Every finding on record at Stoneridge Poplar Run

Based on clinical record review and staff interview it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of three sampled residents. (Residents 1, 2)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included metabolic encephalopathy, dementia, and depression. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated January 29, 2026, noted that Resident 1's dementia diagnosis, delirium, and behavioral symptoms were to be addressed in the care plan. Review of the nurses' notes dated July 3, 6, 12, 16, 17, 20, 24, and 26, 2026, revealed that Resident 2 displayed restlessness, agitation, and exit seeking behaviors. The resident was redirected with a baby doll, taken outside accompanied by staff, and administered as needed anti-anxiety medication (lorazepam). In addition, a review of the elopement (unauthorized departure from the facility) assessment dated [DATE], revealed that the resident wandered and was at risk for elopement. A physician's order dated April 28, 2026, instructed staff to apply an alert bracelet to the resident. There was no documented evidence that the facility included interventions on the care plan to monitor the resident's exit seeking behavior and the use of this device. There was no documented evidence that dementia, delirium, behavioral symptoms, or exit seeking behaviors were care planned for Resident 1. Clinical record review revealed that Resident 2 had diagnosis that included dementia. The MDS CAA summary dated November 14, 2025, noted that Resident 2's dementia diagnosis and behavioral symptoms were to be addressed in the care plan. Review of nurses' notes dated July 7, 16, 17, 21, and 22, 2026, revealed that Resident 2 displayed agitation and having conversations with herself on a nonworking telephone. There was no documented evidence that dementia or behavioral symptoms were care planned for Resident 2.In an interview on July 27, 2026, at 12:44 p.m., the Administrator confirmed there was no documented evidence that the care plans addressed Resident 1's dementia diagnosis, delirium, behavioral symptoms, and exit seeking behavior and Resident 2's dementia diagnosis and behavioral symptoms. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined the facility failed to store food in a sanitary manner on one of two nursing units. (Health Care 1)Findings include:Review of the facility policy entitled, Use and Storage of Food Brought in by Family or Visitors, dated July 24, 2025, revealed that nursing staff were to label and date the resident food items that required refrigeration. Observation on Health Care 1 in the resident pantry on November 13, 2025, at 2:15 p.m., revealed a sign on the refrigerator that indicated it was for resident food only, items should be dated and labeled with the resident's name, and would be discarded within three days if not consumed. In the freezer, there were two opened containers of ice cream and two opened boxes of ice cream popsicles that were not dated or labeled with a resident name. In the refrigerator, there were three juice boxes, one Boost drink and a six-pack of soda that were not labeled with resident names. There was a plastic zip-lock bag that contained cookies on top of another container, neither were dated or labeled with a resident name. There was one opened bottle of orange drink dated October 19, a container of pink grapefruit that was not dated, and a container of spaghetti that was not labeled with a resident name. There were two boxes of candy that were not dated. There were two opened containers of lemonade that were not labeled or dated.In an interview on November 14, 2025, at 12:20 p.m., the Administrator confirmed the refrigerator is for resident food only and that staff were to date and label the items with the resident's name.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 14 sampled residents. (Resident 7)Findings include:Clinical record review revealed that Resident 7 had diagnoses including Parkinson's disease, dementia, dysphagia following cerebral infarction (stroke), moderate protein-calorie malnutrition, and gastro-esophageal reflux disease with esophagitis without bleeding. On September 12, 2025, a physician ordered for staff to provide a regular, mechanical soft diet. Review of the MDS assessment dated , August 15, 2025, revealed that the resident received nutrition through a tube feed. There was no documented evidence that Resident 7 received nutrition through a tube feed. In an interview on November 14, 2025, at 12:20 p.m., the Administrator confirmed that the MDS assessment did not accurately reflect the nutrition status of Resident 7.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a Minimum Data Set assessment for a significant change in condition was completed for one of 14 sampled residents. (Resident 2) Findings include:Clinical record review revealed that Resident 2 experienced a decline in overall status and hospice services began on October 17, 2025. There was no Minimum Data Set (MDS) assessment completed to reflect the significant change in the resident's condition. In an interview on November 14, 2025, at 10:29 a.m., the Administrator confirmed that a significant change MDS assessment was not completed upon a change in the resident's condition.

Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that all the required committee members attended quarterly Quality Assurance and Performance Improvement (QAPI) meetings for three of four quarters of meetings reviewed.Findings include: Review of facility's QAPI sign-in sheets and attendance records for meetings held in the fourth quarter of 2024 revealed that the facility's Infection Preventionist and Medical Director failed to attend.Review of the facility's QAPI sign-in sheets and attendance records for the first three quarters of 2025 revealed the facility's Medical Director failed to attend meetings held during the second and third quarters of 2025. During an interview on November 12, 2025, at 12:10 p.m., the Administrator confirmed that the facility failed to ensure that all the required committee members attended QAPI meetings at least quarterly.28 Pa Code: 201.18(e)(1)(2)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed rate during a hospitalization) and notice of transfers out of the facility to the State Long-Term Care Ombudsman and to the resident, family member, or legal representative for four of four sampled residents who were transferred to a hospital. (Residents 3, 11, 14, and 20)Clinical record review revealed that Resident 3 was transferred to the hospital on July 18, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding facility's bed hold policy or the transfer to the hospital and that the facility notified the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 11 was transferred to the hospital on December 9, 2024, and October 6, 2025, after changes in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the facility's bed hold policy or transfers to the hospital and that the facility sent copies of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 14 was transferred to the hospital on January 31, 2025, and February 11, 2025, after changes in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the facility's bed hold policy or transfers to the hospital and that the facility notified the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 20 was transferred to the hospital on September 26, 2025, and October 25, 2025, after changes in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the facility's bed hold policy or transfers to the hospital and that the facility notified the Office of the State Long-Term Care Ombudsman.In an interview on November 13, 2025, at 2:36 p.m., the Administrator confirmed no transfer and bed-hold notices were provided to the residents or representatives in the cases listed above.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the skilled unit kitchen and the main kitchen of the dietary department. Findings include: Review of the facility's policy entitled, Food Storage, dated August 13, 2024, revealed that when a food item was opened, a use-by date must be noted on the item and the food was to be discarded after this date. Observations during the tour of the skilled unit kitchen on October 1, 2024, at 9:50 a.m., revealed the following: The ice machine had a white substance on the outside of the lid. Inside the ice machine there was a dark substance along the front of the plastic ice shield. The can opener had a black dried substance on the blade. There was a hair on the can opener. Observations during the tour of the main kitchen on October 1, 2024, at 10:15 a.m., revealed the following: In Walk-In Cooler 1 there was an opened package of lunch meat with a use-by date of September 28, 2024, and an opened container of mozzarella cheese with a use-by date of August 31, 2024. In Walk-In Cooler 2, there were two large pans of bread stuffing, two opened containers of sliced turkey, an opened package of unsliced turkey and a pan of pureed sausage that were not dated. In an interview on October 1, 2024, at 10:30 a.m., the Executive Chef confirmed these items were for the Skilled Unit, and should have been dated, and were not. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 14 sampled residents. (Residents 17, 18) Findings include: Clinical record review revealed that Resident 17 was admitted to the facility on [DATE], and had diagnoses that included dementia and a lumbar spine compression fracture. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident received daily scheduled pain medication. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated April 19, 2024, noted that the resident's pain was to be addressed in the care plan. There was no evidence that interventions to address Resident 17's pain were included in the current care plan. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], and had diagnoses that included cognitive communication deficits and anxiety. The MDS assessment dated [DATE], noted that the resident had impaired cognition. The MDS CAA summary dated May 11, 2024, noted that the resident's cognitive loss and dementia were to be addressed in the care plan. There was no evidence that interventions to address Resident 18's cognitive loss and dementia were included in the current care plan. In an interview on October 3, 2024, at 11:05 a.m., the Nursing Home Administrator confirmed the above care areas were not addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of three sampled residents who were transferred to the hospital. (Resident 14, 18, 24) Findings include: Clinical record review revealed that Resident 14 was transferred to the hospital on September 21, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 18 was transferred to the hospital on May 24, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 24 was transferred to the hospital on April 27, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. In an interview on October 3, 2024, at 11:20 a.m., the Administrator confirmed that the residents or resident representatives were not given written notices regarding their transfers.

Based on facility policy review, documentation review, and staff interview, it was determined that the facility failed to ensure that all required staff persons attended Quality Assurance and Performance Improvement (QAPI) Committee meetings on a quarterly basis. Findings include: A review of the facility's QAPI Plan, last reviewed on November 2, 2023, revealed the Quality Assessment and Assurance (QA&A) Committee was responsible for meeting, at minimum, on a quarterly basis, and was to include the Medical Director (MD) and the Infection Prevention and Control (IPC) Officer. A review of QAPI Committee meeting sign-in sheets for April through August 2024, revealed that the Medical Director was last present in April 2024, and the Infection Preventionist was last present in May 2024. In an interview on October 3, 2024, at 12:40 p.m., the Nursing Home Administrator confirmed that the MD and IPC did not attend the minimum required meetings from April through August, 2024. 28 Pa. Code 201.18(e)(1)(3) Management.

Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to provide adequate supervision in order to prevent an elopement for one of two sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Elopements and Wandering Residents, dated May 24, 2023, revealed that the facility was to identify residents with potential and/or actual risk factors for elopement to protect the resident through development and implementation of safety interventions. Elopement occurs when a resident leaves the premises or safe area without authorization and/or the necessary supervision to do so. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included anxiety, cerebrovascular disease, dementia, and depressive disorder. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was independent with walking in the corridor with a walker. On November 27, 2023, at 10:26 p.m., a nurse noted that the resident was attempting to leave the unit. On December 23, 2023, at 9:07 p.m., the nurse noted that the resident had put her coat on and told staff she was going for a walk. She was observed attempting to open the B hall exit door. Resident 1 then walked down the hall towards her room and attempted to open the doors at the end of the hallway. On January 6, 2024, at 2:55 p.m., the resident ambulated with her walker from the common area to the end of C hall, pushed the fire exit door open, and exited the building. Documentation revealed that staff from the personal care unit observed the resident dressed in a coat and sneakers with her walker attempting to get back into the building. Staff from the skilled nursing unit was notified and brought the resident back inside the building. In an interview on January 12, 2024, at 1:45 p.m., the Assistant Nursing Home Administrator stated that Resident 1 pushed the fire exit door bar and eloped from the facility without staff knowledge. The facility failed to ensure adequate supervision for a resident who had exhibited exit-seeking behaviors. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for two of 12 sampled residents. (Residents 7, 16) Findings include: Review of the facility policy entitled, Incontinence - Assessment and Management, last reviewed August 14, 2023, revealed that facility staff was to complete a urinary incontinence assessment upon admission and whenever there was a change in a resident's urinary tract function. Staff would complete a quarterly screening and if there was a change in incontinence staff would implement a seven day toileting diary to determine a resident's voiding pattern for assistance in decision making and development of a toileting program. The type of urinary incontinence was to be identified in the care plan with specific interventions. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included parkinsonism and depression. A Bowel and Bladder Program Screener was completed on April 30, 2023, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated July 18, 2023, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Review of the current care plan revealed that Resident 7's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. Review of the MDS assessment, dated October 12, 2023, indicated that Resident 7 was incontinent of urine and was not on a scheduled toileting program. There was no documentation in the clinical record to support that the resident's urinary incontinence was assessed by the facility upon admission and upon a change in Resident 7's incontinence to determine if normal bladder function could be restored. There was no documented evidence that a seven day toileting diary was completed upon identification of a change in Resident 7's incontinence status or that a scheduled toileting program had been implemented. Clinical record review revealed that Resident 16 was admitted to the facility with diagnoses that included congestive heart failure and depression. A Bowel and Bladder Program Screener was completed on October 5, 2023, and indicated that the resident was a candidate for a scheduled toileting program. According to the MDS assessment, dated October 12, 2023, the resident needed assistance from staff for toileting, was frequently incontinent of urine, and was not on a toileting program. Review of the current care plan revealed that Resident 16's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. In an interview on November 8, 2023, at 12:45 p.m., the Assistant Nursing Home Administrator confirmed that there was no documented evidence that Resident 7's urinary incontinence had been assessed per facility policy or that toileting programs were implemented for Residents 7 and 16. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide housekeeping services to maintain a clean environment in resident rooms and common areas of the nursing unit. Findings include: Observations during environmental tour of the nursing unit on April 26, 2022, at 2:00 p.m., revealed the following: Resident room 135 had small pieces of debris and a sticky spot on the floor. There was a layer of dust under bed B. These conditions were still present when observed on April 27, 2022, at 12:15 p.m. Resident room 147 had small pieces of debris on the floor. There were food crumbs, dust and two napkins under bed A. These conditions were still present when observed on April 27, 2022, at 12:46 p.m. Observations during an environmental tour of the nursing unit on April 27, 2022, from 12:30 to 12:55 p.m., revealed the following: Resident room 132 had a layer of dust, debris, and three crumpled tissues under bed A. Resident room 134 had a layer of dust, debris, small pieces of paper, and three salt packets under bed B. Resident room 136 had small pieces of debris and three disposable plastic cups under bed B. Resident room 145 had a layer of dust and small pieces of debris under beds A and B. Resident room 151 had pieces of debris on the floor. There was a layer of dust, debris, and two oat circle cereal pieces under bed A. There were paper pieces and dust under bed B. The resident activities room area was observed with a coating of dirt and small pieces of debris, such as paper, on the floor along the mouldings. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to immediately, but not later than two hours, report an allegation of resident abuse to the Administrator and other officials, including the State Survey Agency, for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Policy, dated July 9, 2021, revealed that sexual abuse included, but was not limited to, sexual harassment, sexual coercion, sexual assault, and non-consensual sexual contact of any type with a resident. Policy directed that allegations were to be immediately reported to the Administrator and Director of Nursing and that the Department of Health, Area Agency on Aging, police department (if warranted by circumstances), and Department of Aging were to be notified. Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance for activities of daily living. Documentation by the social worker on April 22, 2022, revealed that the resident's family member alleged a staff member had been inappropriate during morning care. Further documentation on a grievance report of the same date indicated that the staff member had touched the resident's breast. It was noted that the social worker met with the resident who stated that the staff member had touched her breast during care. There was a lack of documentation to support that the Administrator, the State Survey Agency, and other officials had been immediately notified within two hours of the allegation of abuse. During an interview on April 26, 2022, at 10:00 a.m., the Administrator confirmed that he was not notified of the April 22, 2022, allegation of abuse until April 25, 2022, and that the State Survey Agency and other officials had not been notified. The facility processed the report as a grievance instead of an allegation of abuse since the accused was not assigned to that resident and during the interview with the resident she stated the incident happened during the provision of care. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 211.10(d) Resident care policies.

Based on observation, review of facility policy and staff interview, it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. (Main Kitchen and Skilled Nursing Kitchen) Findings include: Review of the facility policy entitled, Sanitation and Infection Control, Receiving and Storage, reviewed July 9, 2021, revealed that products in storage were to be labeled with the date on delivery and once the product was opened the package was to be labeled with an opened and discard date. Further, dry bowlpack cereal and bottled juices were to be discarded after the use by date on the package and packaged dry goods, such as pasta and rice, were to be used within 12 months of receipt of product. In addition, frozen meats such as pork products were to be used within 3 months of receipt of the product. Observation during the initial tour of the main kitchen on January 4, 2022, at 11:00 a.m., revealed an opened, undated box of Quaker creamy wheat and frosted walnuts in the dry storage room. Additionally there were two packages of burger buns with a best by date of December 30, 2021, nine bottles of fish sauce, best by June 30, 2021, one bottle of Sri Racha hot chili sauce best by August 2021, and 13 bottles of Tropicana fruit juice with an expiration date of December 5, 2021. There was eight packages of Thai Rice stick noodles received December 12, 2019, with no expiration date on the container. There was a package of Uncle Ben's classic corn bread with no expiration date and the received sticker had no date. Observation of the freezer revealed a package of [NAME] bangers (pork) with a shipped date of March 14, 2021, and no received date. In the skilled nursing kitchen there were 17 bowlpack size Rice Krispies with a best by date of October 14, 2021. Review of the facility's oven cleaning schedule for 2021, revealed that the left and right ovens in the main kitchen were to be cleaned monthly and as needed with a degreaser. Observation in the main kitchen revealed both the oven walls and outside of the doors and oven racks had grease buildup and debris. Observations of the skilled nursing kitchen revealed the exhaust fans over the stove were dirty and had dusty buildup. The ceiling tile above the food preparation table was covered in a black substance. In an interview on January 4, 2022, at 11:20 a.m., the Chef Manager confirmed that all opened food items were to be dated prior to storage. In an interview on January 4, 2022, at 11:45 a.m., the Dietitian confirmed that the skilled nursing kitchen exhaust fans were last cleaned on May 10, 2021. 28 Pa.Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to report a change in condition and accurately assess a resident's weight to ensure that residents maintained acceptable parameters of nutritional status for two of 15 sampled residents. (Residents 2, 32) Findings include: Review of the facility's policy entitled Weight Policy, last reviewed July 9, 2021, revealed that residents would be weighed monthly by the 10th of the month. If a significant weight loss or gain was confirmed, the following would occur: dietary would be notified, the physician would be informed, the responsible party/family would be notified, and the RNAC would be notified. Clinical record review revealed that Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required supervision for eating. Review of the current care plan identified the resident was at nutritional risk due to decreased meal intakes. Review of the resident's weight record revealed that he had a weight loss of 21.8 pounds between August 17, 2021 and December 15, 2021, representing a significant weight loss of 10.91% in a four month period of time. There was no documented evidence that the resident's responsible party was notified of the significant weight loss. In an interview on January 6, 2022, at 3:29 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident 2's responsible party was notified of the significant weight loss as per facility policy. Clinical record review revealed that Resident 32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated December 14, 2021, revealed the resident required supervision with eating. Review of the current care plan revealed an intervention for the resident to be weighed monthly per schedule. Review of the resident's weight record revealed that the resident's last documented weight was on November 2, 2021. There was no documented evidence that the resident was weighed monthly per facility policy and resident care plan in December 2021. In an interview on January 6, 2022, at 3:29 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident 32 was weighed monthly in accordance with the resident's care plan and facility policy. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity to two of 15 sampled residents. (Residents 26, 32) Findings include: Clinical record review revealed that Resident 26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 4, 2022, from 12:16 p.m. until 12:32 p.m., Nurse Aide (NA) 1 was observed standing to assist Resident 26 with her lunch. Clinical record review revealed that Resident 32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated December 14, 2021, revealed that the resident required supervision with eating. On January 4, 2022, from 12:27 p.m. until 12:58 p.m., Registered Nurse (RN) 1 was observed standing to assist the resident with her lunch. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to provide adequate supervision for a resident who exhibited behaviors, in order to prevent accidents for one of six sampled residents with behaviors. (Resident 11) In addition, the facility failed to provide adequate supervision and assistive devices, non-skid footwear, in order to prevent falls for one of eight sampled residents who were at risk for falls. (Resident 11) Findings include: Clinical record review revealed that Resident 11 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, exhibited both physical behavior and wandering behavior, and utilized a walker. Current physician orders [REDACTED]. Review of the current care plan identified the resident had impaired decision making and delusional behavior due to [MEDICAL CONDITION] and was at risk for falls due to not using the walker consistently and wandering. An intervention to help prevent falls was for the staff to provide the resident with appropriate foot wear. The care plan also identified the resident as wandering in the hallways and in and out of other resident rooms with increased agitation at times. Review of nursing documentation revealed that on November 7, 2020, at 10:53 a.m., the resident was restless and frequently walking without her walker in the hallway and going into other resident rooms. A nurse noted on November 16, 2020, at 8:15 a.m., that the resident had increased wandering behaviors and was exit seeking down the D wing hallway (the D wing was opposite of the A wing in which the resident resided). A nurse noted on November 29, 2020, at 10:57 a.m., that the resident was alert but confused, wandering down hallways without her walker and she attempted to remove cups and hand sanitizer from the medication cart and required re-direction. A nurse noted in a late entry note on November 29, 2020, that the resident had been walking and roaming into other resident's rooms. Resident 11 was found in the kitchen on the skilled unit, eating lettuce and butter that was on the counter. In an interview on January 21, 2021, at 12:19 p.m., the Director of Nursing stated that Resident 11 had been found on November 29, 2020, in the satellite kitchen between 4:00 and 4:30 p.m The door to the satellite kitchen was unlocked which allowed the resident to enter the area unknown to staff. A nurse noted on December 1, 2020, at 2:40 p.m., that Resident 11 had increased wandering today and was very hard to re-direct. On December 15, 2020, at 10:39 p.m., a nurse noted that the resident continued to wander into other resident rooms this shift, had increased restlessness and was very hard to re-direct. On December 17, 2020, at 1:38 p.m., the resident was noted as restless this morning, walking without her walker and frequently moving wheelchair and lifts in the hallway. The resident was also pushing her table in the hallway, walking barefoot and ripping up the styrofoam dishware into pieces that her food had been served in. Resident 11 was noted as walking into other resident rooms and not easily re-directed. On December 20, 2020, at 3:51 p.m., a nurse noted that she was seen walking down the D hall attempting to exit near the rear doors. On December 29, 2020, a nurse noted that at 4:00 p.m., the resident was ambulating on the skilled unit without her walker. Resident 11 attempted to sit down on the trash can attached to the treatment cart and when she did so, the trash can broke off the cart and the resident fell to the floor. The resident was noted hitting her head on the side of the treatment cart. In addition, on December 29, 2020, at 2:28 p.m., a nurse noted that the resident's wandering was becoming more difficult to re-direct and at one point she removed the dresser from her room into room [ROOM NUMBER] (which was across the hall from her room). A nurse noted on December 31, 2020, that Resident 11 had increased behaviors and decreased ability to be re-directed today. This morning around 10:00 a.m., the resident was noted to be sitting over by the windows in the dining room. A staff member noted that the resident's voice was garbled and she found that the resident had eaten an unknown plant as well as the potting soil. The resident's cheeks and mouth were full of soil. Review of an incident report dated December 31, 2020, revealed that due to this incident, the Director of Nursing placed the resident on 15 minute checks for safety reasons. On the same day, December 31, 2020, at 11:30 a.m., a staff member found Resident 11' s' walker unattended. Resident 11 was found on the floor in the bathroom across the hall from her own room in the dark with the lights turned off and the door shut. The nursing documentation indicated that the shoes were not non-skid and were slick on the floors. The facility failed to provide adequate supervision for a resident who repeatedly wandered and exhibited behaviors in order to prevent accidents. In addition, the facility failed to provide adequate supervision and failed to implement assessed safety interventions, (non-skid foot wear), in order to prevent falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, review of manufacturer instructions and staff interview, it was determined that the facility failed to maintain medication storage according to manufacturer's instructions in one of one medication storage rooms and two of two medications carts. (A and B wing medication cart and C and D wing medication cart) Findings include: Review of the facility policy's policy entitled Medications Administration and Storage of Medications, last reviewed [DATE], revealed that all drugs were to be administered and stored in compliance with state and federal regulations. Medications were to be administered from containers labeled with an expiration date when applicable. Observation on [DATE], at 10:00 a.m., of the A and B wing medication carts at 10:00 a.m., revealed two [MEDICATION NAME] (insulin) pens solutions that were opened with no identified open date and no expiration date. Observation of the C and D wing medication cart on [DATE], at 10:20 a.m., revealed three [MEDICATION NAME] pens solution with no identifed open date and no expiration date. The manufacturer's instructions recommended that once the medication was open for 28 days the medication was to be discarded. Observation of the medication storage room on [DATE], at 9:40 a.m., revealed there was one open bottle of multi-dose [MEDICATION NAME] solution with no identified open or expiration date. The manufacturer's instructions recommend once the medication was open for 30 days, the medications were to be discarded. In an interview, on [DATE], at 9:40 a.m., the Director of Nursing stated that the staff was to label all medications with open and expiration dates and all expired medication was to be removed from the medication cart and the medication storage room. 28 Pa. Code 211.9(h)(i) Pharmacy services. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on clinical record review and incident report review, it was determined that the facility failed to monitor and assess the effectiveness of a safety intervention for one of six sampled residents at risk for falls. (Resident R48) Findings include: Clinical record review revealed that Resident R48 had [DIAGNOSES REDACTED]. The ongoing care plan identified that the resident had the potential for falls with an intervention that directed staff to apply an alarm on the resident while in bed that would alert staff when the resident attempted to rise out of bed. On January 1, January 5, January 10, January 22, January 24, March 8, and April 8, 2017, the resident had unwitnessed falls from bed and the alarm did not sound. Review of the incident reports revealed that there was a lack of documentation to support that the staff thoroughly investigated the circumstances of the fall, including the status of the alarm and why it did not function. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/25/16