested LPN 1 to page the supervisor immediately. The Hospice Nurse 1 said she returned to the resident's room to re-position, clothe, and cover him. Hospice Nurse 1 said she returned to the LPN 1, and at that same time, the supervisor arrived with the [MEDICATION(S)], and administered it to the resident. Hospice Nurse 1 also questioned LPN 1 about [MEDICATION(S)] and was informed that the [MEDICATION(S)] wasn't available and would be delivered later. After the administration of the [MEDICATION(S)] on January 23, 2021, at 11:00AM, the Hospice Nurse 1 at approximately 11:15 AM stated that she re-assessed the resident's respirations, they were less rapid at 36 breaths per minute. Hospice Nurse 1 stated that prior to leaving the facility, requested LPN 1 to administer the [MEDICATION(S)] every 2 hours until the resident's respirations are within a normal range (12-16 breaths per minute). During a telephone interview with Hospice Nurse 2 on January 28, 2021, at 1:30 PM, she stated she admitted Resident 7 to hospice services on Friday January 22, 2021, between the hours of 12:00 PM and 2:30 PM. She stated that the resident had labored breathing, respirations were 36 breaths per minute, and was end of life status, she recommended [MEDICATION(S)] routinely every 4 hours, and as needed every 2 hours between the routine doses. She provided the nurse with her documented recommendations and notified the family by telephone with the hospice recommendations. A review of the pharmacy restock packing form revealed that [MEDICATION(S)] was delivered to the facility. The top of the pharmacy restock packing form is dated January 22, 2021, indicating when it was packaged for delivery by pharmacy. The receiving LPN signed the bottom of the pharmacy restock packing form and dated the form January 23, 2021. There was no documented time on the form when the [MEDICATION(S)] was received. The pharmacy staff entered the [MEDICATION(S)] into the Omnicell. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to provide the actual time the actual Omnicell was restocked, after this information was requested on two occasions. Correspondence with the provider pharmacy on January 28, 2021, at 8:16 PM, revealed that the [MEDICATION(S)] was delivered and re-stocked in the Omnicell at the facility on January 23, 2021, at 2:23 AM. During an interview with the NHA and DON on January 28, 2021, at 3:49 PM, and at 4:55 PM they were asked why the medication wasn't administered when it arrived. Their response was that the medication was delivered to the other building, and that building wouldn't have any idea that this building needed the medication. Additionally, they stated that an agency nurse was covering on the night shift on January 23, 2021, and agency staff do not have access to the Omnicell (medication unit). They stated that the day shift nurse had to call pharmacy for a new access code, since the first authorization code wasn't used within the appropriate timeline. They also stated that they would have to review the hospice agreements to determine if hospice can supply the medications in the future. 28 Pa Code 211.12(c)(d)(1)(3)Nursing Services

Based on clinical record reviews, review of select facility policy, review of documentation submitted by the facility, and staff and resident interviews, it was determined that the facility failed to ensure that the residents were free from physical abuse and mental anguish for one of six residents reviewed (Resident 1) resulting in harm in the form of bruising to both arms, a skin tear, and mental anguish. Findings include: Review of the facility's current abuse policy stated it is the policy of the facility that acts of physical abuse against residents are absolutely prohibited. Each resident has the right to be free from all abuse, corporal punishment (physical punishment), involuntary seclusion, mistreatment, and neglect. Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Review of Resident 1's quarterly Minimum Data Set (MDS) (a set of screening and assessment tools that is part of a resident assessment) dated (MONTH) 5, 2019, and Resident 1's comprehensive MDS dated (MONTH) 3, 2019, revealed that she scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS). The BIMS test is conducted to evaluate cognitive status. Intact cognition score is 13-15, moderate cognitive impairment is 8-12, and severe cognitive impairment is 0-7. Resident 5 is Resident 1's roommate, and review of the clinical record for Resident 5 revealed [DIAGNOSES REDACTED]. Resident 5 had a comprehensive MDS on (MONTH) 28, 2019, in which she scored a 15/15 on the BIMS. Review of a statement provided by Licensed Practical Nurse (LPN) 1 on (MONTH) 4, 2019, at approximately 4:30 PM Resident 5 approached LPN 1 with tears in her eyes and stated, I have to tell you something, I have to tell you what they did to (Resident 1) last night. Resident 5 said that last night Resident 1 yelled out two times. Registered Nurse (RN) 3 and Nurse Aide (NA) 1 came in the room and NA 1 started yelling at Resident 1 for yelling out and using her call bell. Resident 5 stated that the next thing to happen was Resident 1 was being ripped out of her bed. Resident 1 was fighting and saying she didn't want to go, and she was cold. NA 1 told Resident 1 that she was coming with her and you're not going to do this tonight. Resident 5 told LPN 1 that she begged for them to leave Resident 1 in her bed, but RN 3 told her to let them do their job, they knew what to do with this resident. Resident 5 stated, I could see the terrified look in her eyes when she (NA 1) threw her in the wheelchair, (Resident 1) was still fighting and begging to be left in bed because it's cold and she was tired. LPN 1 immediately went to talk to Resident 1 and asked Resident 1 if anything happened last night. Resident 1's eyes got big and she stated, they said I was screaming, they ripped me out of the bed and threw me in the wheelchair. I begged them not to; I fought, kicking at them to stop. Please I trust you, you are a good person, please do not tell, I am afraid. LPN 1 explained to the resident that she had to report it. She reported the incident to RN 2. Review of a statement date (MONTH) 12, 2019, by RN 2 revealed she spoke with Resident 5 and Resident 5 repeated the same story and said that Resident 1 was pulled from her bed by her arms and placed in a wheelchair. Resident 5 also reported that she heard Resident 1 call her husband in the morning and tell him, they dragged me from my bed and hurt my left arm. She is a horrible, horrible woman. RN 2 spoke with the husband who confirmed the phone call. Review of a statement date (MONTH) 4, 2019, by RN 3's revealed she wrote that she heard screaming and found NA 1 assisting Resident 1 into the wheelchair. Review of a statement date (MONTH) 4, 2019, by NA 1's revealed that the nurse asked her if she could bring Resident 1 to the nursing station. She went into the room to try to get her out of bed and she was hollering. RN 3 came in and the two of them transferred Resident 1 into the wheelchair. Review of the Resident 1's care plan revealed that her transfer status is a two assist with transfer board. On (MONTH) 4, 2019, at 6:11 AM, RN 3 filled out an incident report titled, skin injury which noted that Resident 1 had a skin tear on her left forearm and left shin. On (MONTH) 4, 2019, at 7:20 PM, RN 1 assessed the resident and filled out an incident report titled, injury of known which noted that Resident 1 was found to have bruises on both arms above the wrists. During an interview with Resident 5 on (MONTH) 1, 2019, at 2:15 PM she repeated the same story of what happened to Resident 1. She stated that RN 3 did not assist but instead watched the whole thing happen. Resident 5 said that she begged them to stop. She said that NA 1 grabbed Resident 1 above the wrists and pulled her out of bed and into the wheelchair. She said that Resident 1 yelled out 2 times and accidently hit her call bell and that is when NA 1 came in. Resident 5 had tears in her eyes saying, I wish I could have stopped them, it was like something out of the movies, it was awful. On (MONTH) 1, 2019, at approximately 2:30 PM, Resident 1 and her husband entered the room. She confirmed the incident but stated that she was not feeling well. She began to vomit, and staff entered the room to assist the resident. During an interview with the Assistant Director of Nursing on (MONTH) 1, 2019, at 12:50 PM she confirmed that NA 1 did not follow the care plan for a two person assist. She stated that RN 3 reported that she entered the room after the resident was in the wheelchair and did not assist in the transfer. During an interview with the Director of Nursing on (MONTH) 1, 2019, at 1:45 PM she confirmed that there was conflicting information between NA 1 and RN 3. She stated that Resident 1 and 5 repeated the same story and upon assessment Resident 1 was found with bruises on both arms. The facility failed to ensure that the residents were free from physical abuse for (Resident 1) resulting in harm in the form of bruising to both arms, a skin tear, and mental anguish. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. Previously cited 12/28/18, 5/30/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/20/18, 7/9/18, 5/30/18, 12/20/17, 10/26/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/28/18, 9/20/18, 7/9/18, 5/30/18, 10/26/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 12/28/18, 9/20/18, 7/9/18, 5/30/18, 4/19/18, 10/26/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/9/18, 5/30/18, 10/26/17. 28 Pa. Code 201.29(a) Resident rights. Previously cited 2/6/19, 9/20/18, 7/9/18. 28 Pa. Code 201.29(d) Resident rights. Previously cited 7/9/18. 28 Pa. Code 201.29(j) Resident rights. Previously cited 2/6/19, 12/28/18, 9/20/18, 4/19/18. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 9/20/18, 7/9/18, 12/20/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/20/18, 7/9/18, 5/30/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 12/28/18, 7/9/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/28/18, 11/20/18, 9/20/18, 7/9/18, 5/30/18, 12/20/17, 10/26/17. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 12/28/18, 9/20/18. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 12/28/18, 9/20/18, 7/9/18, 5/30/18, 3/6/18, 12/20/17, 10/26/17.

Based on review of policies, investigative reports and clinical records, as well as staff interviews, it was determined that the facility failed to implement interventions and adequate supervision to prevent accident hazards for one of nine residents reviewed (Resident 1), which resulted in harm by burns, transfer to a hospital and subsequent transfer to a burn center with admission, resulting from smoking while continuous oxygen was being used by the resident. Findings include: The facility's policy regarding smoking, dated (MONTH) 22, (YEAR), indicated that Spring Creek is a non-smoking facility. Safe smoking will be permitted in an outside designated area for those resident smokers who were admitted prior to the facility being designated as non-smoking. The policy goes on to state that violation of the policy will bring possible discharge from the facility if behaviors present a danger to self or others. A review of Resident 1's clinical record revealed he was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. The facility's Smoking Evaluation dated (MONTH) 17, (YEAR), states that Resident has been evaluated and IS NOT safe to smoke. Resident is on continuous oxygen. The resident's care plan, dated (MONTH) 18, (YEAR), revealed that he had chronic respiratory disease, would not smoke unless approved by the facility and an intervention dated (MONTH) 8, (YEAR), was that resident would be educated on the dangers of using oxygen while smoking. Based on the aforementioned Smoking Evaluation, resident was not approved to smoke. A review of nursing progress notes in Resident 1's clinical record dated (MONTH) 9, (YEAR), stated staff made aware that resident was outside smoking. Resident re-educated about smoking and how it is harmful to his existing condition and also the dangers of smoking with oxygen. Unit manager made aware. Also, in Resident 1's clinical record is a respiratory progress note dated (MONTH) 8, (YEAR), which stated Patient has been educated on the dangers of smoking while wearing oxygen. A statement written by the Assistant Nursing Home Administrator (ANHA) for Resident 1 states that on (MONTH) 15 (no year), he spoke with Resident 1 about not being allowed to smoke due to the facility's smoking assessment deeming the resident unsafe to smoke. The statement also stated that there are other options available to the resident to help with his nicotine dependence, the resident declined looking into any other option the facility could provide him. There was no documentation in Resident 1's clinical record regarding this offer of smoking cessation options that could be provided by the facility. In an interview with Respiratory Therapist (RT) on (MONTH) 3, (YEAR) at 10:00 a.m. she stated that she had spoken with Resident 1 numerous times about smoking and he didn't want to quit that the damage is done. RT also stated that she had spoken with Resident 1's girlfriend numerous times about his smoking; that resident would sneak off the unit, RT didn't know how many times because Resident 1 would leave with his girlfriend. Review of the facility's Elopement Risk Evaluation dated (MONTH) 8, (YEAR) revealed that Resident 1 was oriented to person and place and was not at risk for elopement, despite the aforementioned sneaking off the unit without signing out. Facility report of an incident dated (MONTH) 1, (YEAR), revealed that at approximately 12:00 p.m. Resident 1 left the unit without signing out. He was smoking outside in the courtyard with an oxygen tank on the back of his wheelchair. An Activities Aide found the resident on fire and extinguished the fire with a fire extinguisher. Licensed Practical Nurse (LPN) 1 arrived at the scene as Resident 1 was being wheeled in his wheelchair away from the area and brought back to his room to be assessed. The resident was assessed by a wound nurse (LPN 2) and 911 was called. Resident 1 was transported to the hospital and subsequently transferred to a burn center where he was admitted [MEDICAL CONDITION] his left flank (side of the body between the rib cage and the hip bone), right back and left hand. Review of Resident 1's clinical record failed to reveal documentation of an assessment by a Registered Nurse (RN) while he was still at the facility, prior to his transfer to the hospital. An interview with the Nursing Home Administrator on (MONTH) 3, (YEAR), at 3:00 p.m. confirmed that the facility educated Resident 1 on the dangers of smoking with oxygen, but offered no explanation as to why other interventions were not implemented or why the facility's smoking policy was not enforced. The facility failed to implement interventions and provide adequate supervision to ensure the resident did not smoke with oxygen to prevent accident hazards for Resident 1 which resulted in harm by burns, transfer to a hospital and subsequent transfer to a burn center with admission, resulting from smoking while continuous oxygen was being used. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 10/26/17, 8/31/17, 7/26/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/30/18, 12/20/17, 10/26/17, 8/31/17, 6/15/17, 4/20/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/30/18, 10/26/17, 8/31/17, 7/26/17, 5/3/17, 4/20/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/30/18, 4/19/18, 10/26/17, 8/31/17, 7/26/17, 5/3/17, 4/20/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/30/18, 10/26/17, 8/31/17, 4/20/17. 28 Pa. Code 201.29(a) Resident rights. Previously cited 4/20/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 12/20/17, 8/31/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 5/30/18, 8/31/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 8/31/17, 4/20/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/30/18, 12/20/17, 10/26/17, 9/18/17, 8/31/17, 7/26/17, 6/15/17, 4/20/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/30/18, 3/6/18, 12/20/17, 10/26/17, 8/31/17, 4/20/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/30/18, 3/6/18, 12/20/17, 10/26/17, 9/18/17, 8/31/17, 7/26/17, 6/15/17, 4/20/17.

Based on review of clinical records, facility reports, and interviews with staff, it was determined that the facility failed to develop a care plan for three of 5 residents reviewed (Residents 1, 2 and 3). Findings include: Review of Resident 1's clinical record revealed medical [DIAGNOSES REDACTED]. Review of the facility's incident reports (a form used when a resident has a fall) for Resident 1 dated June 9, 11, and 12, 2016, revealed that Resident 1 fell on each of those dates and was found on the floor at the side of the bed each time. Review of Resident 1's care plan for falls revealed the care plan was not initiated until June 12, 2016, at which time interventions were added with a goal to be free of injury from falls. An interview with the Nursing Home Administrator on August 3, 2016, at 3:00 p.m. revealed no explanation as to why a care plan was not initiated following Resident 1's fall on June 9, 2016. Clinical record review revealed that Resident 2 had [DIAGNOSES REDACTED]. functioning) and gangrene (the death of body tissue due to lack of blood flow or bacterial infection). Resident 2's current care plan dated May 22, 2013, and last revised on June 19, 2016, indicated that the staff should, check all of body for breaks in skin and treat promptly as ordered by doctor and to, identify areas of non-compliance or other difficulties in my diabetic management. Review of Resident 2's progress note dated July 6, 2016, at 6:30 p.m. revealed that Resident 2's spouse asked Registered Nurse (RN) 1 to look at the resident's right great toe and second toe which had a small amount of dried blood. The area was cleansed and the dried blood was removed. No open area or bruising was found. Gauze (a bandage) was placed on the toe in case of any additional drainage. A progress note dated July 8, 2016, stated, every Friday skin to be assessed on shower day, resident refused shower. A progress note dated July 16, 2016, at 6:30 p.m. revealed that Resident 2's spouse called Licensed Practical Nurse (LPN) 1 to look at Resident 2's toe which was noted to have a blackened area on the right great toe. A progress note dated July 16, 2016, at 8:30 p.m. revealed that Resident 2 was assessed by RN 2 due to a darkened area on the toe. The resident's spouse requested a transfer to the hospital emergency department. The resident was transferred to the hospital at 8:45 p.m. A review of hospital records revealed a [DIAGNOSES REDACTED]. A review of Resident 2's treatment record revealed skin checks had been done on July 1, 2016, and the resident refused on July 8, 2016, with no evidence of additional attempts made to perform the skin assessment. An interview on August 3, 2016, at 3:00 p.m. the Nursing Home Administrator confirmed that the resident is non-compliant at times but had no explanation as to why further attempts were not made to assess Resident 2's skin. Clinical record review for Resident 3 revealed [DIAGNOSES REDACTED]. Review of Resident 3's care plan, initiated March 22, 2016 and which continued to present, revealed the potential for injury related to falls and one of the interventions was to have auto locking brakes on her wheelchair (also known as anti roller back brakes-a brake arm that grabs the wheelchair tires to prevent the wheelchair from rolling back and away). A review of the facility's fall reports revealed that Resident 3 had a fall on June 18, 2016, when she was transferring herself from the bed to the wheelchair and the wheelchair moved and she slid off and fell . The report states that the resident had a different wheelchair without anti-roller back brakes (auto locking brakes) that had been obtained to use for visiting with family on June 17, 2016. Her wheelchair with the anti-roller back brakes had been left at therapy. An interview with the Assistant Director of Nursing on August 3, 2016, at 3:00 p.m. revealed that Resident 3's own wheelchair should have been returned to her and the care plan should be followed. 42 CFR 483.20(k)(1) Develop Comprehensive Care Plans. Previously cited 4/24/15. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/24/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/20/16, 5/26/16, 9/23/15, 4/24/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/26/16, 4/24/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/20/16, 5/26/16, 9/23/15, 7/16/15, 4/24/15.

Based on clinical record reviews and interviews with the staff and residents, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being with regard to the administration of medications in compliance with parameters as ordered by the physician for two residents out of 19 reviewed (Residents 4, and 13). The facility failed to provide adequate supervision and adequate assistance to prevent a fall, failed to provide an assessment by a registered nurse after a fall and failed to investigate and report a fall that occurred using a mechanical lift which resulted in injury for one of 19 residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49. Professional and Vocational Standards, Chapter 21. State Board of Nursing, Subchapter B. Practical Nurses, Functions of the LPN (Licensed Practical Nurse) Section 21.145(a) states, The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with the licensed professional nurse and the patient's health care team members to seek guidance when: (i) the patient's care needs exceed the licensed practical nursing scope of practice. Review of Resident 4's July 2016, physician's orders [REDACTED]. Additional review of Resident 4's July 2016, Medication Administration Record [REDACTED]. Give 1 tablet via PEG Tube (Percutaneous endoscopic gastrostomy -a tube passed into the stomach through the abdominal wall to provide a means of feeding, and medication administration) every 12 hours. Hold for HR (heart rate) less than 60 BPM (beats per minute), or SBP (systolic blood pressure, the top number in a blood pressure reading) less than 120 mmHg (millimeters of Mercury). Further review of the July 2016, MAR indicated [REDACTED]. Resident 4's heart rate was documented on July 16, 2016 as 57 BPM. Review of the MAR for July 2016, revealed that Licensed Practical Nurse, LPN 2, administered the [MEDICATION NAME], on July 9, despite the physician's orders [REDACTED]. Review of the MAR for July 2016, revealed LPN 3 administered the [MEDICATION NAME] on July 16, despite the physician's orders [REDACTED]. Review of policy entitled, Pain Management (instruction on how to treat pain), last reviewed March 2016, states, A standard Pain and Severity Scale will be used by all caregivers. The standardized 1-10 scale is utilized by this facility. For categorization purposes and to better tailor interventions, we shall consider a rating of 1-3 as mild pain, 4-7 as moderate pain, and 8-10 as severe pain. Review of the clinical record for Resident 13 revealed [DIAGNOSES REDACTED]. Review of Resident 13's current physician's orders [REDACTED]. No pain parameters (physician order [REDACTED]. Further review of Resident 13's MAR for July 2016, revealed an order dated March 15, 2016, for Tylenol ([MEDICATION NAME]- an [MEDICATION NAME] pain medication) 325 MG, give two tablets by mouth every 6 hours as needed for pain. Do not exceed 3000 MG/24 hours. No pain parameters appeared on this order for the nursing staff to determine the type of pain and the pain level for which the medication was to be given. An interview with the Nursing Home Administrator (NHA) on July 20, 2016, at 7:40 p.m. revealed the expectation that medications should be administered according to pain management policy. Review of the facility's, Incident by Incident Type list (a document that records incidents that occurred at the facility by type, ex falls) on July 20, 2016, at 9:15 a.m. revealed that Resident 1 was listed as having a fall that occurred on July 15, 2016, and was currently in the hospital. Review of the clinical record progress notes (documentation about the daily events and care of residents as they occur) written by Licensed Practical Nurse (LPN) 1 dated July 15, 2016, at 1:13 p.m. stated the following details regarding Resident 1's fall: Resident requested to get OOB (out of bed) to w/c (wheelchair). Resident requires a total assist of 3 and the Hoyer lift. Nurse Aides (NAs) reported that while the resident was up in the air, in the lift pad (sling that attaches to the Hoyer lift that a person sits in to be transfer from one area to another), the NA's were maneuvering the resident over the w/c. At that time, resident slid through lift pad and onto the chair. Resident was sitting in chair and required to be repositioned. Resident denies pain. No injury noted. Resident is currently sitting up in w/c beside nurses' station. RN (Registered Nurse) Unit Manager has been made aware. Lift pad was inspected, and determined unsafe based on documentation in the clinical record by Staff Licensed Practical Nurse (LPN) 1 Sling was then placed in the trash. Review of a late entry progress note dated July 15, 2016, at 1:38 p.m. by LPN 1 indicated documentation of Resident 1's fall incident. The incident note (progress notes regarding the fall) prompted the staff to answer specific questions regarding an incident, and the questions and responses were documented as follows: Staff LPN 1 indicated that she was not in the room when the incident happened but the resident was brought to the nurses' station by a NA, Nurse Aide; the resident was alert and oriented with no visible injuries; the resident said that she was OK but wanted her pain medication, which was given by LPN 1; the resident was taken to activities; and the LPN notified the Registered Nurse Supervisor, the physician, and the family. Review of the Medications Administration Record for Resident 1 revealed the following medication administration for pain, after the incident: July 15, 2016, 1:36 p.m. [MEDICATION NAME] (narcotic pain medication) for moderate pain. July 15, 2016, 5:38 p.m. [MEDICATION NAME] sulfate (narcotic pain medication) for severe pain. July 15, 2016, 8:41 p.m. [MEDICATION NAME] for moderate pain. July 16, 2016, 4:31 a.m. [MEDICATION NAME] for moderate pain. July 16, 2016, 8:20 a.m. [MEDICATION NAME] sulfate for severe pain. July 16, 2016, 12:34 p.m. [MEDICATION NAME] for moderate pain. July 16, 2016, 5:55 p.m. [MEDICATION NAME] sulfate for severe pain. July 16, 2016, 9:23 p.m. [MEDICATION NAME] for moderate pain. July 17, 2016, 4:55 a.m. [MEDICATION NAME] sulfate for severe pain. July 17, 2016, 11:02 a.m. [MEDICATION NAME] sulfate for severe pain. July 17, 2016, 2:19 p.m. [MEDICATION NAME] for moderate pain. July 18, 2016, 1:02 p.m. [MEDICATION NAME] sulfate for severe pain. July 18, 2016, 7:30 a.m. [MEDICATION NAME] for moderate pain. July 18, 2016, 10:27 a.m. [MEDICATION NAME] sulfate for severe pain. In addition to the narcotic pain medications, Resident 1 received Tylenol (a pain medication) every 6 hours as needed for mild pain. Review of the Medication Administration Record [REDACTED]. The July 17, 2016, 10:20 a.m. note by LPN 4 stated, Resident noted to have bruise (tissue injury which blood accumulates under the skin) above open area 7.5 cm (centimeter- metric unit of measure) x 0.2 cm. (2.5 cm equals 1 inch) no voiced c/o (complaint of) or discomfort noted at this time. Call put out to house call (Certified Registered Nurse Practitioner), awaiting call back. On July 17, 2016, at 10:20 a.m. the clinical record reveals, New order to clean left thigh with NSS (Normal Saline Solution) apply [MEDICATION NAME] (an antibiotic ointment) and cover with dry dressing per CRNP (Certified Registered Nurse Practitioner). Message left for Resident 1's daughter ., awaiting call back. Review of the clinical record dated July 17, 2016, at 3:30 p.m. as documented by Registered Nurse, Staff RN 1, stated, Resident telling her family that she had fallen on Friday and has been having increased pain. Resident did not have any falls at the facility on Friday or recently for that matter. I called and spoke with the resident's family regarding resident's statements. They are aware resident did not fall. Resident wanted to go to the hospital due to her pain level. I spoke with resident to make her aware that the physician would be in on Monday (July 18, 2016) to see her and we could call them to discuss possibly increasing her pain medication. I made resident aware that we are able to do everything the hospital can do and keep her comfortable here. Resident refused and stated, I have internal bleeding and I need to go to the hospital. I also made resident's family aware of resident's requests to go to the hospital. They stated, She knows her body and she is having that much pain then she should go. She hates hospitals, so something must be wrong if she is actually asking to go. The family is aware that we will contact the physician and send the resident to the hospital per the resident and family request. Review of a nursing note dated July 17, 2016, at 4:51 p.m. revealed that the on-call physician was notified and the resident was transferred to the hospital. Review of the hospital emergency room notes provided by the Nursing Home Administrator (NHA) for the July 17, 2016, at 7:38 p.m. hospital visit, stated the following findings: An X-ray (electromagnetic [MEDICAL CONDITION] that takes a picture of the bones) of the pelvis (area where the trunk joins the legs) and hip (joint where your thigh bone meets your pelvis bone) due to complaints of hip pain with no fracture found. X-ray of the spine was performed due to resident complaints of back pain with no fracture was identified. Resident 1 was transferred back to the nursing home. Review of the clinical record progress note for Resident 1, revealed documentation by Staff RN 1 dated July 18, 2016, at 6:15 p.m. that indicated the resident, was observed by a NA (nurse aide) to be choking. Resident was observed to be breathing shallow with a gurgle/grunting sound noted and her tongue protruding. Resident unresponsive to verbal and physical stimuli. Resident turned on side and airway checked and noted to be clear. Supervisor was called to the unit and vital signs were: blood pressure 189/110, temp (temperature) 98.6 (degrees Fahrenheit - unit of metric measurement), Pulse (heart rate) 103, Respirations 10, (normal is 12-16 breaths per minute) SaO2 (the amount of oxygen in blood) 23% (normal range 95-100%) on Room Air. O2 (oxygen) at 2 L (liters) per minute applied and rescue respirations started. AED (automated external defibrillator-a portable electronic device that automatically [DIAGNOSES REDACTED]. Resident was transferred to hospital emergency room by ambulance on July 18, 2016, at 7:00 p.m. Review of the laboratory results dated [DATE], at 7:21 p.m. which were sent from the hospital, revealed the following: Hemoglobin 7.7 g/dl (grams per deciliter- metric units of measure - normal range is 11.7-15.1 g/dl.) Hematocrit 23% (normal range is 34.5-43.7%, which indicates blood loss which can be into the tissue. Major blood loss can cause [MEDICAL CONDITION] (fewer red blood cells that normal which makes a person feel weak and tired) which can be caused by bleeding)). Review of the clinical record revealed that the hospital notified the facility on July 18, 2016, at 11:26 p.m. regarding the tibia plateau fracture, decreased H&H (Hemoglobin-component of blood responsible for transporting oxygen in the blood, and hematocrit-ratio of the volume of red blood cells to the total volume of blood) and informed the facility of the resident's possible need of blood transfusion (administration of another person's donated blood into another person intravenously -into the vein by needle) and the need to admit the resident to the hospital. Review of the hospital clinical records dated July 19, 2016, at 12:15 a.m. revealed, a left tibial plateau fracture, secondary to fall from a Hoyer lift at the nursing home, extensive hematoma (a collection of blood outside of a blood vessel) suspect causing acute, chronic [MEDICAL CONDITION] (chronic [MEDICAL CONDITION], symptoms typically begin slowly and progress gradually; whereas in acute [MEDICAL CONDITION] symptoms can be abrupt and more distressing.) Review of the hospital record revealed that Resident 1 was admitted to the hospital on July 19, 2016, at 12:15 a.m. with a chief complaint of left leg pain. The hospital report also revealed the following, in the Emergency Department patient was complaining of feeling sore all over as she unfortunately has suffered a fall 3 days ago from a Hoyer lift (mechanical lift that allows a person to be lifted and transferred using a sling (a cloth device that supports the person and attaches to the lift) with a minimum of physical effort). She does also complain of pain in her left side but since this fall she had more pain in her left leg area. An interview with the Nursing Home Administrator (NHA) July 20, 2016, at 11:45 a.m. confirmed that Resident 1 was admitted to the hospital with [REDACTED]. During an interview with the NHA and the Assistant Director of Nursing (ADON) on July 20, 2016, at 11:45 a.m. when inquiring about Resident 1's fall, they stated, We just found out about the fall yesterday and reported it to our Corporate Office, we are waiting to hear back from them. When asked if the fall was investigated internally, the NHA responded, We are in the process of beginning the investigation. The surveyor asked the NHA if a report was made to the Department of Health after the hospital informed the facility of Resident 1's fracture. The NHA responded, No report has been made to anyone but the facility's Corporate Office. An interview with the NHA and the ADON on July 20, 2016, at 4:30 p.m. confirmed that there was no registered nurse (RN) assessment made when the fall was reported to the RN Supervisor because there were no injuries and the resident said she was okay. The NHA informed the surveyor that Resident 1 was sent to the hospital on two occasions. The first date was on July 17, 2016, and at that time, no [MEDICAL CONDITION] was found. According to an interview with the NHA, the hospital did not X-ray the lower leg on the first visit to the hospital because the resident was complaining of hip and back pain. An interview with the Nursing Home Administrator (NHA) on July 20, 2016, at 4:45 p.m. revealed that she was able to talk with two of the three NAs that transferred Resident 1 on July 15, 2016, when she fell from the sling to the wheelchair. The NHA stated that NA 3 informed NHA that she was bent over during the resident transfer and that when the resident fell from the sling into the wheelchair, something hard hit her on the back of her head. Review of the personnel files of the three NAs involved in Resident 1's fall on July 15, 2016, indicated that the three NAs had received Hoyer lift training and abuse training. The facility failed to assure Resident 1 was transferred safely using a Hoyer lift resulting in a fall, two hospitalization , a tibial plateau fracture. The facility failed to assure that Resident 1 was assessed in a timely manner resulting in a delay in treatment with suspected [MEDICAL CONDITION] which required a blood transfusion at the hospital. 42 CFR 483.25 Provide Care/services for Highest Well Being. Previously cited 5/26/16, 9/23/15. 28 Pa Code 201.18(b)(1) Management. Previously cited 5/26/16, 9/23/15, 4/24/15. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/26/16, 9/23/15. 28 Pa Code 211.10(d) Resident Care Policies. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 5/26/16, 9/23/15, 7/16/15, 4/24/15. 28 Pa. Code 211.9(a)(1) Pharmacy services. Previously cited 5/26/16.

Based on observation and staff interview, it was determined that the facility failed to ensure the resident environment was free of accident hazards for three of 8 floors (McBride Building Floors 1, 2 and 4) and the facility failed to provide an assessment by a registered nurse after a fall, the facility failed to investigate and report a fall that occurred using a mechanical lift which resulted in injury for one of 19 residents reviewed (Resident 1). Findings include: Multiple observations of the McBride Building, Floors 1, 2 and 4 on July 20, 2016, during the initial tour between 8:30 a.m. and 9:00 a.m. revealed clean linen carts stored in the resident corridor against corridor hand rails. During the initial tour on July 20, 2016, between 8:30 a.m. and 9:00 a.m., it was observed that the linen carts were positioned directly against the corridor handrail in the following areas in the McBride Building, directly across the hall from resident rooms 111, 116, 119, 123, 204, 209, 216, 223, 404, 411, 419, and 423. Additional observations were made on July 20, 2016 between 2:50 p.m. and 3:00 p.m. on McBride Building Floors 2 and 4 across from rooms 203, 209, 216, 220, 404, 411, 419 and 423. In an interview with the Nursing Home Administrator on July 20, 2016, at approximately 3:00 p.m. she stated that she had been auditing the placement of the linen carts and they were supposed to be kept in the tub rooms when not in use. Review of the facility's, Incident by Incident Type list (a document that records incidents that occurred at the facility by type, ex falls) on July 20, 2016, at 9:15 a.m. revealed that Resident 1 was listed as having a fall that occurred on July 15, 2016, and was currently in the hospital. Review of the clinical record progress notes (documentation about the daily events and care of residents as they occur) written by Licensed Practical Nurse (LPN) 1 dated July 15, 2016, at 1:13 p.m. stated the following details regarding Resident 1's fall: Resident requested to get OOB (out of bed) to w/c (wheelchair). Resident requires a total assist of 3 and the Hoyer lift. Nurse Aides (NAs) reported that while the resident was up in the air, in the lift pad (sling that attaches to the Hoyer lift that a person sits in to be transfer from one area to another), the NA's were maneuvering the resident over the w/c. At that time, resident slid through lift pad and onto the chair. Resident was sitting in chair and required to be repositioned. Resident denies pain. No injury noted. Resident is currently sitting up in w/c beside nurses' station. RN (Registered Nurse) Unit Manager has been made aware. Lift pad was inspected, and determined unsafe based on documentation in the clinical record by Staff Licensed Practical Nurse (LPN) 1 Sling was then placed in the trash. Review of a late entry progress note dated July 15, 2016, at 1:38 p.m. by LPN 1 indicated documentation of Resident 1's fall incident. The incident note (progress notes regarding the fall) prompted the staff to answer specific questions regarding an incident, and the questions and responses were documented as follows: Staff LPN 1 indicated that she was not in the room when the incident happened but the resident was brought to the nurses' station by a NA, Nurse Aide; the resident was alert and oriented with no visible injuries; the resident said that she was OK but wanted her pain medication, which was given by LPN 1; the resident was taken to activities; and the LPN notified the Registered Nurse Supervisor, the physician, and the family. Review of the Medications Administration Record for Resident 1 revealed the following medication administration for pain, after the incident: July 15, 2016, 1:36 p.m. Percocet (narcotic pain medication) for moderate pain. July 15, 2016, 5:38 p.m. Morphine sulfate (narcotic pain medication) for severe pain. July 15, 2016, 8:41 p.m. Percocet for moderate pain. July 16, 2016, 4:31 a.m. Percocet for moderate pain. July 16, 2016, 8:20 a.m. Morphine sulfate for severe pain. July 16, 2016, 12:34 p.m. Percocet for moderate pain. July 16, 2016, 5:55 p.m. Morphine sulfate for severe pain. July 16, 2016, 9:23 p.m. Percocet for moderate pain. July 17, 2016, 4:55 a.m. Morphine sulfate for severe pain. July 17, 2016, 11:02 a.m. Morphine sulfate for severe pain. July 17, 2016, 2:19 p.m. Percocet for moderate pain. July 18, 2016, 1:02 p.m. Morphine sulfate for severe pain. July 18, 2016, 7:30 a.m. Percocet for moderate pain. July 18, 2016, 10:27 a.m. Morphine sulfate for severe pain. In addition to the narcotic pain medications, Resident 1 received Tylenol (a pain medication) every 6 hours as needed for mild pain. Review of the Medication Administration Record revealed that Resident 1 typically only received 1 dose of Percocet and 1 dose of Morphine daily prior to the fall from the Hoyer lift to the wheelchair incident on July 15, 2016. The July 17, 2016, 10:20 a.m. note by LPN 4 stated, Resident noted to have bruise (tissue injury which blood accumulates under the skin) above open area 7.5 cm (centimeter- metric unit of measure) x 0.2 cm. (2.5 cm equals 1 inch) no voiced c/o (complaint of) or discomfort noted at this time. Call put out to house call (Certified Registered Nurse Practitioner), awaiting call back. On July 17, 2016, at 10:20 a.m. the clinical record reveals, New order to clean left thigh with NSS (Normal Saline Solution) apply Bacitracin (an antibiotic ointment) and cover with dry dressing per CRNP (Certified Registered Nurse Practitioner). Message left for Resident 1's daughter ., awaiting call back. Review of the clinical record dated July 17, 2016, at 3:30 p.m. as documented by Registered Nurse, Staff RN 1, stated, Resident telling her family that she had fallen on Friday and has been having increased pain. Resident did not have any falls at the facility on Friday or recently for that matter. I called and spoke with the resident's family regarding resident's statements. They are aware resident did not fall. Resident wanted to go to the hospital due to her pain level. I spoke with resident to make her aware that the physician would be in on Monday (July 18, 2016) to see her and we could call them to discuss possibly increasing her pain medication. I made resident aware that we are able to do everything the hospital can do and keep her comfortable here. Resident refused and stated, I have internal bleeding and I need to go to the hospital. I also made resident's family aware of resident's requests to go to the hospital. They stated, She knows her body and she is having that much pain then she should go. She hates hospitals, so something must be wrong if she is actually asking to go. The family is aware that we will contact the physician and send the resident to the hospital per the resident and family request. Review of a nursing note dated July 17, 2016, at 4:51 p.m. revealed that the on-call physician was notified and the resident was transferred to the hospital. Review of the hospital emergency room notes provided by the Nursing Home Administrator (NHA) for the July 17, 2016, at 7:38 p.m. hospital visit, stated the following findings: An X-ray (electromagnetic radiation that takes a picture of the bones) of the pelvis (area where the trunk joins the legs) and hip (joint where your thigh bone meets your pelvis bone) due to complaints of hip pain with no fracture found. X-ray of the spine was performed due to resident complaints of back pain with no fracture was identified. Resident 1 was transferred back to the nursing home. Review of the clinical record progress note for Resident 1, revealed documentation by Staff RN 1 dated July 18, 2016, at 6:15 p.m. that indicated the resident, was observed by a NA (nurse aide) to be choking. Resident was observed to be breathing shallow with a gurgle/grunting sound noted and her tongue protruding. Resident unresponsive to verbal and physical stimuli. Resident turned on side and airway checked and noted to be clear. Supervisor was called to the unit and vital signs were: blood pressure 189/110, temp (temperature) 98.6 (degrees Fahrenheit - unit of metric measurement), Pulse (heart rate) 103, Respirations 10, (normal is 12-16 breaths per minute) SaO2 (the amount of oxygen in blood) 23% (normal range 95-100%) on Room Air. O2 (oxygen) at 2 L (liters) per minute applied and rescue respirations started. AED (automated external defibrillator-a portable electronic device that automatically [DIAGNOSES REDACTED]. Resident was transferred to hospital emergency room by ambulance on July 18, 2016, at 7:00 p.m. Review of the laboratory results dated [DATE], at 7:21 p.m. which were sent from the hospital, revealed the following: Hemoglobin 7.7 g/dl (grams per deciliter- metric units of measure - normal range is 11.7-15.1 g/dl.) Hematocrit 23% (normal range is 34.5-43.7%, which indicates blood loss which can be into the tissue. Major blood loss can cause anemia (fewer red blood cells that normal which makes a person feel weak and tired) which can be caused by bleeding)). Review of the clinical record revealed that the hospital notified the facility on July 18, 2016, at 11:26 p.m. regarding the tibia plateau fracture, decreased H&H (Hemoglobin-component of blood responsible for transporting oxygen in the blood, and hematocrit-ratio of the volume of red blood cells to the total volume of blood) and informed the facility of the resident's possible need of blood transfusion (administration of another person's donated blood into another person intravenously - into the vein by needle) and the need to admit the resident to the hospital. Review of the hospital clinical records dated July 19, 2016, at 12:15 a.m. revealed, a left tibial plateau fracture, secondary to fall from a Hoyer lift at the nursing home, extensive hematoma (a collection of blood outside of a blood vessel) suspect causing acute, chronic anemia (chronic anemia, symptoms typically begin slowly and progress gradually; whereas in acute anemia symptoms can be abrupt and more distressing.) Review of the hospital record revealed that Resident 1 was admitted to the hospital on July 19, 2016, at 12:15 a.m. with a chief complaint of left leg pain. The hospital report also revealed the following, in the Emergency Department patient was complaining of feeling sore all over as she unfortunately has suffered a fall 3 days ago from a Hoyer lift (mechanical lift that allows a person to be lifted and transferred using a sling (a cloth device that supports the person and attaches to the lift) with a minimum of physical effort). She does also complain of pain in her left side but since this fall she had more pain in her left leg area. An interview with the Nursing Home Administrator (NHA) July 20, 2016, at 11:45 a.m. confirmed that Resident 1 was admitted to the hospital with [REDACTED]. During an interview with the NHA and the Assistant Director of Nursing (ADON) on July 20, 2016, at 11:45 a.m. when inquiring about Resident 1's fall, they stated, We just found out about the fall yesterday and reported it to our Corporate Office, we are waiting to hear back from them. When asked if the fall was investigated internally, the NHA responded, We are in the process of beginning the investigation. The surveyor asked the NHA if a report was made to the Department of Health after the hospital informed the facility of Resident 1's fracture. The NHA responded, No report has been made to anyone but the facility's Corporate Office. An interview with the NHA and the ADON on July 20, 2016, at 4:30 p.m. confirmed that there was no registered nurse (RN) assessment made when the fall was reported to the RN Supervisor because there were no injuries and the resident said she was okay. The NHA informed the surveyor that Resident 1 was sent to the hospital on two occasions. The first date was on July 17, 2016, and at that time, no hip fracture was found. According to an interview with the NHA, the hospital did not X-ray the lower leg on the first visit to the hospital because the resident was complaining of hip and back pain. An interview with the Nursing Home Administrator (NHA) on July 20, 2016, at 4:45 p.m. revealed that she was able to talk with two of the three NAs that transferred Resident 1 on July 15, 2016, when she fell from the sling to the wheelchair. The NHA stated that NA 3 informed NHA that she was bent over during the resident transfer and that when the resident fell from the sling into the wheelchair, something hard hit her on the back of her head. Review of the personnel files of the three NAs involved in Resident 1's fall on July 15, 2016, indicated that the three NAs had received Hoyer lift training and abuse training. The facility failed to assure Resident 1 was transferred safely using a Hoyer lift resulting in a fall, two hospitalization , a tibial plateau fracture and suspected anemia which required a blood transfusion at the hospital. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices. Previously cited 5/26/16, 4/24/15. 28 Pa. Code 205.9(c) Corridors. Previously cited 5/26/16.

Based on observation, clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure adequate supervision and prevention of harm for 2 of 30 residents reviewed (Residents 20 and 25 ). Findings include: Review of Resident 20's April 2015, physician's orders [REDACTED].). Review of Resident 20's Interdisciplinary Progress Notes dated December 23, 2014, revealed she was crying in her room and told the staff that she was going to kill herself. Further review of the progress notes revealed that the Certified Registered Nurse Practitioner visited Resident 20 on the same day and initiated new orders for Lexapro (medication used to treat anxiety) 5 mg every day and Seroquel (medication used to treat depression) 12.5 mg every day. Further review of the progress notes revealed that there was no documentation of follow up or interventions by the staff to monitor verbal ideations or monitor for possible future suicide attempts following Resident 20's suicidal statement. In an interview with the NHA on April 23, 2015, at 3:35 p.m., she acknowledged that a suicide policy and protocol were not developed and in place at the time of Resident 20's suicidal statements. Review of the clinical record for Resident 25 revealed a [DIAGNOSES REDACTED]. Review of the care plan for Resident 25 revealed a focus area initiated on September 19, 2013, and current which stated, "I am demonstrating physical behaviors related to anger and scratching my wrists." Interventions implemented included that the staff would, "check on me every 15 minutes to assure that I am safe and free from self-harm" and, "suicide precautions." There were no detailed instructions under "suicide precautions" which addressed how the staff were to respond to Resident 25's attempts to cause self-harm. There was no documentation indicating that 15 minute checks were done to assure Resident 25's safety. Review of the nursing progress notes for Resident 25 dated April 6, 2015, at 12:10 p.m., indicated that the resident revealed to the staff, "an approximate six inch streak of blood and scratches on the inside" of the left arm. The nursing progress notes indicated that Resident 25 refused to allow the nursing staff to assess his arm and that a razor blade, silverware and pens were removed from resident's room. Further review of the progress notes indicated that Med Options Behavioral Health Services was contacted to request an emergency visit with Resident 25. There were no precautions put in place following this suicide attempt to address future attempts or to provide guidance to staff on how to address Resident 25's self-harming behaviors. Review of the Med Options Behavioral Health Services assessment for Resident 25, dated April 6, 2015, at 4:27 p.m., revealed, "patient is currently a threat to self or others" and indicated verbal and written notification to facility staff to have the resident transferred to the hospital for a psychiatric evaluation. Review of the nursing progress notes for Resident 25 on April 6, 2015, at 4:45 p.m., revealed, "The Resident was sent to Harrisburg Hospital for crisis intervention due to suicide attempt." Review of the nursing progress notes for Resident 25 dated April 6, 2015, at 10:29 p.m., revealed that Resident 25, "returned from the hospital without notification to facility. I called ER and spoke to nurse that had resident. He stated that crisis saw resident in ER and resident promised he wouldn't do it again. Placed on frequent checks." Review of the progress notes for Resident 25 on April 7, 2015, at 4:34 p.m., revealed that the Director of Social Services met with the resident because the resident, "recently returned from hospital after being sent out for attempting to harm self with a razor." The progress note lacked documentation that the resident was assessed for suicidal ideation. Review of the Med Options Behavioral Health Services assessment for Resident 25, dated April 8, 2015, at 12:34 p.m., revealed that the, "patient is currently NOT a danger to self or others." Review of the nursing progress notes for Resident 25 dated April 9, 2015, at 11:37 a.m., revealed that the resident had a razor in his eyeglass case, which he surrendered to nursing staff, and the resident denied suicidal ideation. Review of the physician's progress notes for Resident 25 dated April 13, 2015, at 11:32 a.m. and April 15, 2015, at 2:15 p.m., revealed that the resident was assessed by a Certified Registered Nurse Practitioner (CRNP), however the resident was not assessed for suicidal ideation and the resident's suicide attempt was not noted. In an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on April 23, 2015, at 3:35 p.m., they were unable to provide documentation of an assessment at Harrisburg Hospital, documentation of frequent checks on Resident 25, or an incident report regarding the razor in the resident's room on April 9, 2015. There were no changes to the care plan following the April 6, 2015, incident. In an interview with the NHA on April 23, 2015 at 3:35 pm., she acknowledged that a suicide policy and protocol were not developed and in place at the time of Resident 25's suicide attempt. Observations on April 23, 2015, at 1:30 p.m., while touring with the Environment Director (ED 1) revealed a propane gas grill in the area where the residents smoke. There was a bucket with water in it for disposing of smoking materials beside the grill. An interview on April 23, 2015, at 1:30 p.m., with ED 1 revealed that the propane bottle should not be in the designated smoking area. An interview on April 23, 2015, at 3:08 p.m., with the Nursing Home Administrator (NHA) revealed that she was not aware of the propane tank being in the designated smoking area. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services. Previously cited 10/14/14

Based on clinical record review and staff interview, it was determined that the facility failed to ensure acceptable parameters of nutritional status for 1 of 30 residents reviewed (Resident 11). Findings include: Review of the clinical record for Resident 11 revealed a [DIAGNOSES REDACTED]. Resident 11 was admitted to the facility on [DATE], with an enteral feeding (a way to provide food through a tube placed in the nose, stomach or small intestine) order. Review of Resident 11's facility Medication Administration Record [REDACTED]. The March 2015, MAR indicated [REDACTED]. Review of the Registered Dietician's progress note dated April 3, 2015, revealed oral intakes between 50%-100% and that the enteral feeding had not been needed since admission. Review of the clinical record revealed a weight record indicating an admission weight of 168 pounds and height of six feet. On April 10, 2015, the weight was recorded as 162.5 pounds. On April 10, 2015, the physician's orders [REDACTED]." This order was then discontinued and a new order instructing, "document % meal intake for each meal and % supplement intake in nursing progress note in PCC, start April 11, 2015 and end April 17, 2015." An additional physician order [REDACTED]." Review of the Nutrition Progress Note dated April 10, 2015, indicated that the calorie counts were ordered to evaluate Resident 11 for discontinuance of tube feeding. Review of the Dietitian's Progress Note dated April 13, 2015, revealed, "Note that kcals (calories) are estimations based on Nursing documentation and CNA documentation in PCC as well as estimate of approximately 2200 kcals day provided in the 3 meals at Spring Creek." Review of daily weights during the course of the, "calorie count" revealed a gradual drop down to 154 pounds on April 16, 2015. A slight increase was noted on April 17, 2015, to 154.8 pounds and then continued to decrease to 152 pounds on April 20, 2015, for a 9.5% decrease from admission on March 19, 2015 to April 20, 2015. Review of the Nutrition assessment dated [DATE], revealed, "although calorie count appears to have resident meeting his needs on most days, weight loss continues. Suspect some unreliability of documentation as well as resident presenting with higher than first calculated calorie needs." In an interview with the Dietary Director (DD 1) and the Dietary Tech (DT 1) on April 24, 2015, both DD 1 and DT 1 revealed they did not believe there was a policy/procedure for calorie counts. In an interview with the Nursing Home Administrator (NHA) on April 24, 2015, at approximately 11:30 a.m., the NHA confirmed that there was no policy/procedure for conducting calorie counts. 28 Pa. Code: 201.14(a) Responsibility of license. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure the highest practicable wellbeing for 1 out of 3 residents reviewed (Resident 1). Findings Include: Review of facility policy reviewed January 2014 titled "Occurrence Reporting" revealed that staff are expected to completely report all information needed for investigation of the event. Examples of an occurrence include skin injuries. Review of clinical record for Resident 1 revealed a [DIAGNOSES REDACTED]. Review of Resident 1's clinical record revealed a nursing note entry dated July 14, 2014 which indicated a red/blue bruise was found on Resident 1's left shoulder. Actions taken included "assessed area 6 inch x 5 inch". Nursing notes also revealed an Occurrence Note entry dated July 22, 2014 "Notified that resident had a bruise and lump on her forehead"; actions taken stated "assessed area, appears to be in no pain/discomfort" . Another Occurrence Note entry dated July 29, 2014 stated "A dark red bruise noted to left mid inner thigh of left leg, left leg noted to be swollen and range of motion limited"; actions taken included a full body assessment. Physician was notified and in to see resident. physician progress notes [REDACTED]. Nursing reported pain with manipulation of left lower extremity and has been giving patient Tylenol as needed for pain control. Nursing also reported at this time increased anxiety". The Physician ordered an xray of left hip and left thigh. Xray results revealed positive femur fracture. Review of staff witness statements revealed that on July 24, 2014 a nursing assistant noted whimpering during care and reported it to the nurse. On July 25, 2014 another nursing assistant noted whimpering during Resident 1's care "which she never did before but had been doing it all week" . She also stated "her legs are usually very active but were not, she was mostly moving her upper body, and she looked "sickly and pale". On July 27, 2014 a nursing assistant wrote in an employee statement that Resident 1 seemed really off and was difficult to turn, noting the bruise to Resident 1's forehead and indicating Resident 1's left knee was bluish/purple on lateral side and looked "kinda swollen". "Resident kept screaming, difficult to provide care". An employee statement from a licensed nurse indicated that a nurse aid informed her of the bruise on July 28, 2014 and she forgot to report it to the supervisor and didn't document it immediately. Six other employee statements stated that they also saw the bruise on the leg on July 28, 2014. Bruises of unknown origin found on July 14, 2014 and July 22, 2014 revealed that the action taken was only to assess the bruise and no further body assessment was done. Several staff report that resident was crying or whimpering and there was not a pain assessment done on the resident. During an interview with DON on October 14, 2014 at 2:45 p.m. she stated that there was no pain assessment and no documentation of neurological checks being done after the bruise of unknown origin on Resident 1's forehead. Review of Resident 1's July 2014 Medication Administration Record [REDACTED]. DON also confirmed that resident was not given any PRN (as needed) Tylenol. She stated that Licensed staff thought it was anxiety from a dose reduction and discontinuation of [MEDICATION NAME] (anti-depressant medication). Staff did not report the need to re-start the anti-depressant medication until the physician saw the resident on July 29, 2014.

Based on review of clinical records and interviews with staff, it was determined that the facility failed to provide necessary care and services for one of six residents (Resident R2) reviewed. Findings include: Review of Resident R2's care plan dated March 8, 2011, for diabetes included to observe for signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar levels). The physician's orders [REDACTED]. Additionally, he was to be given [MEDICATION NAME](rapid-acting insulin to lower the blood sugar level and a meal is to be eaten within 5-10 minutes of taking the insulin) in an amount specified by the physician dependent on the blood sugar results. The resident's April 22, 2011, Medication Record reported that he was given [MEDICATION NAME]injections as follows: at 7:30 a.m.,15 units of [MEDICATION NAME]for blood sugar level of 377 milligrams/deciliter (mg/dl) at 12:00 p.m.,15 units of [MEDICATION NAME]for blood sugar level of 384 mg/dl and at 5:00 p.m., 6 units of [MEDICATION NAME]for blood sugar level of 248 mg/dl. Nurses' notes dated April 22, 2011, at 6:10 p.m., reported that the resident's face was flushed and he was diaphoretic (excessive sweating). The resident was responsive with much stimulation but was unable to speak or verbalize if he was having any pain. The resident's heart rate was 110 beats/minute and was irregular and thready (pulse beats alternate from weak to strong). At 6:15 p.m., the resident was given a [MEDICATION NAME] tablet (medication used to treat heart conditions) and '911' (emergency transport number) was called. At 6:20 p.m., the resident was unresponsive, opened his eyes periodically to touch, was given another [MEDICATION NAME] tablet, but remained flushed and diaphoretic. At 6:25 p.m., the resident was transferred to the hospital (15 minutes after the episode began). The hospital records recorded at 7:08 p.m., revealed that he was treated for [REDACTED]. There was no evidence that Resident R2's blood sugar level was checked when he demonstrated symptoms of low blood sugar (change in level of consciousness, sweating, no verbal response, etc.). Review of Resident R2's Meal Intake detail report for April 22, 2011, revealed that he had eaten 75% for breakfast and only 25% at lunch. It was recorded as the resident being "out of the facility" for supper. Review of the scheduled meal times revealed that supper was not delivered to his nursing unit until 5:50 p.m. (50 minutes after his insulin injection was given). Review of Resident R2's blood sugar levels from April 2-11, and 21, 2011, revealed that the resident's blood sugar levels ranged from 87-177 mg/dl at breakfast, 120-210 mg/dl at lunch and 116-184 mg/dl at supper. There was no evidence that the physician was notified of the resident's high blood sugar levels that day which were out of the normal for the resident. Interview with the Director of Nursing on April 27, 2011, at 11:35 a.m., revealed that Resident R2's blood sugar level had not been checked, that "things happened so quickly" and she was unable to explain why the physician had not been notified regarding the change in blood sugar levels or why the [MEDICATION NAME] was given. Interview with Physician 1 on April 29, 2011, at 10:05 a.m., revealed that he was not aware of Resident R2's blood sugar levels on April 22, 2011, that Resident R2 should have been given his meal after the insulin injection and that his blood sugar level should have been checked when he presented with the identified symptoms. 483.25 Quality of Care. Previously cited 8/25/10, 12/17/10 28 Pa. Code: 201.18 (b)(1) Management. Previously cited 2/25/10, 5/10/10, 6/23/10, 12/17/10, 4/12/11 28 Pa. Code: 201.18 (e)(1) Management. Previously cited 2/25/10, 5/10/10, 6/23/10, 11/24/10, 12/17/10, 4/12/11 28 Pa. Code: 211.11 (a) Resident Care Plan. Previously cited 12/17/10 28 Pa. Code: 211.12 (d)(1) Nursing Services. Previously cited 2/25/10, 5/10/10, 6/23/10, 8/25/10, 10/1/10, 12/17/10, 1/21/11, 4/12/11 28 Pa. Code: 211.12 (d)(5) Nursing Services Previously cited 2/25/10, 5/10/10, 6/23/10, 10/1/10, 11/24/10, 12/17/10, 1/21/11, 4/12/11

Based on review of clinical and facility records and interviews with staff, it was determined that the facility failed to provide the proper ventilator care for one of five residents (Resident R2) reviewed. Findings include: Review of the facility's Ventilator Alarm and Ventilator Response Protocol policy dated [DATE], included that response time to any ventilator alarm should be immediate (,[DATE] seconds) and if the alarm cause is not evident, the staff would immediately begin to use a manual resuscitation bag to support breathing and call for help. Review of Resident R2's Minimum Data Set admission assessment dated [DATE], identified that he was on a ventilator (machine to help a resident breathe), had a [MEDICAL CONDITION] (surgical opening through the neck into the windpipe) and received respiratory therapy services daily. Respiratory therapy notes dated [DATE], reported that while Resident R2 was in the therapy gym area in the adjoining building, his ventilator alarm was sounding and showing low pressure. Respiratory therapy was paged and did respond. Occupational Therapy Assistant (COTA) 2 remarked that one of Resident R2's, "tubes came off" and she put it back on the ventilator. Respiratory Therapists (RT) 1 and 2 confirmed that the ventilator circuit connections were connected properly. Subsequently, an occurrence report dated [DATE], at 10:55 a.m., reported that Resident R2 was in the therapy gym area, was unresponsive and had a ventilator circuit interruption. Nurses' notes dated [DATE], at 11:30 a.m., reported that an emergency response was called at 10:55 a.m., and that Registered Nurse (RN) 2 responded to the South therapy gym and found Resident R2 sitting in his wheelchair, unresponsive, pale/ashen in color and pulseless. Emergency transport "911" was called, the resident was placed on the floor and CPR (Cardiopulmonary Resuscitation-breathing and chest compressions delivered during a [MEDICAL CONDITION]) was initiated at 11:00 a.m. Resident R2 was emergently transferred to the hospital at 11:14 a.m. The facility transfer form to the hospital reported that Resident R2 was exercising in therapy, the resident's ventilator alarm was sounding, he became unresponsive, CPR was started and 911 was called. The hospital records dated [DATE], reported that he had PEA (pulseless electrical activity) or [MEDICAL CONDITION] (heart stopped) and was admitted to the hospital. The facility failed to inform the ambulance staff or the hospital that the resident had a ventilator interruption prior to his PEA. Review of the ambulance report dated [DATE], revealed that the emergency 911 call was made at 11:02 a.m., the ambulance arrived at 11:08 a.m. and Resident R2 was transferred out of the facility at 11:22 a.m. emergency room records dated [DATE], reported that he was found in therapy slumped over, had no pulse and was unresponsive. Review of facility documents revealed the following: COTA 1 reported that Resident R2's ventilator alarm was still sounding after COTA 2 had walked away from him. COTA 2 reported that his ventilator alarm was sounding at approximately 10:50 a.m., that Physical Therapy Assistant (PTA) 1 was calling respiratory therapy and she (COTA 2) approached Resident R2 and noticed the tubing was not connected to the ventilator. COTA 2 reconnected the tubing and requested help from Physical Therapist 1 as Resident R2 was unresponsive and pale. PT 1 instructed PTA 1 to page the emergency response team. RT 3, RT 4 and RN 3 responded and noted that Resident R2 was not breathing and was cyanotic (color change to the body due to lack of oxygen). RT 4 observed that the ventilator alarm was reading low pressure and that the ventilator tubing was connected to the wrong port and RT 4 reconnected it correctly. However, Resident R2 was then pulseless, was lowered to the floor and CPR started. Interview with the Administrator on [DATE], at 8:07 a.m., confirmed that all therapy staff had been trained on ventilators but "in the heat of the moment connected the circuit to the wrong port." Interview with the Director of Nursing on [DATE], at 8:31 a.m., and [DATE], at 11:35 a.m., respectively, revealed that changes were made in reference to ventilator emergencies and that she felt the response time to the event was appropriate. Review of the event timeline submitted on [DATE], at 4:54 p.m., revealed that between 10:53 a.m. and 10:55 a.m. (2 minutes), the ventilator alarm was sounding and not stopping as usual. The COTA 2 notices tubing is disconnected and reattaches the tubing and the emergency response team is paged. The facility failed to follow its Ventilator Response protocol policy. Manual ventilation, CPR and the 911 call occurred between 10:55 a.m. and 10:58 a.m. (although the ambulance report indicates the call came in at 11:02 a.m., which is four minutes later). Interview with Physician 1 on [DATE], at 10:05 a.m., revealed that he was not aware of this occurrence. 483.25 (k) Treatment/care for Special Needs. Previously cited [DATE] 28 Pa. Code: 201.18 (b)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code: 201.18 (e)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code: 211.5 (f) Clinical Records. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code: 211.10 (d) Resident Care Policies Previously cited [DATE], [DATE], [DATE] 28 Pa. Code: 211.12 (d)(1) Nursing Services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code: 211.12 (d)(5) Nursing Services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]