Every finding on record at St John Neumann CTR for Rehab & Healthcare

Based on review of facility policy, and review of clinical record, it was determined that facility did not ensure to develop and implement a care plan related to incontinence care and bed side rails for one of seven residents reviewed. (Resident R2)Findings include: Review of facility policy 'Comprehensive Person - Centered Care Plans,' indicates that a person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review of policy indicated that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of Resident R2's clinical record revealed a medical history of anemia (low red blood count), history of falling, chronic kidney disease, type two diabetes mellitus (failure of the body to produce insulin), high blood pressure, dementia (progressive degenerative disease of the brain). Further review of Resident R2's clinical record revealed a nursing note, dated April 4, 2026, at 9:10 pm, indicating resident was incontinent of bowel and bladder. Further review of Resident R2's clinical record revealed bed rail evaluation completed on September 10, 2025, at 3:47 pm, indicating approved bed side rails to promote independence. Review of Resident R3's care plan revealed no evidence of goals or interventions related to incontinence care or use of bed side rails. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations and interviews with staff and residents, it was determined that the facility failed to maintain a safe, clean home-like environment in resident-use and service areas for two of three nursing units observed. (600 and 700 nursing units)Findings Include: Review of facility policy titled, Soiled Linen, revied August 11, 2014, revealed that soiled linen is considered potentially contaminated and must be always covered with a lid. Observations conducted on January 21, 2026, at approximately 11:45 a.m. on the 600 nursing unit shower rooms revealed both shower floors were visibly soiled with dirt and muddy footprints smeared across the surfaces. The shower room bathroom trashcan was observed to be overflowing and had no hand clothes or paper towels were available for hand hygiene. Additional observations on the 700 nursing unit shower rooms revealed a dirty linen cart overflowing with soiled linens with the lid unable to be fully closed, in both shower rooms. A strong, unpleasant odor was noted throughout the shower rooms. An interview with the Unit Manager, Employee E3, conducted on January 21, 2026, at 12:00 p.m. confirmed the above-mentioned findings. The Unit Manager stated that the soiled linen cart is stored in the shower room and is removed at the end of each shift. Interviews with Residents R2 and R4 conducted on January 21, 2026, at 12:13 p.m. revealed that the shower room floors are consistently dirty and that the bathroom trash is frequently overflowing. An interview with Resident R1 conducted on January 21, 2026, at 11:35 a.m. revealed that housekeeping does not clean the resident bathroom even when requested. Further observations of the resident bathroom confirmed a dirty bathroom with visible grime and poor sanitation. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on record review and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed within 14 days after the Assessment Reference Date (ARD) for four of seven sampled residents (Residents R32, R109, R16 and R164).Findings include:According to the RAI User's Manual, Chapter 2, Completion Timing, federally required MDS assessments must be completed (locked and signed) no later than 14 days after the Assessment Reference Date (ARD).Record reviews of the MDS submissions for Residents R32, R2, R3, and R4 showed that their scheduled assessments exceeded the required 14-day completion timeframe following the established ARD.Resident R32's ARD was June 21, 2025, for an annual assessment; the MDS was completed on July 14, 2025, exceeding the 14-day requirement.Resident R109's ARD was October 7, 2025, for a quarterly assessment; the MDS was completed on October 23, 2025, exceeding the requirement.Resident R16's ARD was June 17, 2025, for a quarterly assessment; the MDS was completed on Julu 2, 2025, exceeding the requirement.Resident R16's ARD was September 17, 2025, for the next quarterly assessment; the MDS was completed on October 15, 2025, exceeding the requirement.Resident R4's ARD was October 8, 2025, for a quarterly assessment; the MDS was completed on October 23, 2025, exceeding the requirement.During an interview on November 20, 2025, with the MDS Coordinator confirmed the assessments were not completed timely for Residents R32, R109, R16 and R164.28 Pa. Code 211.5(f) Clinical Records.

Based on review of clinical records, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards for 2 of 6 medication carts reviewed. (400 cart 2 and 400 split cart) Findings include: Observation of the 400-unit split cart on [DATE], at 10:22 a.m., with Employee E10, Licensed Practical Nurse, revealed an insulin vial (Degludec) with two dates written on the bottle, listed as [DATE], and [DATE]. Employee E10 could not specify which date represented the date the vial was opened.Further observation revealed a vial of insulin glargine in the cart with an opened date written as [DATE]. Employee E10 confirmed that the insulin had expired more than two months ago.Continued observation revealed a bottle of Famotidine 10 mg tablets that had expired in [DATE].Observation of the 400 cart two on [DATE], at 10:36 a.m., with Employee E11, Licensed Practical Nurse, revealed an insulin vial (Amelog) with a date written on the bottle as [DATE]. The bottle was labeled to discard the medication 28 days after opening.Further observation revealed a vial of insulin lispro with two dates written on the bottle, [DATE], and [DATE]. The instructions on the bottle indicated that the medication should be discarded 28 days after opening.28 Pa. Code 211.12(d) Nursing services

Based on observation, staff interviews, and policy review, it was determined that the facility failed to ensure staff followed proper infection control practices by not cleaning and disinfecting a blood glucose monitor after the use for one of one observation (Employee E9)Findings include:Review of the facility policy titled Glucometer Cleaning and Disinfection Policy dated October 2025 revealed: The facility will ensure blood glucometers are cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. The glucometers should be disinfected with a wipe pre-saturated with an EPA-registered healthcare disinfectant that is effective against HIV, Hepatitis C, Hepatitis B virus, and C. diff. Glucometers should be cleaned and disinfected before and after each use and according to the manufacturer's instructions, regardless of whether they are intended for single-resident or multi-resident use. Two (2) glucometers will be maintained on the cart to allow drying time between residents.Observation of the morning medication pass for Resident R183 on November 17, 2025, at 10:28 a.m., with Employee E9, Licensed Practical Nurse, revealed that the employee obtained the resident's blood glucose and returned the glucose monitor to the medication cart. The employee removed and discarded the test strip and then placed the monitor back in the cart. Employee E9 did not clean or disinfect the monitor.Interview with Employee E9 after the observation revealed that she did not clean the monitor because she believed it did not come into contact with blood. When asked if she knew how to properly clean the monitor, she stated that she would use small alcohol wipes, which were stored on the cart for skin preparation prior to needle sticks. Employee E9 was not aware of the required cleaning process using wipes pre-saturated with an EPA-registered healthcare disinfectant or the required drying time.28 Pa. Code 211.12(d) Nursing Services

Based on review of clinical records, observations and interviews with staff, it was determined that the facility did not ensure that resident was appropriately assessed for risk of entrapment and did not obtain informed consent related to bedrails for one of 35 residents reviewed (Resident R24). Findings include:Review of Resident R24 's clinical record revealed that Resident R24 was admitted to the facility on [DATE], with diagnoses of, Intracerebral hemorrhage(stroke), Aphasia (Communication disorder that affects your ability to speak, understand, read, or write).Review of Resident R24's MDS (Minimum Data Set), Quarterly assessment dated [DATE], revealed that Resident R24 has a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment.Observation of Resident R24 on November 19, 2025 at 11:02 am revealed Resident R24 awake, in bed with Bilateral 3/4 length rails, in up position, running from resident's shoulder to hip.Interview with Employee E8, Licensed Practical Nurse on November 19, 2025 at 11:12 confirmed findings of bilateral bed rails, in up position, running from resident's shoulder to hip.Review of Resident R24's clinical record revealed resident assessed for bedrails on October 25, 2025 and that bedrails are indicated at this time and Bedrails are indicated and serve as enabler to promote independence. Further review revealed that Resident has been provided with informed consent of the risks of utilizing bedrails and displayed understanding.Review of Resident R24's clinical record revealed resident assessed for bedrails on July 25, 2025. The assessment indicated that resident is currently using the bedrail for positioning and support. Further review revealed no recommendation made during assessment and no informed consent provided.Review of Resident R24's clinical record revealed resident assessed for bedrails on June 25, 2025. The assessment indicated that the resident is currently using the bedrail for positioning and support. Further review revealed bedrails are not indicated at this time.Review of Resident R24's clinical record revealed resident assessed for bedrails on June 16, 2025. The assessment indicated that the resident is currently using the bedrail for positioning and support. Further review revealed bedrails are not indicated at this time.Review of Resident R24's clinical record revealed resident assessed for bedrails on March 25, 2025. The assessment indicated that the resident is not currently using the bedrail for positioning and support. Further review revealed bedrails are not indicated at this time.Review of Resident R24's clinical record revealed resident assessed for bedrails on December 25, 2025. The assessment indicated that the resident is currently using the bedrail for positioning and support. Further review revealed no bedrail recommendations made during assessment and no informed consent provided.Review of Resident R24's clinical record revealed resident assessed for bedrails on December 21, 2025. The assessment indicated that the resident is currently using the bedrail for positioning and support. Further review revealed bedrails are indicated and serve as an enabler to promote independence. No documented evidence of informed consent of risks of utilizing bedrails and displayed understanding.Interview with Employee E2, Director of Nursing on November 20, 2025 at approximately 10:30am confirmed the above listed findings.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of drug information reports, observations, and interviews with staff, it was determined that the facility failed to ensure that a resident was free of a significant medication error related to the administration of Nitroglycerin tablets, which are used to treat and prevent episodes of angina (chest pain) in individuals with coronary artery disease. The medication was administered via the wrong route for one of five residents reviewed (Resident R183). Findings include:Review of FDA-approved prescribing information for Nitroglycerin sublingual tablets revealed that the medication must be administered under the tongue or in the buccal pouch for proper absorption and rapid onset of action. The FDA instructions specify that the tablet should not be swallowed, chewed, or crushed because swallowed nitroglycerin undergoes extensive first-pass metabolism in the liver, which significantly reduces the amount of active medication that enters the bloodstream. As a result, swallowing the tablet greatly decreases its effectiveness and does not provide the rapid relief required during an angina episode.Review of physician order for Resident R183 dated September 21, 2025, revealed an order for Nitroglycerin Sublingual Tablet Sublingual 0.4 MG (Nitroglycerin) Give 1 tablet sublingually as needed for Chest Pain. Observation of the morning medication pass for Resident R183 on November 17, 2025, at 10.28 a.m., with Employee E9, Licensed Practical Nurse revealed that the resident complained to the employee that he was having chest pain. Employee removed Nitroglycerin Sublingual Tablet from the cart and administered to the resident orally with water. Residents were observed swallowing the medication. Interview with Employee E9 on November 17, 2025, at 10.40 a.m. confirmed the above observation. 28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate of less than 5% during a medication administration pass. Three medication errors out of 26 medication administration opportunities observed during medication administration (Medication Error Rate of 11.54%).Findings include: Review of physician order for Resident R89 dated September 21, 2025, revealed an order for Cyanocobalamin Tablet 1000 MCG (A supplement medication) Give one tablet by mouth one time a day. Review of physician order for Resident R183 dated September 21, 2025, revealed an order for Nitroglycerin Sublingual Tablet Sublingual 0.4 MG (Nitroglycerin) Give 1 tablet sublingually as needed for Chest Pain. Review of physician order for Resident R183 dated October 8, 2025, revealed an order for metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM dosing with meal. Observation of the morning medication pass for Resident R89 on November 17, 2025, at 9:59 a.m., with Employee E9, licensed practical nurse, revealed that the employee looked at the medication order and read Cyanocobalamin Tablet 1000 MCG, however she took Oyster Calcium 500 mg, 2 tablets and proceeded to administer the medication. After the employee removed the medication, surveyor intervened and stopped the employee from administering the wrong medication. Observation of the morning medication pass for Resident R183 on November 17, 2025, at 10.28 a.m., with Employee E9 revealed that the resident complained to the employee that he was having chest pain. Employee removed Nitroglycerin Sublingual Tablet from the cart and administered to the resident orally with water. Residents were observed swallowing the medication. Continued observation of the medication pass for Resident R183 revealed that the employee administered the medication Metformin HCl without any food. It was observed that the resident was not eating any meals/food. Interview with Employee E9 on November 17, 2025, at 10.40 a.m. confirmed the above finding and stated the residents breakfast was over around 9:00 a.m.28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide evidence of a Level 1 pre-screening for mental disorders/intellectual disabilities for one of 35 residents reviewed (Resident R52). Findings Include: Review of Resident R52's clinical record revealed resident admitted to the facility on [DATE], with diagnosis of Schizophrenia, Depression. Review of Resident R52's quarterly Minimum Data Set (MDS- federally mandated resident assessment and care screening) dated September 4, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 09, indicating resident cognitively impaired. Further review of Resident R52's MDS dated [DATE], revealed the resident had diagnoses of schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R54's clinical record revealed no documented evidence the facility conducted a Level 1 PASARR screen for Resident R54. Interview on November 20, 2025, at 11:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed the facility was unable to provide evidence of Resident R54's Level 1 PASARR screen. 28 Pa. Code 211.5 (f)(iv) Medical records.28 Pa. Code 211.10 (c) Resident care policies.

Based on review of clinical records, interview with residents and review of facility provided documentation, it was determined that facility did not ensure to develop and implement a comprehensive resident centered care plan for two of 35 residents reviewed related to wound care and bedside rails (Resident R24, R29) Findings include: Review of Resident R24 's clinical record revealed that Resident R24 was admitted to the facility on [DATE], with diagnoses of, Intracerebral hemorrhage(stroke), Aphasia (Communication disorder that affects your ability to speak, understand, read, or write). Observation of Resident R24 on November 19, 2025 at 11:02 am revealed Resident R24 awake, in bed with Bilateral ¾ length rails, in up position, running from resident's shoulder to hip. Interview with Employee E8, Licensed Practical Nurse on November 19, 2025 at 11:12 confirmed findings of bilateral bed rails, in up position, running from resident's shoulder to hip. Review of Resident R24's clinical record revealed resident assessed for bedrails on October 25, 2025 and that bedrails are indicated at this time for positioning and bed mobility. Review of Resident R24's Comprehensive Care Plan on November 19, 2025, revealed no care plan in place for bed rails. Interview with Employee E8, Licensed Practical Nurse on November 19, 2025 at 11:14 am confirmed no care plan in place for bed rails Review of facility policy 'Interdisciplinary Care Planning Protocol,' revised on March 2025, indicates that Nursing provides overview of medical and nursing care regimes. Nursing provides input especially related to ADL, skin, weights, and safety needs. Review of Resident R29 clinical record revealed nursing progress note, dated November 15, 2025, stating that R29's skin alteration on right forearm was noted by nurse aide; nurse noted a large fluid filled blister that appears to have been partially drained. Area was cleansed and skin prep was applied. Wound care consult placed. RP and MD notified. Interview with Resident R29 (BIMS score 11), on Monday, November 17th, 2026 at 10:00 am, revealed that she does not know how or why the blister formed. Review of R29's care plan revealed no evidence of goals or interventions related to right forearm blister. 28 Pa Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services.

Based on observations, review facility policies and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas and dining experience for one of five nursing units observed ([NAME] dementia Unit). Findings Include: Review of facility policy Housekeeping Safe and Sanitary Living Arrangements dated on June 1, 1996, revealed, St. [NAME] Nursing Home shall provide a safe and hygienic living arrangement for residents as designated by governmental agencies for licensure and certification purposes. In order to comply with this mandate, we require that employee within the Housekeeping Department clean resident rooms including bathrooms daily. On May 20, 2025, at 11:12 a.m. an observation was conducted on the nursing unit [NAME] in room [ROOM NUMBER] revealed Resident's R1, R2 and R3 bathroom was dirty. The toilet bowl had spot feces all over with urine smell, bathroom was not clean and had files in the bathroom when opening the door. On May 20, 2025, at 11:14 a.m , an interview was conducted with Registered Nurse, Employee E5 revealed that when families have concerns about the resident's rooms or environment issues nursing staff reply that it's dementia residents with behaviors and will get to it when they have time. Interview with Housekeeping Director, Employee E4 on May 20, 2025 at 11:15 a.m. confirmed the bathroom in room [ROOM NUMBER] was dirty, the toilet had spot of feces all over and housekeeping didn't clean the bathroom because of shortage of housekeeping staff. Interview with the Nurse aide, Employee E6 on May 20, 2025 at 11:28 a.m. revealed that at 9:14 am in the resident R2 task she helped and clean resident R2 after he was in the toilet and had a loose/ diarrhea. Never informed the housekeeping that Resident's R2's bathroom was dirty. Resident R1 was send out to the hospital on May 7, 2025, with the Diagnosis with UTI and ESBL (extended-spectrum beta-lactamase producing bacteria) and still is getting antibiotics. On May 20, 2025, at 12:25 p.m. an interview was conducted with the infection control staff, Employee E7 confirmed that Resident R1was in the hospital and treated for UTI and ESBL (extended-spectrum beta-lactamase producing bacteria). The infection control also confirmed that a person using a dirty bathroom can get the bacteria. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observation, reviews of the electronic maintenance communication logs, interviews with staff and residents, policy and procedure reviews, and clinical record review, it was determined the facility failed to ensure comfortable air temperature levels were provided on the 300 nursing unit placing residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). The cold air temperatures placed 19 of 32 cognitively impaired residents on the 300 nursing unit in an Immediate Jeopardy situation. (Residents R118, R149, R142, R85, R163, R103, R61, R145, R91, R113, R15, R164, R51, R179, R146, R27, R66, R264 and R9). Findings include: Review of the undated facility policy titled Room Temperature Maintenance revealed, it was the facility's responsibility to take and record room and lounge temperatures weekly. The policy indicated the room and lounge temperatures were to be maintained at 71 to 81 degrees Fahrenheit. If the facility had obtained any variance in this temperature range of 71 to 81 degrees Fahrenheit; then it would be the responsibility of that person to report the temperature variance to the administrator and maintenance director. Interview with Resident R91 at 11:00 a.m., on Janaury 22, 2025 revealed his/her room of 313 was extremely cold and uncomfortable. The resident reported the heating system in his/her room does not work. The resident reported that he/she worries about his roommate (Resident 145) being cold and becoming ill. The resident reported that his/her roommate needs warmer clothes and shoes and possibly a jacket to wear inside their bed room. Clinical record review for Resident R91 revealed a quarterly assessment Minimum Data Set (MDS- assessment of care needs) dated January 3, 2025, indicated this resident was able to make his/her needs known to staff. The assessment revealed the resident was independent with upper and lower body dressing (putting on/taking off clothing). Clinical record review for Resident R145 revealed a quarterly MDS assessment dated [DATE], indicated that the resident had severe cognitive impairment. The assessment also indicated the diagnoses of dementia, anemia (a low red blood count) and schizophrenia (mental disease characterized by loss of reality contact). Continued review of the MDS assessment revealed that this resident required staff supervision with upper and lower body dressing. Observations with nursing staff, Employee E8, January 22, 2025, at 11:15 a.m., revealed that the heating unit connected to the wall area heating system in room [ROOM NUMBER] where Resident R91 and Resident R145 resided was not functioning or operational. Observations and air temperatures taken with maintenance staff, Employee E7, January 22, 2025 at 11:30 a.m., of room [ROOM NUMBER] and the hallway outside this room revealed air temperatures of 56 degrees Fahrenheit. Observations conducted with nursing staff member, Employee E8, at 11:35 on January 22, 2025 of room [ROOM NUMBER] revealed the heating unit was blowing warm air, only slightly. The heating system in room [ROOM NUMBER] was blowing cold air. The heating system in room [ROOM NUMBER] was blowing cold air and the heating unit in room [ROOM NUMBER] was blowing cold air. The nursing staff member confirmed, the heating systems in rooms 315, 316 and 317 were non operational. The nursing staff member confirmed, the heating system in room [ROOM NUMBER] was not fully functioning. Observations of rooms 314, 315, 316 and 317 with a maintenance staff, Employee E7 at 11:40 a.m., on January 22, 2025 revealed the following room air temperatures: room [ROOM NUMBER]- 71 degrees Fahrenheit, room [ROOM NUMBER]- 65 degrees Fahrenheit, room [ROOM NUMBER]- 61 degrees Fahrenheit and room [ROOM NUMBER]-62 degrees Fahrenheit. Observations of Resident R142 at 11:45 a.m., on January 22, 2025 revealed the resident was seated in his/her wheel chair in the hall way outside of room [ROOM NUMBER]. This resident was only wearing a thin cotton hospital gown and socks. The resident's arms and legs were exposed to the cold hallway temperatures of 56 degrees Fahrenheit. Observations conducted of Resident 149 at 11:45 a.m., on January 22, 2025, revealed the resident was in bed constantly moving and kicking her sheet and blanket off her body. The resident was wearing a thin cotton hospital gown only. The temperature recorded for room [ROOM NUMBER] was at 64 degrees Fahrenheit at 4:00 p.m It was noted that the two heating units were turned off or not blowing warm air into resident's room. Observations of Residents R27 and R9 at 11:50 a.m., on January 22, 2025, revealed the residents were in room [ROOM NUMBER]. Both residents were lying in bed dressed with multiple layers of blankets and clothes. Interview with the nursing assistant, Employee E8, at this time revealed that this was the only way we could keep Resident R27 and R9 comfortable by using two or three blankets, since the heating units were not functioning and supplying warm air for this room. Resident room air temperatures were taken on the 300 nursing unit with the regional administrative staff Employee E3, at 4:00 p.m., on Janaury 22, 2025, and revealed temperatures below 71 degrees Fahrenheit as follows: room [ROOM NUMBER]- 64 degrees Fahrenheit, room [ROOM NUMBER]-62 degrees Fahrenheit, room [ROOM NUMBER]- 62 degrees Fahrenheit, room [ROOM NUMBER]- 60 degrees Fahrenheit, room [ROOM NUMBER]-69 degrees Fahrenheit, room [ROOM NUMBER]- 62 degrees Fahrenheit, room [ROOM NUMBER]- 61 degrees Fahrenheit, and room [ROOM NUMBER]-62 degrees Fahrenheit. Reviews of the documented maintenance communication system logs (electronic communication system used by the staff to report concerns with resident rooms or the nursing unit environment to the maintenance department and administrator) revealed on November 11, 2024, Registered nurse, Employee E11 documented the heating unit in room [ROOM NUMBER] was not working. Registered nurse, Employee E11 indicated there was no heat for residents in this room. There was no documentation to indicate what staff member responded to the nursing staff member's request to repair the heating unit. Reviews of the documented maintenance communication system logs (an electronic communication system used by the staff to report any issues with resident rooms or the nursing unit environments to the maintenance department and administrator), revealed a work order from the licensed nursing staff, member Employee E9 indicating on November 22, 2024 the nurse alerted the maintenance staff in writing of the heating units in rooms 313, 314, 315, 316 and 317 were not working. The licensed nurse indicated these rooms were cold. The licensed nurse wrote the heating units needed to be repaired immediately. There was no documentation to indicate what staff member responded to the nursing staff member's request to repair the heating units. Interview with the Nursing Home Administrator, on January 22, 2025, at 11:45 a.m. confirmed the temperatures taken with the maintenance staff, Employee E7 were cold and uncomfortable for the residents living on the 300 nursing unit. Interviews with the activities and nursing staff Employees E8, E12, E13, E14, E15 and E16 working on the 300 nursing unit on January 22, 2025, 12:30 p.m., revealed that the heating units had not been fully functioning to provide warmth for the residents in rooms 310, 311, 312, 313, 314, 315, 316 and 317 since November 2024. Licensed nursing staff member, Employee E9, was interviewed on Janaury 22, 2025, at 4:00 p.m., and confirmed that the maintenance communication system was used to alert and document the on-going issue of lack of heat to the maintenance department as well as the administrative staff at the facility. Interviews on January 22, 2025, with the nursing staff Employees E8, E12, E14, E15, E4, E18, E19 and E17 who were most familiar with caring for the residents in rooms 310, 311, 312, 313, 314, 315, 316 and 317 revealed that all 19 residents have a diagnosis of dementia or cognitive impairment. The nursing staff also reported that all of these residents required supervision with activites of daily living, especially dressing. Clinical record review for Resident R118 revealed a quarterly MDS assessment dated [DATE], indicated Resident R118 had a diagnosis of Dementia (progressive disease of the brain) and required staff supervision for dressing. Clinical record review for Resident R149 revealed a quarterly MDS assessment MDS dated [DATE], indicating resident had a diagnosis of cerebral vascular accident (stroke) and required maxium staff assistance for dressing. Clinical record review for Resident R142 revealed a quarterly MDS assessment MDS dated [DATE], indicated resident had a diagnosis of Schizophrenia and required staff supervision for dressing. Clinical record review for Resident R85 revealed an admission comprehensive assessment MDS dated [DATE], that indicated that this resident had a diagnosis of Alzheimer's disease irreversible progressive degenerative disease of the brain) and required maxium staff assistance for dressing. Clinical record review for Resident R163 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required set up staff assistance for dressing. Clinical record review for Resident R103 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required set up staff assistance for dressing. Clinical record review for Resident R61 revealed an annual comprehensive assessment MDS dated [DATE], that indicated that this resident had a diagnosis of dementia and schizophrenia and required maximum staff assistance for dressing. Clinical record review for Resident R113 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required substantial assistance from staff for dressing. Clinical record review for Resident R15 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required substantial assistance from staff for dressing. Clinical record review for Resident R164 revealed a quarterly MDS assessment MDS dated [DATE], that indicated that this resident had a diagnosis of dementia and required substantial assistance from staff for dressing. Clinical record review for Resident R51 revealed an admission comprehensive MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required supervision from staff for dressing. Clinical record review for Resident R179 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required supervision from staff for dressing. Clinical record review for Resident R146 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required moderate assistance from staff for dressing. Clinical record review for Resident R264 revealed an admission comprehensive MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required set up assistance from staff for dressing. Clinical record review for Resident R27 revealed an admission comprehensive MDS dated [DATE], that indicated that this resident had a diagnosis of dementia and required supervision from staff for dressing. Clinical record review for Resident R66 revealed an admission comprehensive assessment MDS dated [DATE], that indicated that this resident had a diagnosis of Alzheimer's disease and required supervision from staff for dressing. Clinical record review for Resident R9 revealed a quarterly MDS assessment dated [DATE], that indicated that this resident had a diagnosis of dementia and required partial assistance from staff for dressing. Clinical record review for Resident R264 revealed an admission comprehensive assessment MDS dated [DATE], that indicated that this resident had a diagnosis of dementia and required set up assistance from staff for dressing. Based on the above findings an Immediate Jeopardy was identified for failure to provide safe and comfortable air temperatures for residents living on the 300 nursing unit. The facility's failure to furnish the necessary maintenance services to ensure that safe and comfortable temperature levels were maintained in resident bedrooms and hallway posed a safety risk with the loss of body heat for 19 residents identified. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of the immediate jeopardy) was provided to the Nursing Home Administrator on January 22, 2025 at 6:46 p.m. The facility's plan of action included the following: The facility indicted that they failed to ensure that air temperatures were maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit for 19 residents. -All affected residents were moved to other areas of the facility (PT Gym and empty resident rooms) where the temperature was maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit. All residents were assessed for signs and symptoms of hypothermia. None were found to be showing signs and symptoms of hypothermia. Vitals signs were taken on all affected residents and none showed any adverse effects, related to being affected by temperatures less than 71 degrees Fahrenheit. All responsible parties and all residents physicians were made aware. -Room temperatures of other units were audited after the affected rooms were identified and all rooms were found to have temperatures between 71 degrees fahrenheit and 81 degrees Fahrenheit. Vital signs were taken on all unaffected residents and none show any adverse effects. -Education was provided to the facility staff that were working when the areas were found to be affected and education will continue for staff who will work until temperatures are maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected rooms. The education includes reporting any residents with concerns of being cold, offering blankets accetable temperature ranges or have signs and symptoms of hypothermia. The is taking hourly temperatures of resident rooms to assure that the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit. Additionally staff has been added to the schedule for the immediate nursing shifts to assure resident safety. Additionally, staff will continue to be added to the schedule to assure resident safety until the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected area and residents are returned to their original rooms. -Industrial heating units have been procured and are expected to arrive in the next two hours. The industrial heating units will be placed in the affected area. -Vital signs will be taken every four hours for all residents at the facility to assure that no resident will have any negative affects as related to the signs and symptoms of hypothermia and vital signs will continue until heat is restored to the affected area. -Repairs of heating units will continue until heat is restored to the affected area and the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit. -The Maintenance Director or designee will audit room temperatures daily for four weeks, then weekly for 8 weeks to ensure that the room temperature is between 71 and 81 degrees Fahrenheit. Corrective action will be taken as necessary. The results of the audits will be reported at monthly QAPI (Quality Assurance Improvement Plan) meeting until substantial compliance is reached. On January 22, 2025, at 9:25 p.m., the facility's immediate action plan was accepted. Interviews with licensed nursing staff, recreational staff, maintenance staff and administrative staff confirmed that they were all knowledgeable of the air temperatures in resident rooms and nursing units and the importance of keeping the residents warm. All staff reported that they were to report to their supervisor immediately any cold rooms, heating units that were not fully functioning to maintain temperatures between 71 and 81 degrees Fahrenheit and any resident complaints of being cold. The supervisors were to report immediately any cold rooms, heating units that were not fully functioning to maintain temperatures between 71 and 81 degrees Fahrenheit and any resident complaints of being cold to the administrator. Interview with the administrative and regional administrative staff confirmed that they were all knowledgeable of their responsibility for the maintenance of equipment to ensure comfortable and safe temperatures in the residents' living environments. Temperatures were taken on all nursing units with special focus on the 300 nursing unit to ensure that the heating equipment was fully functioning and suppling heat to resident rooms and common areas on the nursing unit. Air temperatures were registering between 71 and 81 degrees Fahrenheit. The hourly vital signs auditing was reviewed to ensure residents were not exhibiting signs and symptoms of hypothermia. On January 23, 2025, at 5:42 p.m., the Immediate Jeopardy was lifted. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 PA. Code 204.19 Plumbing, heating ventilation and air conditioning and electric

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain resident care equipment in safe, operating conditions for three of seven nursing units toured (300, 400, and 700 nursing unit). Findings include: Review of facility maintenance work orders for five of five nursing units in the facility dated from September 9, 2024 through January 22, 2024 revealed multiple ongoing and reoccurring requests for residents' bathroom sink malfunction. Work order 7713 clogged sink room [ROOM NUMBER] Work order 7714 clogged sink room [ROOM NUMBER] Work order 7735 clogged sink room [ROOM NUMBER] Work order 7793 clogged sink bathroom Work order 7823 clogged sink room [ROOM NUMBER] Work order 7838 clogged sink rooms [ROOM NUMBERS] Work order 7855 clogged sink room [ROOM NUMBER] Work order 7883 clogged sink room [ROOM NUMBER] Work order 7887 clogged sink room [ROOM NUMBER] Work order 7902 clogged sink room [ROOM NUMBER] Work order 7914 clogged sink room [ROOM NUMBER] Work order 7945 clogged sink room [ROOM NUMBER] Work order 8031 clogged sink rooms 700, 702, 734 Work order 8044 clogged sink med room Work order 8066 clogged sink med room Work order 8106 clogged sink room [ROOM NUMBER] Work order 8131 clogged sink room [ROOM NUMBER], 702, 734 Work order 8040 clogged sink room [ROOM NUMBER] Work order 8068 clogged sink med room Work order 8004 clogged sinrooms706,709,711,722 8095 clogged sink med room Work order 8106 clogged sink rooms 705,706,724 Interview with Residents: R 155, R146, R418, R421, R64, R420, R43,and R425 on January 21, 2025 between the hours of 10:00 a.m. and 12:00 p.m. on the 700 nursing unit revealed complaints and concerns of residents bathroom sinks not functioning properly, the sinks do not drain. Interview with Resident R425 on January 22, 2025 revealed this resident displeased with the equipment. The sink has been leaking since she arrived, she has stated she made many complaints to the facility staff and no employee has been to fix it . Observations of the individual bathroom sinks during these above interviews revealed defective, clogged sinks filled with water. Observations confirmed during tour of the affected rooms on January 21, 2025 at 2:00 p.m. with Housekeeping Employee E20 confirmed the sinks were observed to be clogged. Observations on January 22, 2025, at 10:29 a.m. in the bathroom of room [ROOM NUMBER] revealed the frame of the seat riser above the toilet was rusted. Observations on January 24, 2025, at 02:10 p.m. with the Regional Administrator, Employee E3, revealed the faucet was lose in the bathroom of room [ROOM NUMBER] and the sink was clogged/filled with water in the bathroom of room [ROOM NUMBER]. Further observations on January 24, 2025, at 2:15 p.m. with the Regional Administrator, Employee E3, revealed the rusted seat riser was still in the bathroom of room [ROOM NUMBER]. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of clinical records, facility documentation and interviews with residents and staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in resident rooms and common areas for 19 cognitively impaired residents. This failure to maintain comfortable and safe air temperatures for residents residing in rooms 310, 311, 312, 313, 314, 315, 316 and 317 resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator revealed that the Administrator was responsible for the direct day to day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. The Administrator was responsible to plan, developed, organize, implement, evaluate and direct the facility's programs and activites. The Administrator was responsible to assist department directors in the development and use of developmental policies and procedures and establish rapport in and among departments so that each can realize the importance of team work. The Administrator was responsible to assure that all employees, residents, visitors and the general public follow established facility policies and procedures. The Administrator was responsible to assure that all employees, residents, visitors and general public follow established policies and procedures. The Administrator was responsible for making written and oral reports to the governing board concerning the operation of the facility. The Administrator was responsible for making routine inspections of the facility to assure that established policies and procedures were being implemented and followed. The Administrator was responsible to consult with department directors concerning the operation of their departments to assist in correcting problem areas. The Administrator was responsible for assuring that the building was maintained in good repair. The Administrator was responsible for assuring that the facility was maintained in a clean and safe manner for residents comfort by assuring that necessary equipment and supplies were maintained to perform such services every day. Interview with Resident R91 at 11:00 a.m., on Janaury 22, 2025 revealed his/her room of 313 was extremely cold and uncomfortable. The resident reported the heating system in his/her room does not work. The resident reported that he/she worries about his roommate (Resident 145) being cold and becoming ill. The resident reported that his/her roommate needs warmer clothes and shoes and possibly a jacket to wear inside their bed room. Clinical record review for Resident R91 revealed a quarterly assessment Minimum Data Set (MDS- assessment of care needs) dated January 3, 2025, indicated this resident was able to make his/her needs known to staff. The assessment revealed the resident was independent with upper and lower body dressing (putting on/taking off clothing). Clinical record review for Resident R145 revealed a quarterly MDS assessment MDS dated [DATE], indicated that the resident had severe cognitively impaired. The assessment also indicated the diagnoses of dementia, anemia (a low red blood count) and schizophrenia (mental disease characterized by loss of reality contact). Continued review of the MDS assessment revealed that this resident required staff supervision with upper and lower body dressing. Observations with nursing staff, Employee E8, at 11:15 a.m., revealed that the heating unit connected to the wall area heating system in room [ROOM NUMBER] where Resident R91 and Resident R145 resided was not functioning or operational. Observations and air temperatures taken with maintenance staff, Employee E7, at 11:30 a.m., of room [ROOM NUMBER] and the hallway outside this room revealed air temperatures of 56 degrees Fahrenheit. Observations conducted with nursing staff member, Employee E8, at 11:35 on January 22, 2025 of room [ROOM NUMBER] revealed the heating unit was blowing warm air, only slightly. The heating system in room [ROOM NUMBER] was blowing cold air. The heating system in room [ROOM NUMBER] was blowing cold air and the heating unit in room [ROOM NUMBER] was blowing cold air. The nursing staff member confirmed, the heating systems in rooms 315, 316 and 317 were non operational. The nursing staff member confirmed, the heating system in room [ROOM NUMBER] was not fully functioning. Observations of rooms 314, 315, 316 and 317 with a maintenance staff, Employee E7 at 11:40 a.m., on January 22, 2025 revealed the following room air temperatures: room [ROOM NUMBER]- 71 degrees Fahrenheit, room [ROOM NUMBER]- 65 degrees Fahrenheit, room [ROOM NUMBER]- 61 degrees Fahrenheit and room [ROOM NUMBER]-62 degrees Fahrenheit. Observations of Resident R142 at 11:45 a.m., on January 22, 2025 revealed the resident was seated in his/her wheel chair in the hall way outside of room [ROOM NUMBER]. This resident was only wearing a thin cotton hospital gown and socks. The resident's arms and legs were exposed to the cold hallway temperatures of 56 degrees Fahrenheit. Observations conducted of Resident 149 at 11:45 a.m., on January 22, 2025, revealed the resident was in bed constantly moving and kicking her sheet and blanket off her body. The resident was wearing a thin cotton hospital gown only. The temperature recorded for room [ROOM NUMBER] was at 64 degrees Fahrenheit at 4:00 p.m It was noted that the two heating units were turned off or not blowing warm air into resident's room. Observations of Residents R27 and R9 at 11:50 a.m., on January 22, 2025, revealed the residents were in room [ROOM NUMBER]. Both residents were lying in bed dressed with multiple layers of blankets and clothes. Interview with the nursing assistant, Employee E8, at this time revealed that this was the only way we could keep Resident R27 and R9 comfortable by using two or three blankets, since the heating units were not functioning and supplying warm air for this room. Resident room air temperatures were taken on the 300 nursing unit with with the regional administrative staff Employee E3, at 4:00 p.m., on Janaury 22, 2025, and revealed temperatures below 71 degrees Fahrenheit as follows: room [ROOM NUMBER]- 64 degrees Fahrenheit, room [ROOM NUMBER]-62 degrees Fahrenheit, room [ROOM NUMBER]- 62 degrees Fahrenheit, room [ROOM NUMBER]- 60 degrees Fahrenheit, room [ROOM NUMBER]-69 degrees Fahrenheit, room [ROOM NUMBER]- 62 degrees Fahrenheit, room [ROOM NUMBER]- 61 degrees Fahrenheit, and room [ROOM NUMBER]-62 degrees Fahrenheit. Reviews of the documented maintenance communication system logs (electronic communication system used by the staff to report concerns with resident rooms or the nursing unit environment to the maintenance department and administrator) revealed on November 11, 2024, Registered nurse, Employee E11 documented the heating unit in room [ROOM NUMBER] was not working. Registered nurse, Employee E11 indicated there was no heat for residents in this room. There was no documentation to indicate what staff member responded to the nursing staff member's request to repaired the heating unit. Reviews of the documented maintenance communication system logs (an electronic communication system used by the staff to report any issues with resident rooms or the nursing unit environments to the maintenance department and administrator), revealed a work order from the licensed nursing staff, member Employee E9 indicating on November 22, 2024 the nurse alerted the maintenance staff in writing of the heating units in rooms 313, 314, 315, 316 and 317 were not working. The licensed nurse indicated these rooms were cold. The licensed nurse wrote the heating units needed to be repaired immediately. There was no documentation to indicate what staff member responded to the nursing staff member's request to repaired the heating units. Interview with the Nursing Home Administrator, on January 22, 2025, at 11:45 a.m. confirmed the temperatures taken with the maintenance staff, Employee E7 were cold and uncomfortable for the residents living on the 300 nursing unit. Interviews with the activities and nursing staff Employees E8,E12, E13, E14, E15 and E16 working on the 300 nursing unit on January 22, 2025, 12:30 p.m., revealed that the heating units had not been fully functioning to provide warmth for the residents in rooms 310, 311, 312, 313, 314, 315, 316 and 317 since November, 2024. Licensed nursing staff member, Employee E9, was interviewed on Janaury 22, 2025, at 4:00 p.m., and confirmed that the maintenance communication system was used to alert and document the on-going issue of lack of heat to the maintenance department as well as the administrative staff at the facility. Based on the above findings an Immediate Jeopardy was identified for failure to provide safe and comfortable air temperatures for residents living on the 300 nursing unit. The facility's failure to furnish the necessary maintenance services to ensure that safe and comfortable temperature levels were maintained in resident bedrooms and hallway posed a safety risk with the loss of body heat for 19 residents identified. Based on the deficiencies identified in this report, the Nursing Home Administrator failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate jeopardy situation. 28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 204.19 Plumbing, heating ventilation and air conditioning and electric

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident with a facility-initiated transfer to the hospital was necessary and document the basis for the transfer in the residence medical record for one of three residents reviewed related to transfers. Resident R 212 Finding include: Review of Resident R 212's admission MDS (minimum data set a mandatory resident assessment tool), entry tracking records dated November 22, 2024, revealed that the resident was admitted to the facility on [DATE]. Residence R 212's discharge assessment dated [DATE], revealed that the resident was discharged for reason of behaviors and a return is not anticipated. Review of Resident R 212's clinical record revealed that this resident was admitted to the facility with diagnosis's including unspecified mood disorder, dementia, kidney failure, personal history of transit ischemic attack (a temporary blockage of blood flow to the brain), history of falling, bipolar disorder (a disorder classified by episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, and anxiety disorder. Review of facility documentation dated November 27, 2024, revealed the resident was sent to the hospital reason for transfer states and no on other information was completed on this form. Review of nursing notes for Resident R 212's five days of stay in the facility did not contain any documentation of any behaviors of warranting any safety concerns. Review of nursing notes dated November 22, 2024, patient refused all night meds and morning labs. Review of nursing notes dated November 23, 2024, resident received in bed, resident refused all morning care, food and medications resident noted agitated and yelling at staff. Review of nursing notes dated November 24, 2024; a nursing note revealed resident consumed 75 % to 100% of snacks provided. The resident refused to eat when offering but noted eating after this nurse leave the room. Refused all care and medications. Resident yelling at staff without any provocation. Review of residents nursing note dated November 25, 2024, revealed the resident refused all due medication with verbal aggression. Review of nursing notes dated November 26, 2024, revealed that a psychological consultation was done and a new order for Zyprexa was obtained. Review of nursing notes dated November 27, 2024, revealed Resident is noted with refusing the care, medications, labs, chest X-ray, therapy, changes the clues. Noted with meal percentages of zero to 25%. Resident is noted with aggressive behavior from last five days. Received order for transfer to [hospital] due to safety concerns. Review of Nursing note dated November 27, 2024, revealed resident transfer .with all the belongings. Interview with licensed nurse Employee E4 on January 24, 2025, at 1:22 p.m. confirmed she was familiar with resident R 212's and this resident had behavior concerns. She sates that the resident was refusing all care, including ADL's, bathing, toileting, medication and therapy. Employee E4 states she spoke with the president's wife and was asked to send him to the hospital. Employee E4 then obtained an order for discharge. Interview with Director of Nursing, (DON), Employee E2 on January 24, 2024, at 2:05 p.m. revealed that the resident was discharged due to aggressive behavior towards staff and refusal of care. Employee E2 stated that the resident was discharged due to his resistance to care and refusal of medications. When question why this resident was sent to the hospital with all belongings he stated the resident carries all belonging with him at all times. Employee E2 was unable to provide evidence that Resident R212 transfer was necessary for the resident's welfare, and the facility was unable to meet the residents needs or that the health and safety of individuals at the facility were endangered due to the residence status. The DON state the facility was unwilling to continue to provide ongoing care to resident R 212. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure that a baseline care plan was developed for a one of 35 residents reviewed. (Resident R212. Findings include: Review of Resident R212's admission Minimum Data Set (MDS-a mandatory resident assessment tool), entry tracking dated November 22, 2024, revealed that the resident was admitted to the facility on [DATE]. Resident R212's discharge assessment dated [DATE], revealed that the resident was discharged for reason of behaviors and a return is not anticipated. Review of Resident R212's clinical record revealed that this resident was admitted to the facility with diagnosis's including unspecified mood disorder, dementia, kidney failure, personal history of transit ischemic attack (a temporary blockage of blood flow to the brain), history of falling, bipolar disorder (a disorder classified by episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, and anxiety disorder. Review of facilities documentation dated November 27, 2024, revealed the resident was sent to the hospital, reason for transfer states behavior systems and no on other information was completed on this form. Review of resident's hospital record dated November 20, 2024 revealed the resident was admitted for mental status change. The patient's wife reported at this time patient has become increasingly violent. Patient's wife is unable to take care of him with his psychological issues. Patient remains calm and comfortable, however refuses medications and has refused labs. Review of nursing notes dated November 22, 2024, patient refused all night meds and morning labs. Review of nursing notes dated November 23, 2024, resident received in bed, resident refused all morning care, food and medications. Resident noted agitated and yelling at staff. Review of nursing notes dated November 24, 2024,resident consumed 75 % to 100% of snacks provided. The resident refused to eat when offering but noted eating after this nurse leave the room. Refused all care and medications. Resident yelling at staff without any provocation. Review of residents nursing note dated November 25, 2024, revealed the resident refused all due medication with verbal aggression. Review of nursing notes dated November 26, 2024, revealed that a psychological consultation was done and a new order for Zyprexa was obtained. Review of nursing notes dated November 27, 2024, revealed Resident is noted with refusing the care, medications, labs, chest X-ray, therapy, changes the clues. Noted with meal percentages of zero to 25%. Resident is noted with aggressive behavior from last five days. Received order for transfer to [hospital] due to safety concerns. Interview with licensed nurse Employee E4 on January 24, 2025, at 1:22 p.m. confirmed she was familiar with Resident R 212's and this resident had behavior concerns. She sates that the resident was refusing all care, including ADL's, bathing, toileting, medication and therapy. Employee E4 states she spoke with the resident's wife and was asked to send him to the hospital. Employee E4 then obtained an order for discharge. There was no evidence that a baseline care plan was developed related to refusal of care, medications, and verbal and agitated behaviors. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations of care and services, clinical record reviews and interviews with responsible family members and staff, it was determined that the facility failed to ensure that a consultation with an optometrist or ophthalmologist was obtained for one of 35 residents reviewed (Resident R201) Findings include: Interview with the responsible family member for Resident R201 at 11:00 a.m. on January 21, 2025, revealed that the family member visits the facility at lunch time daily. The family also reported that he had spoken to the nursing staff about having Resident 201's eyes examined by a professional optometrist or ophthalmologist (branch of medicine concerned with the treatment of disorders and diseases of the eyes). Observations of Resident R201 on January 21, 2025, revealed that this resident was sitting in the well illuminated dining area. The family member said that he thinks both eyes were impaired because Resident R201 can not follow objects with her eyes. The family member said that Resident R201 had no corrective eyewear and she needs a pair of corrective lenses. Clinical record review for Resident R 201 revealed an admission comprehensive assessment dated [DATE] that indicated that this resident was admitted to the facility on [DATE]. The assessment also indicated that Resident R201 was severely cognitively impaired. The assessment also indicated that this resident had a diagnosis of dementia. Interview with the licensed nursing staff, Employee E4, at 10:00 a.m., on Janaury 24, 2025 confirmed that the responsible party for Resident R201 had requested for Resident R201 to be evaluated and assessed by an eye specialist in November and December, 2024 and January, 2025. There was no documentation to indicate that the consultation had been discussed with the physician. The registered nurse, Employee E4 confirmed that the responsible party for Resident R201 had requested that the services of an optometrist or ophthalmologist during the months of November, December, 2024 and January 2025; however there was no vision consults available to review for Resident R201. 28 PA. Code 211.12(d)(1)(3)(5) Nursing services 28 PA. Code 201.21(c) Use of outside resources 28 PA. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of seven residents sampled (Resident R 191) Findings include: A review of the clinical record revealed that Resident R191 was admitted to the facility on [DATE], with diagnoses to anxiety disorder, and post-traumatic stress disorder (PTSD) Further review of the clinical record for Resident R191 revealed that the resident PTSD diagnoses is unknown by facility. Resident R191's current care plan on December 19, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. Interview with the Social worker, Employee E6, on January 24, 2025, at 10:12 a.m. confirmed that Resident 191 plan of care for PTSD did not include resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Resident R 88). Findings Include: Review of the admission sheet of Resident R88, revealed that Resident R88 was admitted to the facility on [DATE]. Review of the admission sheet of Resident R88 indicated that, on January 30, 2023, Resident R88 was diagnosed with Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Minimum Data Set assessment (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated December 16, 2024, revealed that Resident R88 had active diagnoses of Non-Alzheimer's Dementia (a progressive form of Dementia that destroys memory and other important mental functions). Review of MDS revealed that Resident R 88 received antipsychotic (Antipsychotic medications have the effect of changing a person's behavior, mood, and emotions), and anti-depressant medications. On January 25, 2025, at 10:16 a.m., review of Resident 88's care plan revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R88. During an interview on January 25, 2025, at 10:19 a.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received. 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.12 (d)(1)(3)(5) Nursing service

Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain and report laboratory results to meet resident needs for three of 35 residents reviewed (Resident R72, R204, and R169). Findings Include: Review of Resident R72's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 21, 2024, revealed the resident had a diagnosis of hyperkalemia (elevated levels of potassium in the blood because the kidneys are unable to excrete the excess potassium - severe symptoms can include muscle weakness or affect the heart). Review of Resident R72's clinical record revealed a physician progress note dated November 28, 2024, by Physician, Employee E10, that indicated Resident R72 had a nephrology (medical specialty that focuses on the study of kidneys) consult on November 8, 2024, with recommendations to implement a low potassium diet and to recheck labs in two weeks. Review of Resident R72's clinical record revealed the resident had labs drawn on November 29, 2024. Per a review of the labs, results were reported the same day which indicated Resident R72 had critical lab values for elevated potassium levels of 6.6 mMOL/L (normal range 3.4 - 5.3 mMOL/L). Review of Resident R72's entire clinical record revealed no documented evidence the physician was promptly made aware of the critical lab values that resulted on November 29, 2024. Continued review of Resident R72's clinical record revealed the physician was not made aware of the lab results until three days later, on December 1, 2024. Resident R72 was subsequently transferred to the hospital on December 1, 2024, for further evaluation and management, as ordered by the physician. Review of nursing note dated December 1, 2024, revealed Resident R72 was admitted to the hospital with a diagnosis of hyperkalemia. Interview on January 24, 2025, at 11:04 a.m. with Registered Nurse, Employee E4, confirmed Resident R72's critical lab values resulted on November 29, 2024, and documentation indicated the physician was made aware on December 1, 2024. Further interview on January 24, 2025, at 11:04 a.m. with Registered Nurse, Employee E4, revealed if lab results are critical the lab will typically call to inform the facility, otherwise the lab results should be checked by nursing. Review of Resident R204's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis including Urinary Tract Infection (Urinary tract infections (UTIs) often start when bacteria get into the tube through which urine leaves the body, the urethra), Sepsis (Sepsis is a life-threatening condition that occurs when the body's immune system overreacts to an infection), Acute Cystitis With Hematuria (a condition where someone experiences a sudden onset bladder infection (acute cystitis) accompanied by the presence of blood in their urine (hematuria), meaning they are experiencing symptoms of a bladder infection along with visible blood when they urinate; this can be a sign of a more severe infection and warrants medical attention), and Pneumonia (Pneumonia is a lung infection that causes the air sacs in the lungs to fill with fluid or pus. This makes it difficult to breathe and limits the amount of oxygen that reaches the bloodstream). Review of clinical records of Resident R204 indicated that on September 20, 2024, the pharmacist recommended for a lab tests on Urine pH with Methenamine, but the physician did order it only on January 8, 2025. Review of Resident R204's entire clinical record revealed no documented evidence to establish that the test was completed in a timely manner, as suggested by the Drug Regimen Review Recommendation of the Pharmacist. Review of the comprehensive quarterly assessment MDS (an assessment of care needs) dated January 1, 2025 for Resident R169 revealed that this resident was admitted to the facility on [DATE]. The resident had diagnoses of Alzheimer's disease, seizure disorder, bipolar disorder and schizophrenia. The assessment also indicated that this resident was prescribed antipsychotic and antidepressant medications. Clinical record review revealed a medication administration record for Resident R169 for the months of December, 2024 and January, 2025 that indicated that the resident was receiving valporic acid (Depakene) 250 milligrams twice a day for the treatment of bipolar disorder. Clinical record review revealed that on December 16, 2024 the physician had ordered laboratory studies for valporic acid (to measure the amount of valporic acid in the blood) to be completed for Resident R169. There was no documentation to indicate that the studies had been completed as ordered by the physician. Interview with the Registered nurse, Employee E4, at 12:30 p.m., on January 24, 2025 confirmed that there were no valporic acid blood level studies completed for Resident R169 for the months of December, 2024 or January, 2025 for this resident as requested by the physician. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, clinical record review, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to adequately supervise one of five residents reviewed (Resident R1), resulting in Resident R1 eloping from a medical facility and missing for a period of almost 55 hours. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy title, Elopement dated December 1, 2021, revealed the facility's protocol and guidelines to follow when a resident cannot be located. Continued review revealed that, Once the resident is returned to the facility the IDT [Interdisciplinary Team] will meet to evaluate the circumstances surrounding the elopement and place appropriate short term interventions to assure the residents immediate safety until a long term plan for safety is determined. Review of Resident R1's admission documentation revealed that the resident was admitted to the facility on [DATE]. Review of Resident R1's care plan, initiated May 17, 2021, revealed that Resident R1 has elopement risk related to dementia with interventions including engage in activities/tasks to keep occupied, monitor behaviors and provide supervision when resident exhibiting exit seeking behaviors. Review of Resident R1's Elopement Evaluation, dated July 22, 2022, revealed that the resident was assessed by the facility to be at risk for elopement. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 12, 2022, revealed that the resident was admitted to the facility May 17, 2021, and had diagnoses of non-traumatic [CONDITION(S)] (inability to pay attention, disorientation, inability to think clearly) cancer, dementia with behavioral disturbance (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities with behaviors such as verbal and physical aggression, wandering and hoarding) and adjustment disorder with anxiety (feeling worried, anxious and overwhelmed). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of six, which indicated that the resident was severely cognitively impaired. Further review revealed that the resident required supervision with set-up assistance for activities of daily living including bed mobility, transfers, walking, dressing, eating, toileting and hygiene. Review of progress notes for Resident R1 revealed a nurses note, dated September 1, 2022, at 12:15 p.m. which indicated that the resident went out of the facility for a urology (branch of medicine that focuses on the urinary-tract system and the male reproductive organs) appointment with a nurse aide at 12:15 p.m. via a contracted transport service. Continued review revealed a nurses note, dated September 1, 2022, at 8:05 p.m. which indicated that after the appointment was completed while waiting for transport back to the facility, the staff member [Employee E5] assigned to accompany Resident R1 needed to use the restroom. The staff member explained to the guard at the security desk that she needed to use the restroom and that the resident had dementia and was a wandering risk. The staff member placed a chair by the security guard station and Resident R1 sat in the chair. The staff member then left to go to the restroom. When the staff member returned, Resident R1 was not in the chair. The staff member asked the security guard where the resident was and the security guard informed the staff member that he did not know. The staff member then initiated a search for Resident R1, notified the facility and the police. Interview on September 8, 2022, at 10:51 a.m. with Employee E5, nurse aide, revealed that while she was waiting for transport back to the facility after Resident R1's medical appointment that she needed to use the restroom. Employee E5 stated that she spoke with security and sat Resident R1 next to the security desk before leaving the resident to go to the restroom. Upon her return from the restroom, Resident R1 was gone. Employee E5 stated that the security guard informed her that Resident R1 ran past a group of people going outside of the building. Employee E5 stated that she looked everywhere but was unable to locate Resident R1. Employee E5 notified the facility and the police to inform them that Resident R1 was missing. Employee E5 confirmed that she recently receiving training related to dementia and elopements and stated that she felt comfortable transporting residents to appointments outside the facility who have dementia and who are at risk for elopement. Review of facility documentation submitted to the Department of Health on September 1, 2022, revealed that Resident R1 went missing on September 1, 2022, at 1:45 p.m. while he was out of the facility on a medical appointment when his assigned staff member left him to use the restroom. Facility staff and police initiated a search for the resident. Resident R1 was located by the police on September 3, 2022, at 8:40 p.m. two days after being missing and taken to hospital for evaluation. Review of hospital records, dated September 6, 2022, revealed that Resident R1 was brought to the emergency room by EMS (Emergency Medical Services) after being found wandering the streets confused. Per EMS report, bystanders saw the patient wandering alone and confused for which they called EMS to assist. Patient has been missing since September 1, 2022, after going to a urology appointment .Patient cannot recall how he got to the appointment or what happened after seeing the doctor. Continued review revealed that the resident was found to have rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can result in kidney damage) and acute kidney injury (kidney damage). The resident was subsequently treated with intravenous fluids and an indwelling urinary catheter at the hospital prior to returning to the facility. Observation on September 8, 2022, at 9:50 a.m. revealed Resident R1 ambulating with therapy staff in the facility's secure dementia unit. Resident R1 appeared pleasantly confused and did not recall any details of his elopement event. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident with dementia who was known to be at risk for elopement. The resident went missing on September 1, 2022, at 1:45 p.m. and was not found until September 3, 2022, at 8:40 p.m., a period of almost 55 hours. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 8, 2022, at 1:53 p.m. On September 8, 2022, at 6:23 p.m. the facility's action plan was accepted. The action plan included the following: 1. 88% of nursing staff will be educated on not leaving residents with dementia unassisted at medical appointments when outside the facility to prevent the potential for elopement on September 8, 2022. Employee education will be completed prior to the start of the employee's next shift and will continue until 100% completion is obtained. 2. The facility will review and audit all residents care plans who have a diagnosis of dementia and are at risk for elopement. This will be completed on September 8, 2022. Care plans will be updated to include the need for supervision when out at an outside appointment. 3. The elopement policy and procedure were updated on September 8, 2022, in the presence of the NHA, DON, Regional Administrator and Regional DON to include adequate supervision of all residents during outside appointments. 4. The facility will audit all residents who are at risk for elopement and have a diagnosis of dementia who have medical appointments outside of the facility daily times four weeks and then weekly times two months. Findings will be reported to QAPI monthly times three months where necessary changes will be made. Review of the facility's updated elopement policy revealed that the facility added an addendum, dated September 8, 2022, which stated, All resident deemed as at risk for elopement will be provided an escort, a member of the nursing staff, to all outside physician appointments. The nursing staff assigned accompany the resident to an outside appointment must stay with the resident until the resident returns to the facility. If an emergency arises for the staff member while out at an appointment with the resident, the staff member must contact facility administration for direction to assure continued safety of the resident. Interviews were conducted with facility staff on September 9, 2022, between 2:30 p.m.- 3:39 p.m. to verify the implementation of the action plan. Facility staff were able to verbalize what they would do if they were assigned to accompany a resident to a medical appointment and what their responsibilities were in case they themselves had an emergent situation. A review was conducted of the education provided to facility staff related to resident elopement. A review of residents' care plan confirmed that resident's care plan were updated to include that a resident was not to be left unattended during appointments. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on September 9, 2022, at 4:03 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records, interviews with staff, review of facility policies and documentation, it was determined the facility failed to ensure that Resident R1 was free from sexual abuse for one of five clinical records reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation for Resident R1 who was a subject to a nonconsensual sexual activity by Resident R2 with a history of incarceration. Findings include: Review of the facility's policy titled, Prohibition of Resident Abuse & Neglect not dated, stated that each resident will be Free from abuse and neglect. The policy continued to state that the facility practices zero tolerance of resident abuse and neglect . including Staff members and other residents. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's annual Minimum Data Set (MDS- assessment of resident care needs) dated June 24, 2022 revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS revealed that the resident had wandering behaviors four to six days, required extensive assistance with dressing and was frequently incontinent of bladder. Review of the Resident R1's care plan dated on admission revealed that the resident had history of being physically and mentally abused, with goals including being free from harm. Further review of the resident's care plan revealed that due to resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan stated the resident was sometimes understood and sometimes understands. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R2's nursing evaluation dated, July 22, 2022, revealed the resident was oriented to self and time, walked frequently outside of his room, and needed staff supervision for grooming, eating, and toileting. Review of Resident R2's nursing note dated July 24, 2022, stated Resident R2 was observed with Resident R1, both were naked, and he (Resident R2) was on top of her in room. The note stated the police were called and told of Resident R2's history of Elopement, drug abuse, incarceration and syphilis. Resident R2's nursing progress note dated July 24, 2022, stated, The police arrived at the facility and were told the resident has (sic) a hx (history) of elopements, drug abuse, incarcerations and syphilis (a sexual transmitted disease). The police arrested Resident R2, escorted him out at the rear of the building, and informed the facility he would be placed in a holding cell. Resident R1 nursing progress note, dated July 25, 2022, indicated that when the family was informed that Resident R1 was found with Resident R2, the resident was sent to the Special Victims Units (a specialized crime unit for sexual assaults). The same note indicated the resident remained with the family. Interview with the Director of Nursing on July 28, 2022, at 10:00 a.m. indicated that earlier that day, on July 24, 2022, an aide observed Resident R1 kissing Resident R2's head and lips in the dayroom. The residents were then separated. Later that day, at approximately 3:00 p.m., a 3-11 nurse aide coming on the shift remembered seeing the residents together again in the dayroom. A few minutes later a nurse aide doing her rounds on the 300 unit went into a room and saw both residents in bed together with their pants down. Review of the facility's investigation dated July 24, 2022, revealed a witness statement from Nursing Assistant (NA) Employee E5 who was assigned to Resident R1 on July 24, 2022, indicated that after breakfast, Resident R1 was sitting with Resident R2 in the common area (located in the facility's memory care lock unit), watching television. The NA stated that Resident R1 got up and kissed him (Resident R2) on his head then pulled his face mask down and kissed Resident R2 on the lips. The NA then moved Resident R1 to the nursing station. Review of the witness statement from Nursing Assistant, Employee E9 stated Sunday (July 24, 2022) Resident R2 was observed in the 300 Unit lounge the NA stated that she did observe Resident R1 wandering around 300 and 400 Units (the facility's memory care locked units) and indicated the NA did redirect Resident R1 a few times back to her 400 unit. Review of the witness statement from NA, Employee E6 stated he started work a few minutes before 3:00 p.m. and saw Resident R1 and Resident R2 sitting down in the 400 Unit lounge together. Review of the witness statement from NA, Employee E7 stated, Around 3:10 p.m. I seen (sic) Resident R2 on top of Resident R1 . her pants and pull-ups (adult briefs) was (sic) down and his pants were (sics) down to his ankles. An interview was conducted with the Director of Admissions, Employee E8, on July 28, 2022, at 11:00 a.m. During the interview the surveyor asked Employee E8 what were the requirements before a prospective resident be admitted to the facility? The Director of Admissions, Employee E8 stated that the First thing is Megan's Law (a public access website used to inform the listed sexual offenders). If someone is on Megan's Law, we do not admit them. The Director of Admission, Employee E8 indicated that before Resident R2 was admitted the Megan's Law website was searched and Resident R2 was not on the list. The Director of Admission, Employee E8 communicated that the facility had a list related to capabilities for a resident to be admitted to the facility. The surveyor requested a copy of the capabilities list. Facility did not provide documented evidence of the list of capabilities for admission to the facility as requested. Further review of Resident R2's clinical record revealed hospital documentation which revealed that the resident was, Unable to return to group home due to dementia and elopements, brother unable to provide 24/7 care. Needs long term placement, SW (Social Worker) trying to get in contact with prison. There was no documented evidence that the facility completed a search of additional governmental website of individuals with a criminal history besides the Megan's Law before Resident R2 was admitted to the facility. During an interview conducted on July 28, 2022, at approximately 11:30 a.m. with the Director of Nursing and Director of Admission confirmed that the Megan's Law website was the only search completed by the facility before Resident R2 was admitted to the facility. Viewing the information on www.pameganslaw.state.pa.us related to the Megan's Law website revealed a disclaimer that indicated the information contained on the website may be outdated or inaccurate and was not a comprehensive listing of every person who has ever committed a sexual offense in Pennsylvania. Viewing of the information on https://ujsportal.pacourts.us/CaseSearch beyond Megan's Law, revealed that Resident R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R2's entire clinical record revealed that the facility failed to develop a care plan and interventions for Resident R2 with a history of incarceration. This failure resulted in Resident R2 engaging in a nonconsensual sexual act with Resident R1. Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified and on July 28, 2022, at 4:10 p.m. the Immediate Jeopardy template was provided to the Director of Nursing and an immediate action plan was requested. The Immediate Jeopardy Template was provided to the Director of Nursing on July 28, 2022, at 4:10 p.m. On July 28, 2022, at 8:05 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. Will review the last 72 hours of documentation to ensure residents are free of unwanted sexual advances. 7/28/2022 2. Facility will review clinical information provided by referral source for all residents and pending admissions for any history of incarceration. 7/29/22 3p.m. 3. Facility will review last 72 hours of documentation to ensure no residents exhibit inappropriate behaviors where necessary interventions will be updated. 7/28/2022 4. Policy was reviewed Regional [NAME] President of Operations, Regional Director of Nursing, Director of Nursing and Nursing Home Administrator via telephone to ensure that policy addressed sexual abuse. Completed 7/28/2022 5. Education was completed with Admissions Director on identifying residents with a sexual abuse history. 7/28/2022 6. Education will be completed with staff on consensual and non-consensual sex. 7/28/22 62% completed. Expect 85% by 3pm 7/29/22. Calls and in-services will continue until 100% or prior to any staff working. Interviews were conducted with facility staff on July 29, 2022, between 2:45 p.m. and 4:29 p.m. to verify the implementation of the action plan. Facility staff were able to verbalize the need to develop and implement interventions when inappropriate behaviors are exhibited by residents including consensual and non-consensual sexual acts. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on July 29, 2022, at 5:50 p.m. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records, interview with facility staff, review of facility policies and documentation, it was determined that the facility failed to adequately supervise and maintain each residents' environment free from accidents for one of six residents reviewed (Resident R1) who dismounted the air conditioning unit and eloped from a secured memory care unit. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility's policy titled, Missing Resident, not dated, stated the facility's protocol and guidelines to follow when a resident cannot be located. The same policy stated, Once the resident is returned to the facility, the IDT, (Interdisciplinary team) will meet to evaluate the circumstances surrounding the elopement and place appropriate short-term interventions to assure the residents immediate safety until a long-term plan for safety is determined. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] diagnosed with Dementia (progressive [CONDITION(S)] disease of the brain), with behavioral disturbances, [CONDITION(S)] (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (major loss of interest in pleasurable activities), anxiety, unspecified [CONDITION(S)] (loss of contact with reality resulting in disorganize thinking) and adult failure to thrive. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of residents' needs), dated May 9, 2022 revealed the resident was cognitively impaired, and needed limited assistance with bed mobility, transfers, toileting, personal hygiene, and had no impairment to his extremities. Review of Resident R1's elopement assessment on admission, dated August 13, 2021, revealed the resident was assessed as a high risk for elopement. Physician orders, dated March 2022, instructed the resident to wear a wanderguard alarm, (device designed to allow the resident freedom on the memory care unit with a sounding alarm when attempts are made to leave the unit). Review of the late entry nursing note dated, June 2, 2022, at 12:01 a.m. revealed Resident R1 could not be located on his memory care unit. Review of the facility's investigation for Resident R1's, June 1, 2022, elopement revealed a staff witness statement, from a nursing assistant, Employee E 30 who stated that she last observed Resident R1 on the unit on June 1, 2022 between 9:30 p.m. - 10:00 p.m. Further review of the investigation revealed that the resident's nephew called the facility on June 2, 2022, informing them, that the local police located the resident and brought him to his (the nephew) house. The investigation stated on June 2, 2022, at 8:45 a.m. the resident was returned to the facility by his daughter and was noted not wearing the wanderguard. Continued review of the investigation revealed that the bolt/safety latch that kept the windows from fully opening in Resident R1's room and the window in the common area, beside the resident's room, had been broken off. Review of Resident R1's care plan revealed that an elopement care plan was not developed at the time the resident was admitted . Further review of the resident's care plan revealed that an elopment care plan was not developed until June 27, 2022, approximately a month after the elopement of June 1, 2022. Interventions included in the elopement care plan were to check the resident's wanderguard for placement and using re-direction diversional activities when the resident was trying to leave the unit. On July 5, 2022, at 1:30 p.m. during an interview with the Director of Nursing (DON) while reviewing a facility reported incident/documentation revealed on July 3, 2022, at 11:15 p.m. the staff started searching for Resident R1 in his memory care unit when the resident could not be found. Documentation stated at 11:30 p.m., the supervisor was notified and the search expanded to the entire facility and the outside area. At 11:50 p.m. the police and family were notified. Facility documentation noted nurse aide, Employee E15, last saw the resident at 10:30 p.m.on July 3, 2022. The next morning, almost 12 hours later at 10:30 a.m. the resident was located approximately 10 miles away at a park. The resident was unable to verbalize how he traveled to the park nor how he exited the facility. During the same interview, the DON indicated that the vent cover to Resident R1's air conditioning unit, facing the outer side of the building, was pushed out and bent and concluded that Resident R1 removed the air conditioning unit, pushed out the cover and exited through the opening. The DON stated, The outside cover to the a/c (air conditioning) unit was held secure by only one screw and the rest were clips. The resident could have easily gotten through. The family placed him in the facility because he always figured out how to escape from his home. They called him Houdini (an escape artist). Observation of the pictures revealed the outside cover was bent up until it reached the one secured bolt/screw. Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator (NHA) on July 8, 2022, at 11:50 a.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the Nursing Home Administrator on July 8, 2022, at 11:50 a.m. On July 8, 2022, at 6:09 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. On 7/4/2022 at around 1:00 a.m. all residents on memory care unit were placed on every-15 minute checks (residents are accounted for every 15 minutes). 2. On 7/4/2022, upon his return to the facility, Resident R1 was placed on 1:1 (continuous one on one supervision with staff ). 3. On 7/4/2022, upon Resident R1 return to the facility, the resident's room was moved closer to nursing station. 4. On 7/4/2022, around 10:00 a.m., the Nursing Home Administrator ensured the resident's picture was posted at the front reception desk. 5. Starting 7/8/2022 Resident R1 will be assessed Q-shift (every shift) for elopement risk by nurse, including exit seeking behaviors as well as fit and function of Wander Guard. 6. On 7/4/2022 the Maintenance Director checked all exit doors leading off of the memory care unit to ensure all locks and alarms worked properly and found no issues. The Maintenance Department will continue to conduct weekly inspections of the automatic locking system of exit doors on memory care unit to ensure doors close and latch into frames and alarms on exit doors function properly. 7. On 7/4/2022 Maintenance Director checked all windows on memory care unit to ensure they would not open more than 3 and found no issues. Maintenance department will continue to conduct weekly inspections of windows on the memory care unit to ensure that they do not open more than 3 (inches). 8. On 7/4/2022 the Maintenance Director Secured all through wall AC outside panels on the memory care unit. The Maintenance Department will continue to conduct weekly inspections of the outside panels of the HVAC (heating, ventilation and air condoning) units on the memory care units to ensure they are secure. 9. On 7/8/2022 Assistant Director of Nursing confirmed that all residents at risk of elopement have their pictures kept in book at front reception desk. 10. Facility began in-servicing Staff on 7/7/2022 on Elopement of Residents. Currently, 40% of total staff have received in-service education with a goal of having 100% of staff in-serviced by 7/15/2022. All staff will receive in-service education prior to working their next shift. 11. Any issues noted during Maintenance Inspections will be immediately brought to the attention of the Nursing Home Administrator and Director of Nursing for resolution. 12. The facility's Elopement Plan will be reviewed at the Quarterly QAPI Meeting for any changes to the plan. Interviews were conducted with facility staff on July 9, 2022 between 3:00 p.m.- 4:29 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors and Resident R1 was observed with 1:1 supervision. A review was conducted of the education provided to facility staff related to resident elopement. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on July 9, 2022, at 4:49 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on interviews, and the review of clinical records, it was determined that the facility failed to ensure that a comprehensive plan of care was developed for a resident with a history of suicide attempts for one out of 18 residents reviewed (Resident R12). This failure resulted in actual harm to Resident R12 who attempted self harm. Findings include: Review of the resident's Physician Narrative History and Physical dated February 7, 2021, and completed by the physician at the facility, indicated that the resident was admitted into the facility from the hospital on February 5, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Narrative History and Physical also indicated that that resident was severely emaciated (abnormally thin) with weight loss, and that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's hospital records also indicated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R12's admission Minimum Data Set assessment (resident assessment of care needs) dated February 11, 2021 identified the resident with a BIMS score (Brief Interview of Mental Status) of 14 which indicated that the resident was cognitively intact. Further review of the resident's MDS assessment revealed that the resident's mood was assessed. The resident expressed feeling tired, having poor appetite, feeling bad about herself, and feeling down. The assessment did not identify any behavior symptoms. Review of Resident R12's interdisciplinary note dated May 23, 2021 at 6:02 p. m. indicated that licensed nurse, Employee E17 was notified by Resident R12's nursing assistant that the resident was crying and said that she wanted to die. Licensed nurse, Employee E17 assessed the resident and noted a cut with mild bleeding on the resident's left forearm. The resident stated to licensed nurse, Employee 17 that she cut herself with a razor. The resident was crying and said that she will do that again because she did not know whether her son had a peaceful death or not. Licensed nurse, Employee 17 took razors and sharp objects from resident's room and provided emotional support and started 1:1 observation. The resident's physician was notified and ordered a transfer to the hospital. Further review of the nursing note revealed that the resident refused to be transfer to the hospital. Review of Resident R12's interdisciplinary note dated May 24, 2021 at 3:35 a.m. revealed that the resident continued on 1:1 supervision. Review of the plan of care dated February 6, 2021 identified as a focus area that the resident had actual/potential for alteration in nutrition and hydration status related to history of substance abuse, [CONDITION(S)], abscess to the right leg, depression, anxiety, [CONDITION(S)], and history of self harm. The intervention listed in the care plan included to administered medications as ordered, administer vitamin, diet per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's plan of care did not include interventions related to the resident's history of suicide attempts, as recorded in the resident's hospital records, and identified in the Physician Narrative History and Physical. During a discussion with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on June 9, 2021 at approximately 5:30 p.m. it was discussed with and confirmed by the Director of Nursing that the resident's person centered plan of care at the time of the resident's suicide attempt in effect on May 23, 2021 did not include a plan of care related to past instances of self harm. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c(1) )Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to provide an environment free of accident hazards for one resident, failed to follow one resident's plan of care for fall prevention and failed to provide adequate supervision and monitoring to ensure the safety of one resident with a history of multiple falls for three of 30 residents reviewed (Residents R25, R44 and R59)resulting in actual harm of injury to two residents (Residents R44 and R59). Findings include: Review of Resident R44's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident R44's quarterly Minimum Data Set (MDS- an assessment of care needs) dated February 27, 2017, indicated that Resident R44 had been admitted to the facility on [DATE]. The resident was severely cognitively impaired with decision making, had long term and short-term memory problems and required extensive physical assistance of two staff with bed mobility, transfers, toilet use, personal hygiene, locomotion throughout the facility, and dressing. The resident was noted to be totally dependent on staff for bathing, was incontinent of bowel and bladder, required extensive assist with meals, and had fallen since admission. A plan of care was developed on July 24, 2014, to address the resident's risk of injury related to generalized weakness, confusion, dementia, anxiety, side effects of necessary medications, and vision impairment. Included in the plan were interventions such as a chair alarm, floor mats when the resident was in bed, a low bed, staff to monitor the resident for unsafe behavior and redirect as needed, provide necessary safety measures and to toilet at the first sign of restlessness. A progress note written on March 3, 2017, at 11:28 p.m. stated that the resident was not able to recall words or conversations that had occured five minutes prior, was unable to identify the season, his room or where to go, and made poor decisions to rise unassisted. The nursing documentation dated for April 14, 2017, at 1:55 p.m. noted that the resident had been found in the resident lounge on the floor by a member of the housekeeping staff, that another resident was attempting to assist Resident R44 to ambulate, that the resident slid to the floor landing on his back and buttocks. A review of information submitted by the facility dated April 15, 2017, at 11:00 a.m. stated that the resident had been found by another resident's family on the floor of the resident television lounge. Progress notes dated April 15, 2017, at 12:18 p.m. stated that the resident was found on his back in the lounge, was grimacing and holding his left hip, was unable to straighten the leg and was keeping it in a bent position. An entry on the same date at 10:15 p.m. stated that the resident had fallen on the 7:00 a.m. to 3:00 p.m. nursing shift, that an X-ray was done and revealed a moderately displaced (out of place), comminuted (two or more pieces) and angulated intertrochanteric (upper part of the thigh bone) fracture of the left femur, that the physician was notified and ordered the resident be sent to the emergency room . Documentation on April 16, 2017, at 6:57 p.m. reported that the resident had been admitted to the hospital with [REDACTED]. that measured 1.5 centimeters by 0.5 centimeters. An investigation of the incident revealed that the fall that occurred on April 15, 2017, was unwitnessed. The chair alarm had not been sounding, and the resident attempts to get up alone and was unsafe to do so. In addition, there was no conclusion or possible root cause analysis included to indicate how the fall had might have occurred. A notation stated that the staff were educated not to leave the resident unsupervised. In a written statement, dated April 15, 2017, Employee E44, the resident's care nurse at the time of the event, noted that the chair alarm was checked, it was broken and not working properly, and that she took the resident to the lounge, placed him at a table and left to find the nurse. Employee E44, Licensed Nurse, reported in a written statement on April 15, 2017, that Resident R44 fell out of his wheelchair in the resident lounge at about 11:00 a.m., that no chair alarm went off and that another resident's family notified her. Employee E13, Nurse Aide, stated in an interview on November 10, 2017, at approximately 11:45 a.m. that she had cared for Resident R44 frequently, that he often would just stand up from the wheel chair but that he was unable to walk, that he had an alarm on the wheel chair and that you would know it's working when he stands up and it goes off. The Director of Nursing stated in an interview on November 9, 2017, at approximately 11:45 a.m. that the resident had an alarm on the wheel chair at the time of his fall, that it was very, very low (in volume) and was difficult to hear. There was no evidence available to review at the time of the survey to indicate if staff were present in the lounge to monitor and supervise the residents at the time that Resident R44 was placed in the lounge. Observation of Resident R59 on November 6, 2017, at 1:00 p.m. revealed the resident had purple colored bruising noted under the right eye and beneath the jawline on the right side of her face. Review of Resident R59's clinical record revealed that the resident had been admitted to the facility on [DATE], with diagnoses, including but not limited to, dementia and a history of falls. A Fall Risk Assessment completed for Resident R59 on August 17, 2017, revealed that the facility had identified the resident at moderate risk for falling. Review of Resident R59's care plan dated last reviewed June 28, 2017, which also indicated that the resident had been identified as at increased risk for injury related to falls. The nursing progress notes dated October 29, 2017, at 20:15 (8:15 p.m.) stated Nsg MDS alert charting Resident requires . 2 person assist with all transfers (movement from one area to another) and toileting . Review of facility documentation related to a fall sustained by Resident R59 on October 30, 2017, at 10:15 a.m. revealed that the facility staff had left the resident unattended in the bathroom and the resident fell . The continued review of facility documentation revealed that the resident sustained [REDACTED]., and an abrasion under the right eye. Review of facility documentation related to the investigation of Resident R59's October 30, 2017 fall, revealed that the resident was known to fall frequently and should never be left unattended in the bathroom. The facility failed to provide adequate supervision of two residents who were confused and had prior history of falls, causing actual harm in the form of a fracture to Resident 44 and hematomas to Resident 59 because of the falls. The comprehensive MDS assessment for Resident R25, dated August 11, 2017, indicated that the resident used a wheelchair as a mobility device and required extensive assistance of two persons for transfers. The assessment also indicated that the resident was not steady with surface to surface transfers and moving on and off the toilet; that the resident could only stabilize with human assistance; and that the resident had a functional limitation in range of motion on one side of the upper and lower extremities. [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R25 fell in the bedroom on April 30, 2017. The resident received three sutures to the forehead as a result of the fall. There was no documentation to indicate that the resident centered care plan had been updated with fall prevention approaches for Resident R25's safety. On June 20, 2017, Resident R25 fell from the wheelchair and sustained a bleeding open area to the nose, upper and lower lip bruises, and a bruised left forearm. The facility documentation indicated that Resident R25 was being transported to the bathroom when the resident fell forward by trying to stand before getting to the toilet. There was no documentation to indicate that the interdisciplinary care team developed a care plan and implemented interventions to prevent further occurrences of falls for Resident R25, after the fall on June 20, 2017. Interview on November 7, 2017, at 3:30 p.m. with Employee E12, Director of Rehabilitation, who was an Occupational Therapist (a therapist who helps others with achieving and performing activities of daily living to promote health and prevent injury), revealed that with the [DIAGNOSES REDACTED]. During an interview with the Director of Nursing on November 7, 2017, at 4:00 p.m. it was confirmed that the facility failed to develop and implement fall prevention care planning after the falls on April 30, 2017 and June 20, 2017, for Resident R25, placing this resident at risk for further falls with injury. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/21/16, 5/20/16, 3/2/16 28 Pa. Code 211.11(a)(b) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited 8/30/17, 8/4/17, 10/21/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 8/30/17, 8/4/17, 4/11/17, 2/10/17, 10/21/16, 5/20/16, 11/2/15, 3/4/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 8/30/17, 8/4/17, 10/21/16, 11/2/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 8/30/17, 8/4/17, 4/11/17, 10/21/16, 5/20/16, 11/2/15, 3/4/15

Based on observation, clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to provide adequate monitoring and supervision for two of 30 residents reviewed (Residents R41 and R42) which resulted in harm to one residents (Residents R41). Findings include; Review of Resident R41's clinical record revealed physcian's orders for October 2016, that indicated [DIAGNOSES REDACTED]. An initial Minimum Data Set assessment (MDS-an assessment of resident care needs) completed on March 28, 2016, indicated that Resident R41 had a BIMS (Brief Interview for Mental Status- a brief screen that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 7 (severely cognitively impaired), and ambulated with supervision. Review of Resident 41's clinical record revealed nursing documentation on June 7, 2016, at 10:56 p.m. that reported that Resident R41 was barricaded in his/her room (a private room) using a dresser. The documentation indicated that a loud noise was heard, the dresser in the resident's room had been turned over, and the resident was observed sitting on her bed and no injury was noted. Nursing documentation for June 10, 2016, at 9:05 p.m. and again on June 13, 2016, at 4:17 a.m. stated that the resident had barricaded the doorway to his/her room with the dresser so that the staff could not enter. There was no evidence available for review at the time of the survey that the facility had developed interventions at that time to address the resident's behavior of barricading the door. A nursing entry dated for June 15, 2016, at 2:04 p.m. stated that Resident R41 had closed the door to his/her room, that he/she placed the dresser in front of the door and he/she hit at staff with his/her hand through the opening in the door. The documentation indicated that the maintenance staff were called to the unit to open the door and when the door was opened, the staff found the dresser face down on the floor. The resident was observed to be crawling across the floor. The physcian was notified and ordered to send the resident to the emergency room . The resident returned to the facility that same day at 10:30 p.m. with a [DIAGNOSES REDACTED]. The facility failed to provide adequate supervision and monitoring of this resident to ensure safety and to prevent injury resulting in actual harm to the resident. Review of Resident R42's clinical record revealed physcian's orders for October 2016, that indicated that the resident had been admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R42's significant change MDS dated [DATE], revealed that the resident had a BIMS score of 5 indicating that the resident was severely cognitively impaired. The resident required extensive assistance of two staff members for transfers, hygiene and dressing, and was frequently incontinent of bowel and bladder. A plan of care developed to address the risk of injury included the interventions developed on May 13, 2015, to provide a safe environment when the resident places his/herself on the floor and developed on May, 17, 2016, to allow the resident to, scoot around Move around on her bottom as long as she is in a safe area, if unable to redirect provide supervision. A plan of care for behaviors included interventions developed on December 6, 2012, to avoid confrontation with the resident during periods of aggressive behavior and reapproach later, remove the resident to a safe area if acting out against others and engage the assistance of co-workers or family that the resident responds well to during episodes of behaviors. On May 3, 2016, Resident R42 had sustained a large abrasion to the back from the toilet lever while sitting on the toilet. A nursing note on May 13, 2016, at 3:13 a.m. stated that Resident R42 was sitting on the floor, was yelling and disrobing, had anxiety and agitation, was pulling the mattress off of the bed, and was observed with multiple bruises of various stages to the back, sides, abdomen, knees, and a healing abrasion to the back. Review of the facility documentation for May 15, 2016, at 3:00 p.m. stated that Resident R42 was found in another resident's room sitting on the floor. The documentation noted that Resident R42 had blood on her hand and back of the head. Both sides of the resident's tongue were bruised and swollen. A 4 centimeter (approximately 2 inch) by 4 centimeter bruise was noted to the bilateral (left and right) buttocks and a 5 centimeter by 4 centimeter bruise was noted to the left flank. There was a scratch to the lower left leg, a 2 centimeter by 1 centimeter bruise to the right lower leg, a scab to the left ankle and an abrasion to the right bunion (deformity to the joint of the big toe). Resident R42 was transferred to the emergency room and received one suture to the back of the head. Nursing documentation for May 29, 2016, at 3:54 a.m. noted that Resident R42 was observed disrobing from the waist down and had sat on the bed and urinated. Later that evening the resident was observed seated on the floor, pulling the bed back and forth and pulling the linens and mattress off of the bed. On June 2, 2016, multiple large bruises were reported on the left arm and left side of body and it was noted that the resident was complaining of pain. On June 5, 2016, at 10:34 p.m. a family member reported a raised, reddened area above the right eyebrow on the resident's forehead and an area on the right cheek below the eye. The resident was unable to inform staff how the injuries happened. On August 6, 2016, at 2:59 a.m. the resident was found seated on the floor with a, CD (compact disc-plastic disc encoded with audio data) in mouth attempting to eat it, and an abrasion and swelling were noted to the forehead. On August 12, 2016, nursing documented that Resident R42 was pulling on the wardrobe closet doors (which had been secured shut) in the resident's room and pulling the stand alone closet towards her. On August 22, 2016, at 3:07 a.m. the staff noted that Resident R42 was seated on the floor, refusing to go to bed, was crying, had delusions and agitation, was scooting into the bathroom and was pulling on the power cord to the bed. A nursing note completed on September 8, 2016, indicated that Resident R42 was seated on the floor, had removed the power cord of her bed from the outlet and was found playing with the cord and with the electrical outlet. Resident behaviors were described in documentation on September 29, 2016 as delusions (belief that something is true despite contradiction by reality), anxiety, crawling out of her room, rummaging through the trash, sitting on the floor mats, refusing to get out of the bathroom and refusing to get off of the shower chair. On October 1, 2016, a nursing note at 5:23 a.m. stated that while toileting the resident, bruises to the left buttock were noted. The bruises were purple in color and measured 8.5 centimeters X (by) 7.5 centimeters and 4.2 centimeters X 2.8 centimeters. On October 2, 2016, at 12:50 a.m. the resident was sitting sideways on her bed, fell forward off the bed, hit her head on the fall mat and then refused to get back into the bed. Review of facility documention related to the above incidents identified the resident's behavior of self transfer, placing self in and out of bed, crawling on the floor and sitting on objects as contributing to the injuries. The facility failed to provide adequate monitoring and supervision to ensure the safety of a resident with behaviors. During an interview on October 20, 2016, at approximately 10:00 a.m. the Director of Nursing stated that the facility did not provide one on one care for the residents and that the facility was attempting to find alternate placement for both Resident R41 and Resident R42. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices. Previously cited 5/20/16, 3/2/16. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)Management. Previously cited 3/2/16, 11/2/15. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 11/2/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/20/16, 11/2/15, 3/4/15.

Based on a review of clinical records, observations, review of facility documentation, and interviews with facility staff, it was determined that the facility failed to provide adequate supervision, monitoring and timely assessment of a resident at risk for injury from hot liquids resulting in actual harm for one of three residents reviewed (Resident R1). A review of Resident R1's most recent Quarterly Minimum Data Set (MDS/a periodic assessment of the residents needs and status) dated May 15, 2013, identified the resident as having severely impaired decision making capabilities and requiring extensive assistance of one staff member while eating and drinking. A review of Resident R1's updated Care Plan dated May 21, 2013 revealed that the resident was at risk for injury do to her confusion, anxiety and [DIAGNOSES REDACTED]. A review of Resident R1's physician orders [REDACTED]. A review of Resident R1's Nursing Note, dated June 3, 2013, at 6:30 p.m. revealed that the licensed nurse was called to the resident's room by a nursing assistant who was undressing Resident R1 and observed multiple intact blisters and an open blister to the resident's right hip and groin areas. A review of the Medical Director's progress note dated June 4, 2013 at 9:50 a.m. revealed that he was asked to see the resident do to having soiled clothing with coffee colored liquids and per staff, it smelled like coffee, while changing her clothing the night before. The Medical Director identified Resident R1's right hip and proximal (nearest the middle of the body) thigh with redness and blistering, measuring 12 x 5 centimeters (cm.-2.5 equal 1 inch). The right proximal/anterior thigh with blisters measuring 12 x 3 cm. with another area above that one measuring 6 x 1.5 cm. A subsequent physician note by Resident R1's primary later on June 4, 2013, identified these burns as second degree burns (also known as partial thickness burns- involving the epidermis and part of the dermis layer of skin-first two layers of the skin). A review of the facility's investigation on June 12, 2013, revealed that the Director of Nursing was notified on June 3, 2013, at approximately 7:30 p.m. that Resident R1 was found to have what appeared to be coffee spilled on her lap, a coffee cup in her wheelchair and that Resident R1 does not get coffee on her food tray. Staff present during the evening meal of June 3, 2013, were interviewed. Employee E7 (nursing assistant) stated that while attempting to feed Resident R1 at approximately 6:15 p.m., the resident stated "It's burning" and Employee E7 stated that she took that as the resident having to go to the bathroom. Employee E8 (nursing assistant), who also attempted to feed Resident R1, stated that the resident complained of burning, but often uses that term when constipated. A statement from Employee E9,(nursing assistant) stated that while undressing Resident R1 she noticed the wet pants, smell of coffee and empty coffee cup in Resident R1's wheel chair as well as redness and blisters on Resident R1's right hip and groin area. Observations of Resident R1's right hip and groin areas with Employees E3 & E10, both licensed nurses, revealed several blistered areas remaining. A review of the last wound note, dated June 10, 2013, by Employee E10 identified these areas, the right outer hip was with two areas measuring 9 x 6 cms. & 4 X 3 cms. round with yellow slough (a layer of dead tissue), and moderate drainage. The right inner thigh was approximately 6 x 18cms. with a center area also cover with slough and drainage. The facility failed to provide adequate supervision and monitoring and timely assessment of a resident at risk for injury from hot liquids resulting in actual harm to the resident. 28 Pa. Code: 201.18(a)(1) Management. 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 Pa. Code: 211:12(d)(5) Nursing services.