Every finding on record at Suburban Woods Health & Reha

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that residents were afforded privacy related to the use of a telephone and medical assessment for two of 23 residents. (Resident R8 and Resident 82) Findings include: A review of the facility policy titled Resident's Rights and Facility Responsibilities Policy. last revised 09/30/2020 revealed, It is facility's policy to comply with all resident's rights, and to communicate these rights to residents and their designated representatives in a language that they can understand. Review of Resident R82's annual Minimum Data Set (MDS - a periodic assessment of care needs) dated March 4, 2026, revealed a Brief Interview for Mental Status (BIMS) of 3 which indicated that the resident cognition was severely impaired. On March 16, 2026, at 10:45 a.m., an observation was made of Resident R82 sitting in the dining room with approximately 15 residents, two staff members, and two otolaryngology consulting staff present, who were providing Ear, Nose, and Throat (ENT) evaluations to residents. Resident R82 received an evaluation in the dining room without privacy. It was observed that the otolaryngologist, Employee E4, approached Resident R82 and examined his/her ear and throat. On March 16, 2026, at 10:48 a.m., an observation was made with the Unit Manager, Employee E3, of the otolaryngologist, Employee E4, performing assessments in the dining room. Upon validation, the Unit Manager, Employee E3, contacted Employee E4 and notified them of the concern, after which Employee E4 ceased conducting assessments in the dining room. Review of Resident R8's annual Minimum Data Set (MDS - a periodic assessment of care needs) dated February 20, 2026, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. On March 16, 2026, at 11:15 a.m., an observation was made of Resident R8 making a personal phone call using the dining room telephone on speakerphone. There were approximately 15 residents, two staff members, and two otolaryngology consulting staff present which did not afford privacy during a phone conversation. After Resident R8 finished the call, an interview was conducted. Resident R8 reported that she/he does not have access to private conversations because the telephone only has a speakerphone function. Resident R8 does not have a cell phone and does not have a telephone in her/his room. Resident R8 stated that the facility had previously provided a working phone line; however, it became broken and was never replaced. As a result, the entire conversation between Resident R8 and her family member was audible to others due to the phone only having a speakerphone function available. On March 16, 2026, at 11:26 a.m., an observation was made with the Unit Manager, Employee E3, who confirmed that the telephone in the dining room does not have a ringtone and only has a speakerphone function available. Additionally, it was validated with Resident R8 that there was no phone line available in Resident R8's room. Maintenance was contacted to repair the dining room telephone and to provide a functional telephone in Resident R8's room. On March 17, 2026, at 10:45 a.m., a Resident Council meeting was held with five alert and oriented residents (R11, R53, R65, R68, and R98). The residents reported that licensed nurses administer medications wherever they can catch you, including in hallways and the dining room. The residents also reported that they received dental screenings in the hallways. 28 Pa. Code 201.29(a) Resident Rights.

Based on staff interviews, review of clinical records, and facility documentation and policy, it was determined that the facility failed to ensure an investigation related to a resident's fall was complete and thoroughly investigated to rule out neglect for one 24 resident records reviewed (Resident R6). Findings include: Review of the facility's Fall Prevention and Management policy updated in February 2025, stated, Falls will be reviewed such review should include results of the new fall risk assessment, discussion with resident and/or any witnessing partied as to potential causal factors, review of the environment where the fall occurred and discussion as to any new interventions which may help to prevent further falls. Resident R6's clinical records revealed the resident was alert and oriented, admitted to the facility on [DATE], with chronic compression fracture (small breaks in your spine) recently hospitalized for weakness. The resident was care planned for incontinent of bowel and bladder needing one person to assist with toileting and a fall risk, that included, keeping the resident's bed in the lowest position and using proper footwear for safety. Review of Resident R6's progress notes indicated the resident had an unwitnessed fall and was found lying on the floor in the resident's room on December 20, 2025. Interview with the resident's daughter on March 17, 2026, at 10:20 a.m. stated that the resident would never get out of bed without calling for help. The resident told the daughter the resident put the call bell on and when no one came the resident attempted to get out of bed herself and fell on a wet floor. Interview with the resident immediately afterwards confirmed the daughter's allegations. Review of the facility's investigation revealed a witness statement was not obtained from the alert and oriented resident, instead a quote that indicated the resident stated, I was trying to get up and that the resident's undergarment was wet when found. In addition, the facility's investigation failed to include the environmental conditions when the fall occurred as a potential causal factor in the investigation. Interview with the Director of Nursing on March 19, 2026, at 10:00 a.m. confirmed the investigation was incomplete and agreed Resident R6 does use the call bell for assistants. 28 Pa Code 211.12(c) Nursing services28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of three residents observed during medication administration (R13, R124).Findings include: On March 17, 2026, at 9:51 a.m., observed that Employee E5, a Licensed Nurse, administered the medicine, Aspirin Tablet Chewable 81 milligrams (MG), to Resident R13. Review of physician order dated May 15, 2026, for R13, revealed an order to administer Aspirin Tablet Delayed Release 81 MG, by mouth one time a day. This represents administration of the incorrect medication formulation. March 17, 2026, at 9:53 a.m., review of Physician order revealed that R13 was signed onto hospice services with a hospice service provider, with a diagnosis of End Stage PVD ( PVD stands for Peripheral Vascular Disease; End-stage Peripheral Vascular Disease is the most severe form of PVD, where blood flow to the limbs is critically reduced, causing pain at rest, non-healing wounds, or tissue damage (gangrene), and care is focused on comfort rather than cure). On March 17, 2026, at 9:51 a.m., observed that Employee E5, a Licensed Nurse, administered the medicine, Tamsulosin 0.4 mg, by mouth to Resident R13. Review of physician order dated May 15, 2026, for R13, revealed an order to administer Tamsulosin 0.4 mg, one Capsule, by mouth, in the evening for Elevated PVR. This represents incorrect medication administration. (PVR stands for Post-Void Residual, which refers to the amount of urine left in the bladder after a person has finished urinating. It's commonly measured to assess how well the bladder is emptying).Review of literature revealed as follows: Physicians usually prescribe Tamsulosin in the evening to reduce side effects and improve nighttime comfort. It can cause dizziness or a drop in blood pressure, so taking it at night helps you rest during these effects. It also relaxes the bladder to reduce nighttime urination (nocturia), improving sleep. Taking it after dinner ensures proper absorption and aligns its peak effect with sleep, while lowering the risk of daytime dizziness. At the time of the observation, interview with Employee E5 confirmed the above findings. On March 18, 2026, at 9:38 a.m., observed that Employee E6, a Registered Nurse, administered the medicine, Vitamin B-12, tablet by mouth to Resident R124, and R124 swallowed it. Review of physician order dated March 11, 2026, for R124, revealed an order to administer Cyanocobalamin (Vitamin B-12), 1000 mcg, tablet, sublingual. This represents incorrect medication administration. Review of literature revealed that Sublingual Vitamin B12 is used to bypass digestive barriers and low stomach acid, providing a fast, needle-free alternative to injections for better absorption. At the time of the observation, interview with Employee E6 confirmed the above findings.The facility incurred a medication error rate of 10.71%. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on interviews and review of resident records, it was determined that the facility failed to promptly notify physician of a change in residents' condition when radiology report confirmed positive for fracture for one of 23 records reviewed (Resident R6). Findings include: Resident R6's clinical records revealed the resident was alert and oriented, admitted to the facility on [DATE], with chronic compression fracture (small breaks in your spine) and recently hospitalized for weakness. The resident was care planned for incontinent of bowel and bladder needing one person to assist with toileting and a fall risk, that included, keeping the resident's bed in the lowest position and using proper footwear for safety. Review of Resident R6's nursing notes indicated the resident had an unwitnessed fall and was found lying on the floor in the resident's room on December 20, 2025 at 8:00 a.m. An order was received from on-call doctor to obtain an x-ray of 2 views of the resident's right Femur. (thigh bone) Review of Resident R6's x-ray results dated December 20, 2026, indicated a right femoral neck fracture (hip fracture). Further review of Resident R6's progress notes indicated the resident was transferred to the hospital on December 23, 2026, due to the resident's hip fracture. Interview with the Director of Nursing on March 16, 2026, at 1:30 p.m. indicated nursing failed to inform the physician of the resident's fracture until December 23, 2026. 28 Pa Code 211.12(c) Nursing services28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medication administration times were following according to physician order for three of three residents reviewed. (Resident R1, Resident R2, Resident R3)Findings include: Review of an undated facility policy, Administration of Medication, under section 6.1 Medication Administration Times, revealed Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed no later than sixty (60) minutes after designated times of administration. Further review revealed Facility should administer medications ordered before meals approximately thirty (30) minutes before mealtimes and should administer medications ordered to be given after meals no later than thirty (30) minutes after a meal has ended. Review of facility meal delivery schedule revealed the following times for all nursing units, Breakfast delivery between 07:35a.m. - 8:25a.m.; Lunch delivery between 11:45a.m. - 12:35p.m.; Dinner Delivery between 4:30p.m. - 6:35p.m. Note: All times are approximate within 10 minutes. Interview with Employee E3, Food Director, on January 22, 2026 at 12:45p.m. revealed no concerns regarding late delivery of food trucks to units, Usually we deliver on time. Interview with Employee E1, Nursing Home Administrator on January 22, 2026 at 1:25p.m. revealed no concerns regarding late delivery of food trucks to units. Confirmed that food trucks are normally delivered on time. No documented evidence of delivery times. Review of Resident R1's clinical record revealed admission date to the facility of November 14, 2025, with diagnosis of Type 2 diabetes. Review of Resident R1's clinical record revealed BIMS (Brief Interview for Mental Statue) score of 15, indicating cognitively intact. Interview with Resident R1 on January 22, 2025 at 10:29 a.m. revealed that medications are late often. Review of Resident R1 MAR (Medication Administration record) dated December 22, 2025 through December 31, 2025 revealed the following: December 22, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 8:40 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 9:21 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 08:00a.m.- 10:00a.m.; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 10:39a.m. Documentation notes late Administration: Charted late. Comment: admin. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 8:18 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 5:00p.m.- 7:00p.m; Carvedilol tablet 12.5mg; give 1 tablet by mouth twice a day for hypertension . Administered at 9:02 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. December 22, 2025- Ordered schedule time 9:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:21p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 23, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 09:12 a.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 24, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 09:14 a.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 24, 2025- Ordered schedule time 11:30 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 1:32p.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 25, 2025- Ordered schedule time 8:00 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:42 a.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 25, 2025- Ordered schedule time 11:30 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 2:05 p.m. Documentation notes late administration: charted late. Comment: admin. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:30a.m. Documentation notes late administration: charted late Comment: admin. No documented evidence of reason or physician notification. December 26, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:20p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 27, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:39a.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 11:30a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 2:19p.m. Documentation notes late administration: charted late. Comment: Admin. No documented evidence of reason or physician notification. December 28, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:02p.m. Documentation notes late administration: charted late. No documented evidence of reason or physician notification. December 29, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 10:12a.m. Documentation notes late administration: charted late. Comment: g. No documented evidence of reason or physician notification. December 30, 2025- Ordered schedule time 8:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 9:55 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. December 31, 2025- Ordered schedule time 11:30a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 1:26p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. December 31, 2025- Ordered schedule time 4:30p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: per sliding scale- Before meals and at bedtime. Administered at 5:38p.m. Documentation notes late administration: charted late. Comment: 0. No documented evidence of reason or physician notification. Review of Resident R2 clinical record revealed admission date to the facility of September 30, 2025 with diagnosis of Hip replacement, Type 2 diabetes. Review of Resident R2 clinical record revealed BIMS (Brief interview for Mental Status) score of 14, indicating cognitively intact. Interview with Resident R 2 on January 22, 2025 at 10:40 a.m. revealed concerns related to insulin. Insulin is often given long after my meals, sometimes a few hours and I am supposed to receive it prior to meals. Review of Resident R2 MAR (Medication Administration record) dated January 1, 2026 through January 22, 2026 revealed the following: January 2, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:37 p.m. Documentation notes late administration: charted late. Comment: cl. No documented evidence of reason or physician notification. January 3, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 9:59 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 3, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 12:54 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 4, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:42 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 4, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 3:30 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 11:21 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 7, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:15 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 8, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 3:37 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 9, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 6:36 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 10, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 6:38 p.m. Documentation notes late administration: charted late. Comment: given. No documented evidence of reason or physician notification. January 11, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:39 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 12, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 2:25 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 13, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:39 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 14, 2026- Ordered schedule time 8:00a.m.-9:00a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:17 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 14, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:42 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification.January 16, 2026- Ordered schedule time 8:00 a.m.-9:00 a.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 10:34 a.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 16, 2026- Ordered schedule time 4:30p.m.-5:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 7:21 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 18, 2026- Ordered schedule time 11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:26 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 20, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:54 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. January 21, 2026- Ordered schedule time11:30a.m.-12:00p.m.; Insulin lispro insulin pen 100unit/ml; amount to administer: 14 units; Inject 14 units subcutaneously before meals for Diabetes Mellitus. Administered at 1:43 p.m. Documentation notes late administration: charted late. Comment: n/a. No documented evidence of reason or physician notification. Review of Resident R3 clinical record revealed admission date to the facility of June 17, 2021, with diagnosis of Scapula fracture, Type 2 diabetes. Review of Resident R3 clinical record revealed BIMS (Brief interview for Mental Status) score of 15, indicating cognitively intact. Interview with Resident R3 on January 22, 2025 at 10:08 a.m. revealed received morning medications late, this happens all the time, medications are always late, especially at night. Review of Resident R3 MAR (Medication Administration record) dated December 25, 2025 through January 22, 2026 revealed the following: December 30, 2025- Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential (primary) hypertension. Administered at 12:31 p.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. December 30, 2025- Ordered schedule time 8:00a.m- 10:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 12:31 p.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. January 5, 2026 - Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential (primary) hypertension. Administered at 11:35 a.m. Documentation notes late Administration: Other. Comment N/A. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00 a.m. - 11:00a.m; Amlodipine 10mg Tablet, give 1 tablet by mouth in the morning related to essential (primary) hypertension. Administered at 11:12 a.m. Documentation notes late Administration: Charted late Comment N/A. No documented evidence of reason or physician notification. January 2, 2026 - Ordered schedule time 4:00p.m- 7:00p.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 8:40 p.m. Documentation notes late Administration: Charted late Comment g. No documented evidence of reason or physician notification. January 5, 2026- Ordered schedule time 8:00a.m- 11:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 11:35 a.m. Documentation notes late Administration: Other. Comment N/A. No documented evidence of reason or physician notification. January 6, 2026- Ordered schedule time 8:00a.m- 11:00a.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 11:12 a.m. Documentation notes late Administration: Charted late Comment No documented evidence of reason or physician notification. January 8, 2026- Ordered schedule time 4:00 p.m- 7:00 p.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:14 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. January 9, 2026- Ordered schedule time 4:00p.m.- 7:00p.m.: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:07 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. January 16, 2026- Ordered schedule time 4:00 p.m.- 7:00p.m.: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:58 p.m. Documentation notes late Administration: Charted late. No documented evidence of reason or physician notification. January 21, 2026- Ordered schedule time 4:00p.m- 7:00p.m: Oxycodone- Schedule II tablet 5 mg, take 1 tablet by mouth twice a day for pain. Administered at 7:07 p.m. Documentation notes late Administration: Charted late Comment ok. No documented evidence of reason or physician notification. Interview with Employee E2, Director of Nursing on January 22, 2026 at 1:30p.m. confirmed above referenced findings and revealed when medications are late they have to be manually entered into the chart and documented as late. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record reviews, observations, interviews with residents and staff and reviews of the job descriptions, it was determined that the facility failed to ensure the safety of one of two resident reviewed after the resident was returned to the facility from a contracted transportation company, who transported the resident to a medical appointment. (Resident R1) Findings include:Observation of Resident R1 at 10:45 a.m., on December 3, 2025, revealed that this resident was only able to have vision from the left eye. Interview with Resident R1 at the time of the observation revealed that he was having problems with vision in the left eye. Review of Resident R1's clinical record revealed a physician's assessment dated [DATE], that indicated Resident R1 had a history of right eye exenteration for melanoma. Continued review of the physician's report revealed that Resident R1 had been recommended prescription eyeglasses and at this time was diagnosed with a cataract of the left eye. Review of Resident R1's comprehensive assessment MDS (an assessment of care needs) dated September 12, 2025, indicated that this resident had visual impairment. The assessment indicated that this resident could only see large print. The assessment also indicated that this resident did not have corrective lenses. The resident's had a diagnosis of diabetes mellitus (failure of the body to produce insulin). The resident was assessed with having pain was present routinely. Clinical record review revealed physical therapy and occupational therapy assessments for Resident R1 dated August 8, 2025, and September 12, 2025. The assessments indicated that Resident R1 was able to ambulate with a rollator walker on level surfaces and uneven surfaces with the supervision of staff. The assessment indicated that pacing was advised for Resident R1. The assessment also indicated that community mobility was not determined for this resident. Interview with the occupational therapist, Employee E13, at 10:30 a.m., on December 4, 2025, confirmed Resident R1's ambulation ability was that which requiring supervision of staff for level and unlevel surfaces inside and outside the facility. The occupational therapist also confirmed Resident R1 was not evaluated for community mobility (crossing a four-lane highway or walking on a roadway or sidewalk or inclines). Interview with the Administrator, Employee E1 at 10:30 a.m., on December 3, 2025, revealed that Resident R1 was using the contracted medical transport service to go to medical appointments outside the facility on a routine basis since the resident's admission to the facility in July 2025. Clinical record review revealed that Resident R1 had a physician's approval for a leave of absence from the facility with supervision by a staff member, resident family or other authorized individual. The supervision was assumed by the person responsible for the resident during such time. Clinical record review for Resident R1 revealed that this resident left the facility at 8:00 a.m., on November 24, 2025, for a medical appointment. Interview with Licensed Practical Nurse, Employee E4, at 1:00 p.m., on December 3, 2025, revealed that at 3:30 p.m., on November 24, 2025, the nurse began to question the whereabouts of Resident R1. The Administrator, Employee E1 and Director of Nursing, Employee E2 also reported at 1:30 p.m., on December 3, 2025, that they were not able to find Resident R1 at 3:54 p.m., on November 24, 2025, anywhere inside the building. The Administrator and Director of Nursing also reported on December 3, 2025, at 2:00 p.m., that they had no policies and procedures in place to ensure that Resident R1 was returned safely to the facility and into the care of the nursing staff after medical appointments. The administrator and director of nursing had no documentation or procedure for the medical transportation services to bring Resident R1 into the building and sign Resident R1 into the care of the staff (nursing) at the facility. On December 3, 2025, at 2:00 p.m., the Administrator and Director of Nursing reported that they had no idea where Resident R1 was, since the resident was not inside the building. The administrative staff said that they had to contact the driver of the transportation services company on November 24, 2025, to inquire the whereabouts of Resident R1. The Director of Nursing reported that the driver of the transportation services reported dropping Resident R1 off at the facility, did not escort the resident into the building, sign the resident back into the facility or positively identify the resident with the nursing staff for continuation of care. Interview with the Licensed nurse, Employee E4, responsible for Resident R1 on November 24, 2025, revealed that it was at 4:35 p.m., on November 24, 2025, that she recognized Resident R1 walking through the parking lot of the facility toward the front entrance of the building. Licensed nurse, Employee E4 reported that Resident R1 told her that he walked down the road adjacent to the facility alone after being left off by the transportation driver near the front entrance of the facility at about 3:54 p.m. The resident then crossed the four-lane highway that was under construction to get some food at a fast- food restaurant. Licensed nurse, Employee E4 reported that the total distance from the facility entrance to the restaurant was 0.2 miles or 1, 056 feet. The nurse reported that Resident R1 was a diabetic and had not eaten any food or been provided with a nutritious snack since leaving the facility at 8:00 a.m., on November 24, 2025, for a medical appointment with the contracted transportation services. 28 PA. Code: 201.14(a) Responsibility of licensee28 PA. Code: 201.18(b)(1)(3)(d)(e)(1)(1) Management28 PA. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on March 31, 2025, at 9:15 a.m. with Employee E5, Food Service Director (FSD), revealed the following concerns: Observation in the receiving dock revealed a lot of trash scattered around the loading dock next to the dumpster including empty milk carton, plastic juice cups and paper. Observation in the dry storage area revealed a buildup of dust, dirt and black substance on the floor under she shelves next to the aluminum freezer walls. Observation in the walk-in freezer revealed that the floor was dirty and had debris on the floor under the shelves. Observation in the walk-in cooler revealed that the floor was dark and dirty with [NAME] stains on the floor under the shelves. Observation of the wall in the dish room area behind the high-pressure spray hose and scrap sink revealed the paint on the wall was dirty and the paint was peeling off. Observation of the convection oven revealed a heavy build-up of dark black burned on food splatter and grease drippings on the inside surfaces of both ovens. Interview with the FSD on March 31, 2025, at 9:25 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based upon interviews with residents and staff, review of clinical records, facility documentation and policy, it was determined that the facility failed to ensure residents were free from abuse and neglect for one of 21 resident records reviewed (Resident R94). Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation revised July 2024, states, The facility will not tolerate abuse, neglect, mistreatment, of residents. The same policy states that Mental abuse includes humiliation, punishment and deprivation. Review of Resident R94's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of bipolar disorder (moods of extreme highs and of extreme lows), depression, muscle weakness and scoliosis (unnatural curvature of the spine). Review of Resident R94's nursing note dated March 20, 2025, stated, Resident reported to staff that she had put her call light on and requested to go to the bathroom, she stated that staff informed her she should go in the brief she was wearing, and she would come back to change her once she was finished. She stated that when she was finish, she rang her call light to be changed, and staff changed her while she was in bed. During an interview with Resident R94's roommate, Resident R57 on April 1, 2025 at 12:30 p.m. stated, I overheard an aide say to Resident R94 that she was tired of changing the resident and told the resident to go in her pants. On April 2, 2025, at 10:57 a.m. during an interview with Resident R94 stated, The aide was getting me ready for bed and I told her I had to use the bathroom. She said to go in my pants, and she would come back to change me. I couldn't hold it, and I went in my pants. It felt degrading and I am embarrassed to even say it happened. Interview with the Unit Manager Employee E3 on April 2, 2025 at 12:39 p.m. stated Resident R94 is continent of urine. She is able to feel when she has to urinate. When she has to use the bathroom, she tells us and we assist her to the toilet. Review of the facility's reported event submitted on March 20, 2025, and the facility's investigation concluded he allegation was found substantiated and the nursing assistant was terminated for mental abuse. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(a)(c) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent an elopement for one of two residents reviewed for wandering/elopement (Resident R308). Findings Include: Review of facility policy Elopement/Unauthorized Absence dated August 2, 2024, revealed the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Review of Resident R308's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 8, 2024, revealed the resident had severe cognitive impairment and had diagnoses of dementia (decline in cognitive function that interferes with daily life) and altered mental status. Further review of the MDS revealed Resident R308 was independent for transfers and ambulation. Continued review of Resident R308's MDS dated [DATE], revealed the resident exhibited the behavior of wandering daily. Review of Resident R308's comprehensive care plan dated June 1, 2024, revealed the resident had cognitive impairment related to dementia diagnosis with wandering/elopement. Review of Resident R308's clinical record revealed a nursing note dated June 3, 2024, that revealed the interdisciplinary team (IDT) met and discussed Resident R308's elopement risk. Per the IDT/Elopement Risk note dated June 3, 2024, Resident R308 was placed on 15-minute checks due to the resident removing his wander guard. Continued review of Resident R308's clinical record revealed a nursing note dated August 1, 2024, that revealed IDT met again to discuss Resident R308's elopement risk. Per the IDT/Elopement Risk note, dated August 1, 2024, Resident R308 remained on 15-minute checks due to his continued refusal to wear the wander guard and continued wandering on the unit at times. Review of Resident R308's clinical record revealed a nursing note dated August 15, 2024, by Registered Nurse, Employee E6, that revealed staff were unable to locate Resident R308. Review of facility documentation revealed an incident report dated August 15, 2024, that indicated Resident R308 was last seen ambulating in the hallway at 7:30 p.m. At 7:45 p.m. when the resident's assigned nurse aide, Employee E7, went to check on Resident R308, the resident could not be located. A code was promptly announced to notify staff in the building that Resident R308 could not be located, and staff immediately began to search inside and outside the building. Further review of the incident report dated August 15, 2024, revealed the Director of Nursing, Employee E2, was able to locate Resident R308 in the parking lot at approximately 9:00 p.m. Resident R308 was subsequently brought back into the building and no injuries were identified upon assessment. Review of Resident R308's clinical record revealed the resident was subsequently put on 1:1 supervision status-post the elopement for increased supervision. Interview on April 3, 2025, at 12:05 p.m. with the Director of Nursing, Employee E2, confirmed this employee found Resident R308 in the parking lot around 9:00 p.m. Further interview with Director of Nursing, Employee E2, revealed Resident R308 admitted to exiting the facility through the front door. Director of Nursing, Employee E2, reported that it was assumed that Resident R308 must have followed behind a family member (of another resident) who was exiting the building. 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of clinical records, and interviews with staff, it was determined that the facility failed to ensure timely provision of professional services furnished by outside providers, for one of 21 resident records reviewed (Resident R93). Findings include Review of Resident R93's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of Huntington's disease (a rare, inherited neurological disorder that causes nerve cells in the brain to break down, leading to progressive physical and mental decline). Review of nursing note dated January 8, 2025, indicated the resident refused to go to an outside appointment with the hospital related to the diagnosis of Huntington disease. Continue review of the same note stated, Appointment attempted to be rescheduled, message left to contact facility to schedule a new appointment date and time. Further review of Resident R93's clinical record revealed no documented evidence that the facility ensure that the appointment was rescheduled. The Director of Nursing on April 3, 2025, at 10:00 a.m. confirmed no new appointment was made. 28 Pa. Code 211.12 (d)(1) Nursing Services.

Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records related to diagnoses for physician ordered medications for two of 21 records reviewed (Residents R18 and R81). Findings include: Review of clinical documentation for Resident R18 revealed a physician order, dated January 1, 2025, for Metoclopramide HCl 10MG tablet, with the instructions 1 tab, oral, three times a day .before meals. On the order sheet, the area marked ICD-10 Diagnosis was filled out as N/A (not applicable). There was no reason for use given for the medication. Further review revealed another physician order, dated January 30, 2025, for Systane Hydration, 0.4-0.3%, with the instructions 1 drop in each eye once a day. On the order sheet, the area marked ICD-10 Diagnosis was filled out as N/A. There was no reason for use given for the medication. Review of clinical documentation for Resident R81 revealed a physician order, dated March 20, 2025, for Lidocaine HCl .cream; 4%, with the instructions administer cream to right shoulder [every] shift. On the order sheet, the area marked Diagnosis was blank. There was no reason for use given for the medication. Interview with the Director of Nursing, Employee E2, on April 3, 2025, at 2:15 p.m. confirmed that all medication orders must list the diagnosis or reason for use to be complete. 28 Pa. Code 211.12(c) Nursing service 28 Pa. Code 211.12(d)(1) Nursing service 28 Pa. Code 211.12(d)(2) Nursing service 28 Pa. Code 211.12 (d)(5) Nursing service

Based on review of resident records and interviews with staff, it was determined the facility did not ensure antibiotics were administered with adequate indication for use for one of 21 resident records reviewed (Resident R94). Findings include: Review of Resident R94's clinical record revealed that the resident was admitted to the facility on [DATE] diagnosed with bipolar disorder (moods of extreme highs and of extreme lows), depression, muscle weakness and scoliosis (unnatural curvature of the spine). Review of Resident R94's physician note dated October 28, 2024 indicated the resident's urinalysis was abnormal, noting the resident's white count was improving, the urinalysis weakly suggestive of infection and was still waiting for the colony count and cultures and sensitivities and noted the resident denied any urinary symptoms. Further review of Resident R94's nursing notes, dated October 28, 2024, revealed the labs were further reviewed by a Nurse Practioner that ordered an antibiotic, Bactrim DS for three days. Interview with the Director of Nursing on April 2, 2025, at 3:00 p.m. stated that during QAPI I remind the physicians about prescribing antibiotics with no indication for use and Resident R94 was used as an example. 28 Pa. Code 211.12 (d)(1) Nursing Services.

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 21 sampled (Residents R48 & R93). Findings included: A review of Resident R48's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident R48's physician orders revealed a February 4, 2025, order to admitted to hospice care with the diagnosis of Parkinson's Disease (progressive disease of the central nervous system). Further review of a Significant Change Minimun Data Set (MDS) assessment dated [DATE], section J revealed that the resident had a life expectancy of less than six months, and that section O did not indicate that the resident was on hospice. Interview with the MDS Coordinator, Employee E4 on April 2, 2025, at 11:25 a.m. confirmed that Resident R48 was put on hospice care on February 4 and that Section J of the February 4, 2025, MDS indicated a life expectancy of less than six months and that Section O of the MDS should have been triggered for hospice services. Review of Resident R93's clinical record revealed a Quarterly MDS dated [DATE]. Review of Section C: Cognitive Pattern within the MDS dated [DATE], revealed this section was not completed and marked as not assessed. Interview on April 3, 2025, at 10:15 a.m. with MDS Coordinator, Employee E4, revealed interviews for mental status could not be completed timely by the social services department and subsequently needed to be coded as no information. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility documentation, observations, and staff and resident interviews, it was determined that the facility failed to ensure meals were served in accordance with resident preferences for two of two nursing units (1st and 2nd floor). Findings Include: Interview on May 14, 2024, at 12:30 p.m. with Resident R100 revealed lunch used to be served at noon. Recently, lunch has been coming later since change in process of delivering food trucks. Interview on May 14, 2024, at 12:35 p.n. with alert and oriented Resident R68 and R81 revealed residents were upset because lunch is supposed to be served at noon but still has not been delivered. Further interview revealed lunch has been getting served late and has come late as 2:00 p.m. Observations on May 14, 2024, at 12:42 p.m. revealed a lunch truck was just delivered to the 1st floor dining room. Interview on May 14, 2024, at 1:00 p.m. with Nurse Aide, Employee E3, revealed the 1st floor nursing unit is still waiting for 2 more food trucks to be delivered. Further interview revealed a total of 3 food trucks are delivered to the 1st floor nursing unit, and were waiting for about 30-35 more lunch trays for the residents. Continued interview on May 14, 2024, at 1:00 p.m. with Nurse Aide, Employee E3, revealed there was a change in process for the delivery of meal trays and that breakfast is now served too early on the 1st floor nursing unit, and most residents are not awake when breakfast is delivered. Further interview revealed lunch and dinner are now served later and most residents are upset with the change in meal times. Observations on May 14, 2024, at 1:06 p.m. revealed the 2nd food truck was delivered to the 1st floor nursing unit. Interview on May 14, 2024, at 1:15 p.m. with Resident R6 revealed the resident was upset because she was not served lunch yet. Resident R6 reported lunch and dinner are always late and that dinner was not served until almost 7:00 p.m. the night prior. Interview on May 14, 2024, at 1:24 p.m. with Resident R13 revealed the resident did not get lunch yet and that lunch is usually late. Resident R13 reported he would like his lunch earlier. Observations on May 14, 2024, at 1:34 p.m. revealed the 3rd lunch truck was delivered to the 1st floor with approximately 16 meal trays. Observations on May 14, 2024, revealed Residents R69 and R3 were the last to be served lunch on the 1st floor nursing unit at 1:42 p.m. On May 15, 2024, at 10:30 a.m. a resident council meeting was held with nine alert and oriented Residents (R103, R95, R76, R81, R8, R66. R85, R53). Residents reported that breakfast is being served too early in the morning and lunch is being served too late. 28 Pa. Code 201.18(b) Management

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of two nursing units observed (2 floor nursing unit). Findings include: Facility policy titled Occupied Resident Room Cleaning Procedure last revised on August 30, 2022 revealed Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. This step is to reduce the volume of organisms on a surface and remove foreign material that could interfere with disinfection. Occupied resident rooms will be cleaned daily to maintain a sanitary environment. On May 14, 2024, at 11:23 a.m. observations on the Second-floor unit room [ROOM NUMBER] B bed revealed quarter of the privacy curtain was falling off as there was no curtain hooks. There was a floor mat with all four edges ripped. The floor mat covered with spots. room [ROOM NUMBER] the wall was chipped by the door. On May 14, 2024, at 11:43 a.m. an interview with Resident R34 who was residing in room [ROOM NUMBER] B bed revealed that the bathroom sink is very slowly draining the water. The wall behind the bed was observed to be scrapped off, wall on the left side of the room when you are facing the window was scrapped off. Bathroom had brown spots all over the bathroom wall and around the toilet. The sink was not draining the water once the water was running. Resident R34's dresser which was located between the two closet had a missing third shelve. The dresser had a layer of dust, with sugar spilled. The air conditioning unit had a layer of dust, brown spots of old spills which went into the wall. Resident's clothing was laying on the floor in large bags on the top of each other by the bedside of an A bed. room [ROOM NUMBER] the edges of the floor were dirty with brown spots. The bathroom had brown spots all over the walls and toilet. Bathroom had running water in the sink and the hot water handle was broken which did not allow the water to turn off. The floor was dirty and there was an unrolled toilet paper laying on the dirty floor. On May 14, 2024, at 11:57 a.m. an interview with the unit manager, Employee E9 and Maintenance and Housekeeping Director Employee E10 confirmed, the above observations. On May 14, 2024, at 12:28 p.m. Maintenance and Housekeeping Director, Employee E10 tested the hot water in room [ROOM NUMBER] with his hand and it never got hot. room [ROOM NUMBER] hot water revealed temperature 97 F. (Fahrenheit). Further observation revealed that there was a bug running on the wall. Employee E10 killed the bug while testing the water. Hot water tested the water on the Second-floor shower room revealed that the hot water was between 95 F.-99 F. which was not comfortable hot water temperatures for the residents. On May 14, 2024, at 1:44 p.m. Resident R38's family interview revealed that facility was not clean, and that there was a urine smell present. Two months ago, there was a dry stool all around the restroom in room [ROOM NUMBER]. Nursing assistant provided a family with wipes and family member had to clean up the stool. Since it was dry family member knew that it was there a for a while. On May 15, 2024, room [ROOM NUMBER] sink was unclogged, and the water temperature went to 99 F. and there was a basin observed collecting drips of water from the sink pipe. On May 15, 2024, at approximately 1:15 p.m. observation was taken place in room [ROOM NUMBER] Resident's R49 call bell's plate was off the wall and exposed wires were visible. This observation was confirmed by the Maintenance and Housekeeping Director, Employee E10. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 204.15(a) Windows 28 Pa Code 205.67(c) Electric requirements for existing construction

Based on review of facility policies, review of clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans related to medication administration and recovery of history alcohol abuse to meet the care needs for one of three residents reviewed. (Resident R50) Findings include: Review of the facility's policy titled Comprehensive Care Planning Policy revealed that the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes a measurable objective and timetables to meet the resident medical nursing, and mental and psychosocial need that are identified in the comprehensive assessments. There may be additional problem area not triggered by the MDS (Minimum Data Set, federal mandated process for clinical assessment of all residents) which will need to be addressed in the care plan. Review of residents clinical record revealed that Resident R50 has a diagnosis of Diabetes type 2 (chronic condition which blood glucose level are too high), muscle weakness, spinal stenosis (narrowing of the spine resulting in pressure on the spinal cord and nerves), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), anxiety(an emotion of fear or worry), neuromuscular dysfunction of bladder (loss of control of the bladder muscles), toxic encephalopathy(abnormal brain function caused by toxins in the brain), morbid obesity (a body mass index of 40 or more). Continued review of Resident R50's May 2024 physician orders revealed an order for insulin Lispro (a fast-acting insulin that works by lowering levels of sugar in the blood) 100/ml order to give 6 units three times a day with meals. Review of resident R50's May 2024 medication administration record (MAR), revealed that Resident R50 routinely refuses accu check s(a blood glucose test) and insulin. Review of Resident R50's current care plan revealed that Resident R50 has a diagnosis of diabetes mellitus containing a goal to be free of signs and symptoms of hypoglycemia and hypoglycemia with intervention of assessment, documents, and reports sign and symptoms of hypoglycemia and encourage the resident to practice good health practices. Continued review of the resident's are plan revealed that there was no care plan developed to address refusal of medication, education of resident and staff, and any plan or implementation of hypoglycemia (low blood sugar, require immediate treatment). Interview with Licensed nurse, Employee E8 on May 15 at 8:30 a.m. on the second-floor nursing floor during medication pass, employee was observed distributing medication for Resident R50. Interview with Licenced nurse E8 during the observation revealed that Resident R50 declines her daily accu checks. Employee E8 stated that Resident R50 notifies the staff when she feels the need for the prescribed insulin. Interview with Resident R50 May 16, 2024 at 11:25a.m., revealed that she does not have her blood sugar levels taken with accu checks. She stated that she just lets the nurses know when she feels like she needs it. Continued interview with Resident R50 May 16, 2024, at 11:30 a.m. revealed that this resident greatest accomplishment of her life was maintaining sobriety. Although Resident R50 has been alcohol free for many years and she still feels the need to attend meeting twice a week outside the facility. Observation of Resident R50's room revealed diplomas on the wall and a picture by her bed that was explained as her greatest's supporter, her sponsor. Continued review of Resident R50's care plan did not included the diagnosis of soberness and there was no care plan developed related to coordinating care and support for the resident as well of implementing resident assistance to prepare and travel outside the facility of group meeting. Interview with Director of Nursing, Employee E2 confirms the above findings. 28 Pa Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(3) Nursing Services

Based on observation, review of facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to provide appropriate Activity of Daily Living (ADL) for three of 21 residents reviewed who were unable to carryout ADL care independently. (Resident R19, R29, and R75) Findings include: A review of the Facility Policy titled, Personal Care last revised on November 8, 2023, revealed Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Residents who can perform their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled two times weekly or more or less often according to resident preference. Further under procedures number 7. Provide shaving as desired by resident 9. Provide fingernail care Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R19 dated April 24, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, and toileting. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 8 which indicated that the resident's cognitive status for daily decision making was moderately impaired. Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R29 dated May 14, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, toileting, dressing, bed mobility. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 13 which indicated that the resident's cognitive status for daily decision making was intact. Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R75 dated April 25, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, toileting, dressing, bed mobility. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 15 which indicated that the resident's cognitive status for daily decision making was intact. On May 14, 2024, at 1:17 p.m. an interview and observation revealed that Resident R75 had a beard and has been asking since Sunday May 11, 2024 to shave his beard. A nursing assistant. Employee E12 responded to Resident R75 I don't have time on Sunday. Resident R75 requested two times on Monday May 12, 2024, and no one provided him a shave. A grievance investigation was conducted for the above concern, and it revealed that Resident R75 did request his beard to be shaved on May 13, 2024 and certified nursing assistant, Employee E12 wrote in the statement dated May 15, 2024 revealed due to lunch arriving late, need to do other residents and then passing down and collecting trays there as no time to shave Resident R75. On May 15, 2024, at 12:20 p.m. Resident R19 was observed sitting in the dining room with facial hair and long nails. Resident R19 did want his nail to be cut and facial hair to be shaved. Unit Manager, Employee E9 did confirmed the observation. On May 17, 2024, at 9:42 a.m. an interview and observation revealed that Resident R29 had long nails and wanted them to be trimmed. License Nurse, Employee E8 confirmed the observations. On May 17, 2024, at 12:30 p.m. an interview with the Registered Nurse Assessment Coordinator, Employee E6 confirmed the Resident R19 required extensive assistance of one person from the staff for ADL care in personal hygiene, bathing, and toileting. Resident R29 required extensive assistance of two person from the staff for ADL care in personal hygiene, bathing, and toileting. Resident R75 required extensive assistance of one to two person from the staff for ADL care in personal hygiene, bathing, and toileting. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of safety data sheet, review of facility documentation, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure residents received adequate supervision during transfers for two of three residents reviewed for falls (Resident R84 and R30) and failed to ensure the resident environment remained free of accident hazards related to access to cleaning agents and the security of windows. Findings Include: Review of facility policy Mechanical Lift revised January 7, 2022, revealed a mechanical lift may be used for transferring residents that cannot be safely transferred by themselves or with staff assistance. Two staff person assist/oversight is required for total body lifts. Review of Resident R84's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 15, 2024, revealed the resident was cognitively intact and was total dependence (full staff performance every time), 2-persons physical assist for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair). Review of Resident R84's comprehensive care plan revised May 22, 2023, revealed the resident had a self-care deficit related to immobility and need for assistance with activities of daily living and transfers. Intervention dated August 5, 2022, revealed resident was hoyer lift for transfers (total body lift - device used to hoist resident with slings that hook up to the lift's arm and cradle the resident during transfer) with assist of 2 people. Review of facility documentation submitted to the State Survey Agency revealed on March 22, 2024, Resident R84 fell during transfer with the hoyer lift. Facility documentation indicated that Resident R84 was transferred with 1-person assist but required 2-person assistance. Review of facility documentation Witness Statement dated March 22, 2024, by nurse aide, Employee E4, revealed the employee was using the hoyer lift to transfer Resident R84. Nurse aide, Employee E4, stated as the hoyer lift was being turned, the lift tipped and Resident R84 fell . Review of facility documentation Witness Statement dated March 22, 2024, by Director of Nursing, Employee E2, revealed the employee responded to a call for help in Resident R84's room. Upon arriving, Resident R84 was on the floor near the night stand and bed with the hoyer lift tilted to the side. Director of Nurse, Employee E2, asked nurse aide, Employee E4, who assisted with the transfer and nurse aide, Employee E4, responded no one. Interview on May 17, 2024, at 12:40 p.m. with Resident R84 confirmed nurse aide, Employee E4, did not have assistance during transfer with hoyer lift at the time of the fall on March 22, 2024. Review of Resident R30's clinical record revealed that resident has a diagnoses of encephalopathy (disturbance of brain function) and schizophrenia (a mental disorder characterized by reoccurring episodes of psychosis) . Further review of Resident R30's care plan developed March 27, 2024, revealed that resident was at risk for falls related to history of placing self on floors, decreased mobility, seizure disorder, lack of coordination, abnormal gait and insomnia. Review of Resident R30's MDS (Minimum Data Set , a federal mandated process for clinical assessment of all residents), revealed that Resident R30's functional status determined that this resident required total dependence of 2 person assists for transfers. Interview with Resident R30 on May 17, 2024, at 10:45 a.m. revealed that the resident confirmed falling while he was been transferred to his bed by one employee. Review of the facility documentation reported to the State Agency revealed a written statement by nursing assistant, Employee E20 which stated was asked to help put patient [Resident R30] . in the bed he was sliding out of the hoyer pad. Employee E21 assisted in the transfer and the hoyer lift was used. Patient was sliding out of chair for the most part to he day assisted with putting him up. Review of the written statement by nursing assistant, Employee E21 revealed that she asked another nurse aide to help with the transfer of Resident R30 with the hoyer lift he said yes he push the resident down to this room while I grab the brief and washcloths when I got back down to the room the resident was already transfer into the bed. The facility concluded that the resident did not substantitiate any injuries. Employee E20 was terminated for failure to follow the resident's care plan appropiately. Tour and Observation of the laundry room conducted on May 16, 2024 at 9:43 a.m. accompanied by Maintenance Director, Employee E10 revealed that the facility outsource's their linens. The facility laundry room is available to the residents for personal use. Observation of the laundry room revealed an industrial soap hung on the wall available for use. This observation concluded that there were no instruction for detergent use nor any measuring apparatus for use. Interview with Employee E10 at time of observation stated that the instruction is for about a cup when question where the measuring cup was, Employee E10 had no response. Employee E10 confirmed that the bottle instructions states for industrial use only . Review of the laundry detergent manufacture produces the product Pyxis Enzyme laundry Detergent, Safety data sheet for the laundry detergent / state industrial products has a hazard identifying serious eye damage category 2A, oral and acute toxicity, dermal category 5. Handling and storage instruction to store locked up. Interview with Resident R95 on May 16, 2024 at 1:25 p.m. revealed that this resident has used the provided laundry detergent. Resident R95 admitted not knowing the instructions for the detergent. This resident has stopped using the detergent due to a skin sensitivity. Resident R95 admitted to acquiring a rash and has since stopped using the detergent. Interview with Licenced nurse, Employee E14, revealed that she has assisted the resident with the laundry. Employee E14 allowed the resident to measure the detergent and pour it in the machine. Employee E14 confirmed not being aware of the instructions for the detergent. Interview with nursing assistant, Employee E15 stated that this employee has assisted residents with the laundry of their personal items. Employee E15 stated that the residents did not wear gloves of PPE (personal protective equipment). Continued tour of the facility accompanied with Maintenance Director, Employee E10 on May 16, 2024, at 10:05 a.m. revealed a window on the second-floor dementia unit not possessing a safety lock on the resident's window. Resident R72 and Resident R373 occupied a room that the window was equipped to open as wide as 17.5 inches. Interview with Maintenance Director, Employee E10 at time of observation revealed that this employee was aware that the windows must have a safety lock that disable the window from opening beyond a specific level and was unaware that the window in the resident's room was able to be open to 17.5 inches. 28 Pa. Code 204.7 Laundry 28 Pa. Code 210.18(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 211.10 (d) Resident Care Policies 28 Pa Code 211.12 (d)(5) Nursing Services

Based on observation, review of facility policy and staff interviews, it was determined that the facility failed to ensure that residents call systems was accessible for 11 out of 11 residents reviewed (Residents R29, R49, R75, R103, R95, R76, R81, R8, R66, R85, R53). Findings: Facility policy titled Operations last revised on February 24, 2023, revealed It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. It further revealed under procedures number 3. Staff will respond to call lights promptly. Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R29 dated May 14, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, toileting, dressing, bed mobility. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 13 which indicated that the resident's cognitive status for daily decision making was intact. Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R49 dated February 13, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, toileting, dressing, bed mobility. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 12 which indicated that the resident's cognitive status for daily decision making was moderately impaired. Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R75 dated April 25, 2024, revealed that the resident was dependent on the staff for personal hygiene, transfer, toileting, dressing, bed mobility. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 15 which indicated that the resident's cognitive status for daily decision making was intact. On May 14, 2024, at 1:17 p.m. an interview was held with Resident R75 who reported that yesterday May 13, 2024, R75 pressed his call bell at 3:50 p.m. and was responded at 4:50 p.m. Many times, Resident R75 uses his phone to call the nursing station to get his call bell answered because staff would not respond to his call bell. On May 15, 2024, at 10:30 a.m. a resident council meeting was held with nine alert and oriented Residents (R103, R95, R76, R81, R8, R66. R85, R53) Residents reported that when they pressed the call bell, facility staff would enter the room and turn off the bell without providing assistance. They were often told, I'm not assigned to you, I'll let your staff know, but no one would return to help. Overall, the response to call bells was poor. On May 15, 2024, at approximately 1:15 p.m. observation was taken place in room [ROOM NUMBER] Resident's R49 call bell was underneath the bed and was not accessible to Resident R49. This observation was confirmed by the Maintenance and Housekeeping Director, Employee E10. On May 17, 2024, at 9:39 a.m. observations were taken place in room [ROOM NUMBER], Resident's R49 call bell was on the floor, not in accessible position. Resident R49 reported I need to be changed and I can't locate the call bell . This observation was confirmed by the license nurse, Employee E8. On May 17, 2024, at 9:42 a.m. Resident R29 was observed in bed and his call bell was located on the dresser. Resident R29 was not able to reach it. License nurse, Employee E8 reported that she will get a clip for Resident R29 to clip his call bell to the sheets. 28 Pa. Code 201.14 Responsibility of Licensee 28. Pa. Code 201.18 (b)(1)Management 28 Pa. Code 211.12 (d)(1) Nursing Services

Based on the review of facility policy, observations and interviews with resident and staff, it was determined that the facility failed to ensure a functional, sanitary environment on one of two nursing units observed (2nd floor nursing units) and for for 6 out of 10 residents reviewed. (Residents R4, R131, R66, R56, R29, and R50). Findings: Review of facility policy titled Occupied resident room cleaning revised August 30, 2022, revealed that occupied resident room will be cleaned daily, it is housekeeping's responsibility to inspect room and report any maintenance issues noted during cleaning. On May 14, 2024, at 11:37 a.m. on the Second-floor north side of the nursing unit at the end of the hallway there was a strong urine odor. License nurse, Employee E11 confirmed the observations and reported that Resident R39 was incontinent and has behavioral issues with her incontinence. On May 14, 2024, at 12:54 p.m. observation was confirmed by the Maintenance and Housekeeping Director, Employee E10 that there was strong urine odor by the second-floor nursing when facing to go into the dining room. On May 14, 2024, at 1:44 p.m. Resident R38's family interview revealed that facility was not clean, that a urine smell was present. Family member was wearing a surgical mask and reported that there was frequent urine odors at the facility and the conditions were unsanitary. On May 15, 2024, at approximately 11:15 a.m. room [ROOM NUMBER] had strong urine odor. Maintenance and Housekeeping Director, Employee E10 confirmed the odor. Observation of Resident R131's room on May 16, 2024 at 10:10 a.m. revealed broken blinds that did not open. Observation of Resident R66 on May 16, 2024 at 10:15 a.m. revealed stained windows and wall. Observation of Resident R56 and R29's room on May 16, 2024 at 10:20 a.m. revealed the privacy curtain between the beds was found to be stained. Interview on May 16, 2024 at 10:20 a.m. with Maintance Director, Employee E19 during above observations confirmed the above findings. 28 Pa. Code. 207.2(a) Administrator's responsibility. 28 Pa Code 201.18 (b)(3) Management 28 Pa Code 214.15 Windows

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident received adequate supervision during care for one of five residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who fell out of bed during care and sustained a 3 centimeter (cm) by 1.5 cm laceration to middle of forehead requiring three sutures. This deficiency was identified as past non-compliance. Findings Include: Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 21, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of traumatic brain injury, need for assistance with personal care, cognitive communication deficit, history of falling, ataxic gait (presence of abnormal, uncoordinated movements), and muscle weakness. Continued review of the MDS assessment revealed the resident had severe cognitive impairment. Further review of the MDS revealed the resident was frequently incontinent of bladder, always incontinent of bowel and required extensive, two-person physical assistance from staff for bed mobility and one-person physical assistance for personal hygiene. Review of Resident R1's care plan revised November 19, 2021, revealed the resident had an activities of daily living self-care performance deficit related to dementia (impaired ability to remember, think, or make decisions that interferes with daily life) and limited mobility. Interventions included for staff to provide assist of two staff for bed mobility. Continued review of Resident R1's care plan revised February 19, 2023, revealed the resident was at risk for falls related to history of falls and lack of coordination. Interventions included bed in lowest position and staff will monitor resident for safety during activities of daily living. Review of Resident R1's clinical record revealed an assessment dated [DATE], by Nurse Practitioner, Employee E6, that indicated Resident R1 had an unwitnessed fall from bed on February 18, 2023 and sustained a laceration to his right scalp. Continued review of Resident R1's clinical record revealed a progress note by Licensed Nurse, Employee E7, dated March 1, 2023, that indicated the resident was found on the floor, in dining room, beside his wheelchair. Review of interdisciplinary team meeting note dated March 3, 2023, by Assistant Director of Nursing, Employee E3, revealed Resident R1's fall on March 1, 2023, was unwitnessed and the resident stated he was trying to walk. Upon assessment, Resident R1 was noted with a bruise and cut to forehead. Review of facility documentation submitted to the Department of Health on April 27, 2023, revealed that on April 27, 2023, Resident R1 sustained a fall out of bed while receiving morning care from nurse aide, Employee E4. Resident R1 sustained a laceration to his forehead and a skin tear to his elbow and was subsequently transferred to the hospital for evaluation. Resident R1 returned from the hospital with three sutures to his forehead laceration. Review of facility investigation documentation related to the incident revealed a written statement by nurse aide, Employee E4, dated April 27, 2023, which stated was getting ready to do [Resident R1's] care, was in the resident's closet getting his belongings when the resident rolled onto the floor . the bed was four feet high. Continued review of facility investigation revealed a written statement by Registered Nurse, Employee E5, dated April 27, 2023, which stated nursing aide [Employee E4] informed writer resident had rolled from the bed to the floor as aide was about to give resident care . resident was found on the left side of the bed on his face. On the floor was a pool of blood. On resident forehead was a 3 cm by 1.5 cm laceration bleeding profusely . According to aide she tried to catch resident but couldn't. Review of hospital records dated April 27, 2023, revealed Resident R1 was treated with sutures to laceration of head. Interview on May 9, 2023, at 12:00 p.m. with Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2 confirmed Resident R1 was care planned for bed mobility assist of two-person physical assist. Further interview confirmed the nurse aide, Employee E4, raised Resident R1's bed to waist height and proceeded to turn around to gather supplies out of the closet, leaving the resident unattended with the bed elevated. Interview with Nurse Aide, Employee E4, on May 9, 2023, at 12:50 p.m. revealed the nurse aide entered Resident R1's room to provide care. Nurse aide, Employee E4, stated she raised the bed to waist height and turned away from the resident to gather care supplies from the closet. Nurse aide, Employee E4, reported she witnessed the resident roll out of bed but was unable to prevent the fall and that it all happened so fast. Review of nurse aide, Employee E4's personnel file revealed that she was hired by the facility as a nurse aide, on June 26, 2013. Review of competencies and trainings revealed that nurse aide, Employee E4, received training for Resident Handling and Proper Body Mechanics on October 23, 2019. Continued review revealed nurse aide, Employee E4, received training for Preventing, Recognizing, and Reporting Abuse on February 6, 2022, and training on Accident Prevention and Management on September 16, 2022. On April 27, 2023, following the incident, the facility immediately implemented the following corrective actions: -Resident R1 was immediately assessed by the Registered Nurse and first aid was provided. -Resident R1's Nurse Practitioner and Responsible Party was made aware who requested the resident be sent to the emergency room for evaluation. -On 4/27/2023 the facility completed an unusual occurrence report. -On 4/27/2023 the nurse aide that was providing care was suspended pending investigation. -To identify other like residents, on 4/27/2023 the Director of Nursing/Designee completed a house-wide audit of residents Kardex [communication tool used in the electronic medical record to communicate resident information and needs] and care plans to ensure they were reflective of resident current status for bed mobility and that they match. MDS assessments were reviewed as well to verify bed mobility or if there had been any changes since last assessment. Negative findings were corrected. Therapy referrals as needed. -To prevent this from recurring, the Assistant Director of Nursing/designee provided education to nursing staff starting on 4/27/2023 and completed education on 4/28/2023 to: 1. Follow Kardex to ensure proper assistance is being provided - if not followed would be neglect. 2. Ensure that you have all items for care at bedside prior to initiating care -Newly hired staff will be educated on following a resident's care plan on care. -Nurse aide [Employee E4] received Resident Handling & Proper Body Mechanics Training on May 1, 2023, conducted by the therapy department. -To monitor and maintain ongoing compliance the Director of Nursing/Designee will interview 5 residents weekly x4 then monthly x2 to ensure staff is providing bed mobility assistance per the plan of care. -The Director of Nursing/Designee will conduct observations of 5 nurse aides when providing care weekly x4 then monthly x2 to ensure bed mobility is provided per plan of care. -The Director of Nursing/Designee will review care documentation for 5 residents weekly x4 then monthly x2 to validate staff is documenting assistance per plan of care (non-interviewable) - An Ad Hoc QAPI [Quality Assurance and Performance Improvement] meeting was held on 4/27/2023 with interdisciplinary team. Medical Director was notified. -The results of audits will be forwarded to the facility QAPI committee for further review and recommendations. Interviews with nursing staff on May 9, 2023, confirmed that they had all been in-serviced on reviewing and following the resident Kardex to ensure proper assistance is being provided with care. Nursing staff also confirmed they were in-serviced on making sure all care items are available at bedside and within reach prior to initiating resident care to ensure adequate supervision. This deficiency was identified as past non-compliance. 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(b)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on observations, review of clinical records, facility policies and procedures, and facility documentation, the Pennsylvania Department of Health Event Reporting System, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision related to incontinence care, meal supervision, smoking and leave of absence for five of 23 residents reviewed (Residents R31, R12, R49, R66, and R81) that resulted in actual harm to Resident R31, and which identified an Immediate Jeopardy to resident health and safety. Findings include: A review of Resident R31's clinical record revealed a physician's order dated November 1, 2016, which indicated [DIAGNOSES REDACTED]. Further review of Resident R31's clinical record revealed an annual Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated September 9, 2016, that indicated Resident R31 was [AGE] years of age, severly impaired cognitively and that the resident's bed mobility and transfer required the extensive assistance with a two person physical assist. Further review of the annual MDS revealed that Resident R31 was always incontinent of bowel and bladder and was identified as a resident with fragile skin, with a high risk of skin tears. A review of Resident R31's, Care Delivery Guide (a form, which is updated on a quarterly basis, informing the nursing staff how to care for a resident) updated on March 23, 2016, indicated that Resident R31 required care with two staff persons present. Review of the nursing progress notes revealed a note dated October 6, 2016, that indicated that Resident R31 was transferred to the local hospital for evaluation and treatment at 9:45 p.m. on October 6, 2016, for a laceration to the right lateral leg. Further review of the nursing progress note indicated that the nursing staff applied 4 x 4 gauze to the area and applied pressure because the site was bleeding profusely and the nursing staff could not get the bleeding to stop. Review of the physician's orders dated November 1, 2016, revealed that Resident R31 had a daily order for 81 milligrams (mgs) of aspirin (a blood thinning medication often used to reduce the risk of heart attacks, the use of which can increase bleeding). The aspirin was administered to Resident R31 related to the hypertension and prevention of clot formation. A review of hospital records dated October 7, 2016, revealed that Resident R31 was treated and evaluated at the local hospital for a 35 centimeter (cm) by 0.3 cm wide gapping laceration which was described as being crescent moon shaped. Further review of the hospital records indicated that Resident R31 required 16 sutures placed in the right lower leg and was ordered Keflex (an oral antibiotic) for seven days, three times a day, as a preventive measure for any possible infection that Resident R31 may experience related to the laceration to the right lower leg. A review of the facility's accident and investigation report dated October 6, 2016, revealed that only one NA (Nursing Assistant), was present during incontinent care to Resident R31, on October 6, 2016, at approximately 9:30 p.m. Further review of the report revealed that during the incontinence care, Resident R31 rolled over and fell out of bed, which caused the laceration. A review of the statement completed on October 7, 2016, from the NA who provided incontinence care to Resident R31 on October 6, 2016, at 9:15 p.m., revealed that they were unaware of what was a Care Delivery Guide and that since working at the facility, they had never received report on the residents at the start of shift, and they had always provided care to Resident R31 independently. An interview with the Director of Nursing on November 10, 2016, at 2:15 p.m. confirmed that Resident R31 was provided incontinence care by one NA (Nursing Assistant) on October 6, 2016, at approximately 9:15 p.m. and Resident R31 rolled over and fell out of bed and sustained an injury which resulted in actual harm to Resident R31. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on November 10, 2016, at 2:30 p.m. related to Resident R31 who received incontinence care with only one nursing staff person present, which resulted in Resident R31, who rolled over and fell out of bed, and sustained a laceration. An interview with the Nursing Home Administrator on November 10, 2016, at 4:05 p.m. revealed that the facility failed to educate the nursing staff about each individual residents' Care Delivery Guide which indicates the type of care and the number of staff that are needed to be present during care. An immediate plan was requested from the Nursing Home Administrator and the Director of Nursing on how education was going to be provided to all nursing personnel regarding the, Care Delivery Guide. The Immediate Jeopardy was removed on November 11, 2016, at 11:30 a.m. after the facility submitted an acceptable corrective action plan and it was verified that the action plan was implemented. Review of the corrective action plan indicated that the facility was going to in-service all nursing staff on their responsibility to know and follow the plan of care, where to find the care delivery cards and care plans, and to follow the plan of care and care delivery cards when providing care to a resident. Further review of the corrective action plan indicated that at the beginning of each shift, the charge nurse will give report to the NA's and instruct the NA's to review the care delivery cards and ensure they are followed. An interview with the Nursing Home Administrator and the Director of Nursing on November 10, 2016, at 6:45 p.m. confirmed that the facility failed to provide adequate and safe supervision related to incontinence care to Resident R31 that resulted in actual harm and failed to educate nursing personnel about the, Care Delivery Guide. Review of the clinical record for Resident R12 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. spasms and/or unresponsiveness). Review of the quarterly Minimum Data Set assessment (MDS - assessment of care needs) dated August 15, 2016, indicated that there was no BIMS score (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) and that the resident was moderately cognitively impaired. The same quarterly MDS noted that the Memory/Recall Ability indicated that Resident R12 was normally able to recall the current season, the location of his/her room, staff names and faces, and he/she was in a nursing home. Also noted was that the resident was understood by others and was able to make himself/herself understood by others. Further review of the same quarterly MDS of August 15, 2016, indicated that Resident R12 required the extensive assist of one staff person for bed mobility, transfers, dressing, and personal hygiene, required limited assistance of one staff person for eating, and the resident had no functional impairments of the upper extremities, but there was functional impairments to both lower extremities. Also noted was that the resident utilized a wheelchair for mobility. Review of the physician orders dated November 1 to November 30, 2016, for Resident R12, advised staff that the resident was to follow a puree diet (all food had been ground, pressed and/or stewed to consistency of a soft, smooth, thick paste) with honey thick liquids (oral fluids that were thickened and coated a spoon when poured and drizzled from a cup or bowl, and prevented choking with difficulty swallowing). The same physician orders advised staff that the resident was to be out of bed to a wheelchair for all meals and close supervision during meals. Review of the TAR (Treatment Administration Record) for November 2016 also noted that Resident R12 was to be out of bed to a wheelchair for all meals with close supervision during meals for the 7-3 shift and 3-11 shift. The TAR was initialed by licensed staff for November 1 to November 7, 2016, (first day of the survey) in the appropriate areas that the resident was out of bed with close supervision during meals. The Interdisciplinary Plan of Care Meeting Summary Tool dated August 30, 2016, stated that the resident feed self, eats in green room. Review of the, Individualized Care Plan for Nutrition, Hydration, Electrolyte Imbalance & Elimination dated initially 5/14/15, and last dated 8/31/16, noted Resident R12 with a swallowing problem and Puree Diet with Honey Thickened Liquids as an intervention. Also written as an intervention for the same swallowing problem was that the resident, Fed self, and ate in the green room. Also noted was that the resident was to, be supervised for all meals. The same care plan noted with a date of 1/25/16, that there was a, choking episode. Review of the nursing progress notes dated November 3, 2016, 7 to 3 shift, no specific time noted, revealed that Resident R12 ate a piece of chicken from another resident's tray. Review of the facility's investigation revealed a statement written by Employee E15, Social Worker, stated that the resident did take the piece of chicken from the other resident's plate, and the incident was also witnessed by Employee E6, a Speech Therapist. Both Employee E15 and Employee E6 advised the resident to spit out the chicken, and at the same time, approached the resident but the resident continued to eat the chicken. Employee E15's statement further stated that the resident, struggled to eat the chicken as he/she continued to attempt to consume it. Further review of the nursing progress notes dated November 3, 2016, for the 7 to 3 shift, revealed that Resident R12 was assessed by a Licensed Nurse Supervisor following the incident with no signs of distressed noted. Review of the, Individualized Care Plan for Behaviors dated 11/4/16, the day after the incident, listed the problem of the resident being non-compliant with diet, and the goal was that the resident would comply with the recommended and medically necessary diet. The intervention for the resident behavior stated that Resident R12 was to move to the green room for meals. During an interview on November 8, 2016, at approximately 9:45 a.m. Employee E4, Assistant Director of Nursing, stated that he/she was, not aware that Resident R12 was to be supervised for meals. Employee E4 also stated that the incident with the chicken occurred with the resident eating in the general dining room with other residents. During an interview on November 8, 2016, at approximately 10:00 a.m. Employee E7, a Dietician, stated that the green room is a separate dining room for residents who need supervision and assistance with meals. Employee E7 also stated that Resident R12 had previous incidents of taking food from other residents' trays and the resident was very impulsive when the incidents occurred. During an interview on November 10, 2016, at approximately 12:00 p.m. Employee E6, a Speech Therapist, stated that Resident R12 was evaluated to be be safe to move to the general dining room for meals, but could not recall by whom or how the decision was determined. The facility failed to provide adequate and proper supervision during meals that resulted in an unsafe environment for one resident. Review of the clinical record for Resident R81 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set assessment (MDS - assessment of care needs) dated August 22, 2016, indicated that the resident had a BIMS (Brief Interview for Mental Status - a screening assessment to aid in determining cognitive impairment) score of 11, indicating that the resident was alert and oriented and cognitively intact. The same quarterly MDS noted that the resident ambulated independently in room and nursing unit and required supervision when in other areas of the facility. Review of the nursing progress notes dated October 9, 2016, at 7:00 a.m. stated that Resident R81, required supervision of 1:1 (in need of staff person to monitor and supervise resident at all times) continued due to resident altercation. Further review of the notes dated October 9, 2016, stated that Resident R81 was not to go out to smoke with other smokers. Review of the nursing progress notes of October 10, 2016, 3 - 11 note, at 7:55 a.m. stated that the resident's physician ordered a, psych consult. The nursing progress note of October 10, 2016, at 10:50 a.m. stated that Resident R81 was seen by a CRNP (Certified Registered Nurse Practioner) psychiatrist. There was no documentation or evidence that Resident R81 was assessed and evaluated by a psychologist and/or psychiatrist available during the days of the survey. Review of the clinical record revealed that Resident R81 was seen on August 29, 2016, by a CRNP (Certified Registered Nurse Practioner) for a Vistamed Psychiatry Follow Consultation. Review of the information dated October 8, 2016 submitted by the facility, stated that Resident R81 hit Resident R66 in the face on October 8, 2016, at 8:30 p.m. during a supervised smoke break. Resident R66 sustained a subconjunctival hemorrhage (broken blood vessel of the eye) of the left eye, according to the emergency room report, was treated and returned to the facility. The report also noted that the facility was actively pursuing appropriate placement for Resident R81. Review of the written statement completed by Employee E24,a NA (Nursing Assistant), assigned to supervise the residents' smoking break, revealed that Resident R66 stated that someone had stole his/her cigarettes that a family member had purchased. Resident R81 then advised Resident R66, why don't you shut your mouth up. Resident R66 then replied, Go and make me. Resident R12 then jumped up out of chair and Employee E24 noted that he/she advised Resident R81 to sit down and smoke cigarette. Resident R66 then stated ,Yeah you better sit down but Resident R81 pushed Employee E24 aside, even though Employee E24 had a hold of his/her sweater, and ran over to Resident R66 and punched him/her in the face. Review of Resident R12's statement revealed that the resident stated ,Resident R66 is a that is just what he/she is. Resident R81 also stated that Resident R66, agitated me and I swung at him/her. Review of the, Individualized Care Plan for Behaviors for Resident R81 revealed a problem/concern that resident has the potential of aggression to other residents and noted resident to resident altercations on 5/12/16, 6/27/16, 7/7/16, and 7/11/16. Further review of the behavior care plan noted written documentation dated 10/10/16, noted increased supervision and dated 10/12/16, noted, trial reduction of supervised observation in common areas. Review of the, Individualized Care Plan for Activities revealed a problem/concern dated 8/22/16, that the resident was, quick to anger. Review of the facility investigation for the altercation of May 11, 2016, (5/12/16 on the Care Plan) noted that Resident R81 was in the first floor dining room and punched Resident R49 in the back of the head. Resident R81 stated that R49 bumped him/her when attempting to sit down next to Resident R81. Review of the facility investigation for the altercation of July 6, 2016, noted that Resident R81 hit Resident R49 in the face while in the elevator on the way to a supervised smoke brake, following a verbal argument. Interventions for both of the altercations was to continue to monitor the resident. There was no documentation of the investigations for the altercations of June 27, 2016, or July 7, 2016, available during the days of the survey on November 7, 8, 9, and 10, 2016. During an interview on November 18, 2016, at approximately 11:45 a.m. Employee E4, the Assistant Director of Nursing, confirmed that Resident R81 had previous altercations with residents prior to October 8, 2016, but stated he/she did not recall specific interventions in place to prevent additional incidents. During the same interview, Employee E4 confirmed that the last psychiatric/psychological evaluation documented for Resident R81 was on August 29, 2016. The facility failed to provide adequate supervision for residents who exhibited aggressive behaviors, and provide a safe environment, and prevent physical and psychological injury to the other residents. Clinical record review for Resident R49 revealed physician's orders dated November 1, 2016, which indicated [DIAGNOSES REDACTED]. During an individual interview with Resident R49 on November 7, 2016, at 3:05 p.m. during the discussion about facility activities, it was revealed by Resident R49 that he goes to the dollar store, at the shopping center across the street from the facility, daily. Further review of Resident R49's clinical record revealed a physician's order, undated, indicating that Resident R49, May go on leave of absence to store independently. Review of Resident R49's care plans updated approximately on August 12, 2016, indicated a Care Plan for Activities, that indicated that Resident R49 may go to the store independently, needs to sign self out and follow facility guidelines related to LOA. A review of the facility policy and procedure titled, Leave of Absence (LOA), updated February 2012, revealed the following: 1. The facility will track the departure and return of the resident by use of the sign out sheet. 2. Resident is to provide facility staff with destination, projected time of return and contact information. 3. Evaluate condition upon return; notify physician of any concerns. Review of the LOA book, for the first floor nursing unit, revealed that resident R49 signed self out of facility as recently as the following dates; November 6, 3, October 31, 24, 21, 20, 13, 2016, and numerous, frequent, additional dates in the past three months. An interview with Employee E5, Licensed Nurse, on November 8, 2016, at 3:30 p.m. confirmed that Resident R49 does sign self out routinely, and indicated not being sure exactly where Resident R49 goes during a LOA. Also, no assessment was available to review which indicated that Resident R49 was assessed as able to safely leave the facility independently for a LOA. The facility failed to provide safe and adequate supervision during meals for one resident, during smoke break for two residents, and for a leave of absence of one resident, and to ensure adequate and safe supervision related to incontinence care for one resident that resulted in actual harm. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 12/04/14, 11/06/15, 07/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/04/14, 02/05/15, 11/06/15, 05/24/16, 07/19/16, 10/26/16 28 Pa. Code 201.18(a) Management Previously cited 02/05/15, 02/24/16, 07/19/16 28 Pa. Code 201.18(b)(1) Management Previously cited 12/04/14, 02/05/15, 11/06/15, 05/24/16, 07/19/16, 10/26/16 28 Pa. Code 201.18(b)(2) Management Previously cited 02/24/16, 05/24/16, 07/19/16 28 Pa. Code 201.18(b)(3) Management Previously cited 12/04/14, 02/05/15, 03/22/16, 07/19/16

Based on observation, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to prevent resident neglect by ensuring that two residents (Residents R8 and R9) with a documented history of physical and verbal altercation with each other, were adequately supervised with sufficient staffing to prevent injury, causing actual physical harm to one resident (Resident R8) and psychological harm to the other resident (Resident R9). Findings include: Review of the clinical record for Resident R9 revealed a social service progress note dated March 10, 2016, indicating the resident was admitted to the facility from an acute care hospital on March 9, 2016, with [DIAGNOSES REDACTED]. The social service progress note further revealed that Resident R9 was alert and oriented to self only (knowledge of person, not place or time) but was able to make basic needs known, had both short term and long term memory impairment and was moderately to severely impaired in decision making tasks. The social service progress note went on to state that Resident R9, at times presents as pleasant, yet unpredictable and demonstrates at times, verbal aggression and explosive behaviors. The social service progress note additionally indicated that Resident R9 required long term care services due to the need for 24 hour care and supervision. Review of a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated May 3, 2016, revealed that Resident R9 had additional [DIAGNOSES REDACTED].) and restlessness. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in determining cognitive impairment) score of 4, indicating that the resident was severely cognitively impaired. Additionally, the resident did not utilize any mobility devices (cane/crutch, walker, wheelchair or limb prosthesis), the resident could ambulate (how a resident walks) with supervision in the resident's room, in a corridor and on the nursing unit, and the resident exhibited wandering behavior (walking around without purpose) one to three days during the seven day MDS assessment period. Further review of the social service progress notes revealed that on April 11, 2016, Resident R9, attacked a staff member, by punching a nurse after the resident asked for a cigarette and the nurse told the resident there were no cigarettes available. On April 14, 2016, Resident R9, asked another resident for a cigarette (and) when (Resident R9) was told that the other resident did not have cigarettes, (Resident R9) punched the other resident. On April 16, 2016, social services noted that Resident R9 was being discharged from the facility to an acute care psychiatric hospital for evaluation. Review of the MDS tracking information in the facility's electronic medical record system confirmed that Resident R9 was out of the facility from April 15, 2016, through April 27, 2016. Review of the nursing progress notes revealed that on May 16, 2016, Resident R9 was confused and standing by the elevator waiting for the facility's established smoking time. The note stated that Resident R9 attempted to get on the elevator with the resident's roommate who informed Resident R9 that Resident R9 could not go down on the elevator alone. The note revealed that Resident R9, turned around and punched roommate in the chest, which was witnessed by a staff member. The note also indicated Resident R9 was verbally abusing staff and calling them a derogatory curse word. On June 19, 2016, Resident R9 was observed with aggressive behavior to another resident. Review of a social service progress note clarified that on June 19, 2016, Resident R9 was, becoming increasingly verbally aggressive, with residents and staff, insisting the resident has cigarettes when Resident R9 does not. The social service progress note further clarified that Resident R9's demeanor was, also becoming aggressive, with the resident clenching the fists and the resident's body, is becoming very tense as (Resident R9) is upset, and yelled and cursed at residents in the dining room at lunch. On June 21, 2016, the nursing progress notes revealed that after Resident R9 went out for the designated smoking time, the resident tried to get on the elevator to try to go to smoke more cigarettes. As another resident was coming off the elevator, Resident R9, grabbed (the other resident's) arm and tried to pull (the other resident) out (of) the wheelchair. On June 22, 2016, the nursing progress notes indicated that Resident R9 was placed on one-to-one supervision (1:1-staff member specifically assigned to closely watch and guard one resident). Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from June 22, 2016, through July 1, 2016. Review of a social service progress note dated July 1, 2016, revealed that while Resident R9 was being monitored on the 1:1 assignment at the nurses' station, another resident in a wheelchair (Resident R8) came behind Resident R9 and hit Resident R9 with the wheelchair and indicated, resident believes it was intentional. The social service progress note went on to reveal that Resident R9 punched Resident R8 in retaliation. Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from July 1, 2016, through July 8, 2016. Review of the social service progress notes dated July 8, 2016, revealed that a social worker witnessed Resident R9 in a, minor verbal altercation with another resident, requiring the social worker to separate Resident R9 from the other resident. Review of the information dated July 9, 2016, submitted by the facility, revealed that on July 8, 2016, around 9:00 p.m. both Residents R8 and R9 were in a dining room when staff observed Resident R9 approach Resident R8. The two residents began to argue, hit each other and both residents fell to the floor. Review of a nursing progress note from Employee E4, a Registered Nurse Supervisor, dated July 8, 2016, at 9:15 p.m. revealed that Employee E4 was notified of an altercation between residents. The note indicated that upon Employee E4's arrival to the second floor dining room, Resident R8 was on the floor in a sitting position, with the resident's nose bleeding and Resident R8's nasal bone, appeared (and) noted to be crooked on lateral side of nose. The nurses' note stated, PCP (Primary Care Physician) notified & new order for X-ray to nasal bones to R/O (rule out) fracture was ordered stat (immediately.) Review of a radiology report for Resident R8 dated July 8, 2016, indicated, fracture is seen at the tip of the nasal bones (broken nose). Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). Review of the facility's investigation documentation into the incident on July 8, 2016, revealed a statement from Resident R8 which was dated July 9, 2016. The statement indicated that while Resident R8 was in the dining room, Resident R9 walked over to Resident R8, a verbal exchange ensued (regarding if Resident R8 was still angry about the altercation that took place between the two residents on July 1, 2016). Resident R8 asked Resident R9 to move out of the resident's way and Resident R9 would not move. The statement further revealed that Resident R8 rolled the wheelchair towards Resident R9 since Resident R9 wouldn't move, and Resident R9 hit Resident R8 from behind, hit Resident R8 several times in the nose, and staff ran in to break them up and they (Residents R8 and R9) fell on the floor. Further review of the facility's investigation documentation revealed Resident R9 remained on 1:1 supervision until the resident was transferred to an acute care psychiatric hospital for evaluation on July 10, 2016. During an interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:30 p.m., Resident R9's behavior was described as being like a, pressure cooker, that the resident's aggression would gradually build over time and suddenly, without warning, Resident R9 would expel verbal and or physical aggression towards others, and then will be fine for a while. Review of the clinical record for Resident R8 revealed an annual MDS assessment dated [DATE], indicating that the resident had [DIAGNOSES REDACTED]. Review of a psychiatric consultation for Resident R8 dated July 15, 2016, revealed that the staff members reported the resident exhibited sexually inappropriate speech and innuendo, of which the resident denied. The consultation went on to report that Resident R8, does not accept limits/social norms, and had, no cognitive/social filter. No remorse. Verbally aggressive. Believe (Resident R8) will engage in physical altercation if provoked. Additional review of the clinical record for Resident R8 revealed no documentation regarding assessment or interventions to prevent any further behavioral issues with Resident R8. Observation of Resident R8 on July 19, 2016, at approximately 2:00 p.m. revealed the resident self-propelled in the wheelchair and addressed the assigned medication nurse, the facility's ADON, Assistant Director of Nursing, in the hallway near the medication cart, asking questions about the resident's medications. Further observation revealed Resident R8's voice escalated in a harsh tone towards the ADON, with Resident R8 swiftly and angrily self-propelling away from the ADON. During an interview with the ADON after the observation, the ADON stated that Resident R8 was upset that the ADON would not administer the resident's medications directly in the hallway, and was not happy when the ADON said the resident's medications needed to be administered in a private area, not out in the hallway. Interview with the Director of Nursing (DON) on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that the facility staff addressed the assessment made by the psychiatric consult. Review of the staffing for the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, there were three nursing assistants (NA's) that called off work and the facility failed to provide other staff to fill in for the three NA's. Further interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with the DON, in the presence of the Nursing Home Administrator (NHA), on July 19, 2016, at approximately 4:00 p.m. confirmed the three NA call offs on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016. Further interview with the DON and NHA, when asked where the 1:1 staff member was when both residents were found on the floor, the DON and NHA indicated they were unable to confirm that Resident R9 was on 1:1 supervision at the time of the incident. Review of a facility care plan audit related to resident behaviors (created as part of the facility's plan of correction for the deficiencies cited on May 24, 2016) dated July 12, 2016, acknowledged that Resident R9 hit another resident (Resident R8) on both July 1, 2016, and July 8, 2016, and that there were, 1:1 blanks on many days on the resident's, Observation Worksheets (documentation that NA's complete when they are assigned to 1:1 duty). Further review of the care plan audits revealed no documentation that the facility addressed the failure of the staff to complete the 1:1 observation worksheets, or that an investigation was initiated to determine the reason for the incomplete documentation. Interview with the DON on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that facility staff addressed the incomplete 1:1 documentation. Further review of clinical and facility documentation revealed no evidence that the facility had an established policy or protocol regarding 1:1 supervision of residents, including definition of what a 1:1 entails, how physically close a staff member needs to be located to a resident on 1:1 supervision, and regarding what the 1:1 staff member needs to document while performing the 1:1 duty. There was no documentation that the facility staff addressed how Resident R8 was able to get so physically close to Resident R9, a resident on 1:1 supervision, causing the incident with the wheelchair on July 1, 2016, or if any new interventions needed to be implemented after this incident. There was no documentation that the facility determined how Resident R9 (a resident with long-standing documented behaviors of physical and verbal aggression, severe cognitive impairment, and a history of a physical altercation with Resident R8), attacked and broke Resident R8's nose on July 8, 2016, while Resident R9 was on 1:1 supervision. Additionally, there was no documentation that the facility staff addressed Resident R8's (a resident with severe cognitive impairment, who freely self-propels throughout the facility without supervision, and was identified as not able to accept limits and will engage in physical altercation if provoked) own potential to harm other residents based on the professional psychiatric evaluation dated July 15, 2016. The facility failed to adequately supervise residents with sufficient staffing to prevent neglect for two residents with a history of physical and verbal aggression, which resulted in actual harm to Residents R8 and R9. Refer to F353 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 5/24/16, 3/22/16, 11/6/15, 2/5/15, 12/4/14 28 Pa Code 201.18(a) Management Previously cited 2/24/16, 2/5/15 28 Pa Code 201.18(b)(1) Management Previously cited 5/24/16, 2/24/16, 11/6/15, 12/04/14 28 Pa Code 201.18(b)(2) Management Previously cited 5/24/16, 2/24/16 28 Pa Code 201.18(b)(3) Management Previously cited 3/22/16, 2/5/15, 12/4/14 28 Pa Code 201.18(e)(1) Management Previously cited 5/24/16, 6/18/15, 12/4/14 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.29(a) Resident rights Previously cited 11/6/15 28 Pa Code 201.29(c) Resident rights Previously cited 5/24/16, 11/06/15 28 Pa Code 201.29(d) Resident rights Previously cited 5/24/16 28 Pa Code 211.5(f) Clinical records Previously cited 12/04/14 28 Pa Code 211.10(d) Resident care policies Previously cited 5/24/16, 2/24/16, 12/4/14 28 Pa Code 211.12(d)(1) Nursing services Previously cited 5/24/16, 11/6/15, 12/4/14 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(3)(5) Nursing services Previously cited 5/24/16, 11/6/15, 6/18/15, 12/4/14

Based on observation, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that two residents (Residents R8 and R9) with documented behaviors were adequately supervised to prevent injury, causing actual physical harm to one resident (Resident R8) and psychological harm to the other resident (Resident R9). Findings include: Review of the clinical record for Resident R9 revealed a social service progress note dated March 10, 2016, indicating the resident was admitted to the facility from an acute care hospital on March 9, 2016, with [DIAGNOSES REDACTED]. The social service progress note further revealed that Resident R9 was alert and oriented to self only (knowledge of person, not place or time) but was able to make basic needs known, had both short term and long term memory impairment and was moderately to severely impaired in decision making tasks. The social service progress note went on to state that Resident R9, at times presents as pleasant, yet unpredictable and demonstrates at times, verbal aggression and explosive behaviors. The social service progress note additionally indicated that Resident R9 required long term care services due to the need for 24 hour care and supervision. Review of a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated May 3, 2016, revealed that Resident R9 had additional [DIAGNOSES REDACTED].) and restlessness. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in determining cognitive impairment) score of 4, indicating that the resident was severely cognitively impaired. Additionally, the resident did not utilize any mobility devices (cane/crutch, walker, wheelchair or limb prosthesis), the resident could ambulate (how a resident walks) with supervision in the resident's room, in a corridor and on the nursing unit, and the resident exhibited wandering behavior (walking around without purpose) one to three days during the seven day MDS assessment period. Further review of the social service progress notes revealed that on April 11, 2016, Resident R9, attacked a staff member, by punching a nurse after the resident asked for a cigarette and the nurse told the resident there were no cigarettes available. On April 14, 2016, Resident R9, asked another resident for a cigarette (and) when (Resident R9) was told that the other resident did not have cigarettes, (Resident R9) punched the other resident. On April 16, 2016, social services noted that Resident R9 was being discharged from the facility to an acute care psychiatric hospital for evaluation. Review of the MDS tracking information in the facility's electronic medical record system confirmed that Resident R9 was out of the facility from April 15, 2016, through April 27, 2016. Review of the nursing progress notes revealed that on May 16, 2016, Resident R9 was confused and standing by the elevator waiting for the facility's established smoking time. The note stated that Resident R9 attempted to get on the elevator with the resident's roommate who informed Resident R9 that Resident R9 could not go down on the elevator alone. The note revealed that Resident R9, turned around and punched roommate in the chest, which was witnessed by a staff member. The note also indicated Resident R9 was verbally abusing staff and calling them a derogatory curse word. On June 19, 2016, Resident R9 was observed with aggressive behavior to another resident. Review of a social service progress note clarified that on June 19, 2016, Resident R9 was, becoming increasingly verbally aggressive, with residents and staff, insisting the resident has cigarettes when Resident R9 does not. The social service progress note further clarified that Resident R9's demeanor was, also becoming aggressive, with the resident clenching the fists and the resident's body, is becoming very tense as (Resident R9) is upset, and yelled and cursed at residents in the dining room at lunch. On June 21, 2016, the nursing progress notes revealed that after Resident R9 went out for the designated smoking time, the resident tried to get on the elevator to try to go to smoke more cigarettes. As another resident was coming off the elevator, Resident R9, grabbed (the other resident's) arm and tried to pull (the other resident) out (of) the wheelchair. On June 22, 2016, the nursing progress notes indicated that Resident R9 was placed on one-to-one supervision (1:1-staff member specifically assigned to closely watch and guard one resident). Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from June 22, 2016, through July 1, 2016. Review of a social service progress note dated July 1, 2016, revealed that while Resident R9 was being monitored on the 1:1 assignment at the nurses' station, another resident in a wheelchair (Resident R8) came behind Resident R9 and hit Resident R9 with the wheelchair and indicated, resident believes it was intentional. The social service progress note went on to reveal that Resident R9 punched Resident R8 in retaliation. Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from July 1, 2016, through July 8, 2016. Review of the social service progress notes dated July 8, 2016, revealed that a social worker witnessed Resident R9 in a, minor verbal altercation with another resident, requiring the social worker to separate Resident R9 from the other resident. Review of the information dated July 9, 2016, submitted by the facility, revealed that on July 8, 2016, around 9:00 p.m. both Residents R8 and R9 were in a dining room when staff observed Resident R9 approach Resident R8. The two residents began to argue, hit each other and both residents fell to the floor. Review of a nursing progress note from Employee E4, a Registered Nurse Supervisor, dated July 8, 2016, at 9:15 p.m. revealed that Employee E4 was notified of an altercation between residents. The note indicated that upon Employee E4's arrival to the second floor dining room, Resident R8 was on the floor in a sitting position, with the resident's nose bleeding and Resident R8's nasal bone, appeared (and) noted to be crooked on lateral side of nose. The nurses' note stated, PCP (Primary Care Physician) notified & new order for X-ray to nasal bones to R/O (rule out) fracture was ordered stat (immediately.) Review of a radiology report for Resident R8 dated July 8, 2016, indicated, fracture is seen at the tip of the nasal bones (broken nose). Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). Review of the facility's investigation documentation into the incident on July 8, 2016, revealed a statement from Resident R8 which was dated July 9, 2016. The statement indicated that while Resident R8 was in the dining room, Resident R9 walked over to Resident R8, a verbal exchange ensued (regarding if Resident R8 was still angry about the altercation that took place between the two residents on July 1, 2016). Resident R8 asked Resident R9 to move out of the resident's way and Resident R9 would not move. The statement further revealed that Resident R8 rolled the wheelchair towards Resident R9 since Resident R9 wouldn't move, and Resident R9 hit Resident R8 from behind, hit Resident R8 several times in the nose, and staff ran in to break them up and they (Residents R8 and R9) fell on the floor. Further review of the facility's investigation documentation revealed Resident R9 remained on 1:1 supervision until the resident was transferred to an acute care psychiatric hospital for evaluation on July 10, 2016. During an interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:30 p.m., Resident R9's behavior was described as being like a, pressure cooker, that the resident's aggression would gradually build over time and suddenly, without warning, Resident R9 would expel verbal and or physical aggression towards others, and then will be fine for a while. Review of the clinical record for Resident R8 revealed an annual MDS assessment dated [DATE], indicating that the resident had [DIAGNOSES REDACTED]. Review of a psychiatric consultation for Resident R8 dated July 15, 2016, revealed that the staff members reported the resident exhibited sexually inappropriate speech and innuendo, of which the resident denied. The consultation went on to report that Resident R8, does not accept limits/social norms, and had, no cognitive/social filter. No remorse. Verbally aggressive. Believe (Resident R8) will engage in physical altercation if provoked. Additional review of the clinical record for Resident R8 revealed no documentation regarding assessment or interventions to prevent any further behavioral issues with Resident R8. Observation of Resident R8 on July 19, 2016, at approximately 2:00 p.m. revealed the resident self-propelled in the wheelchair and addressed the assigned medication nurse, the facility's ADON, Assistant Director of Nursing, in the hallway near the medication cart, asking questions about the resident's medications. Further observation revealed Resident R8's voice escalated in a harsh tone towards the ADON, with Resident R8 swiftly and angrily self-propelling away from the ADON. During an interview with the ADON after the observation, the ADON stated that Resident R8 was upset that the ADON would not administer the resident's medications directly in the hallway, and was not happy when the ADON said the resident's medications needed to be administered in a private area, not out in the hallway. Interview with the Director of Nursing (DON) on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that the facility staff addressed the assessment made by the psychiatric consult. Review of the staffing for the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, there were three nursing assistants (NA's) that called off work and the facility failed to provide other staff to fill in for the three NA's. Further interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with Employee E6 on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with the DON, in the presence of the Nursing Home Administrator (NHA), on July 19, 2016, at approximately 4:00 p.m. confirmed the three NA call offs on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016. Further interview with the DON and NHA, when asked where the 1:1 staff member was when both residents were found on the floor, the DON and NHA indicated they were unable to confirm that Resident R9 was on 1:1 supervision at the time of the incident. Review of a facility care plan audit related to resident behaviors (created as part of the facility's plan of correction for the deficiencies cited on May 24, 2016) dated July 12, 2016, acknowledged that Resident R9 hit another resident (Resident R8) on both July 1, 2016, and July 8, 2016, and that there were, 1:1 blanks on many days on the resident's, Observation Worksheets (documentation that NA's complete when they are assigned to 1:1 duty). Further review of the care plan audits revealed no documentation that the facility addressed the failure of the staff to complete the 1:1 observation worksheets, or that an investigation was initiated to determine the reason for the incomplete documentation. Interview with the DON on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that facility staff addressed the incomplete 1:1 documentation. Further review of clinical and facility documentation revealed no evidence that the facility had an established policy or protocol regarding 1:1 supervision of residents, including definition of what a 1:1 entails, how physically close a staff member needs to be located to a resident on 1:1 supervision, and regarding what the 1:1 staff member needs to document while performing the 1:1 duty. There was no documentation that the facility staff addressed how Resident R8 was able to get so physically close to Resident R9, a resident on 1:1 supervision, causing the incident with the wheelchair on July 1, 2016, or if any new interventions needed to be implemented after this incident. There was no documentation that the facility determined how Resident R9 (a resident with long-standing documented behaviors of physical and verbal aggression, severe cognitive impairment, and a history of a physical altercation with Resident R8), attacked and broke Resident R8's nose on July 8, 2016, while Resident R9 was on 1:1 supervision. Additionally, there was no documentation that the facility staff addressed Resident R8's (a resident with severe cognitive impairment, who freely self-propels throughout the facility without supervision, and was identified as not able to accept limits and will engage in physical altercation if provoked) own potential to harm other residents based on the professional psychiatric evaluation dated July 15, 2016. The facility failed to adequately supervise residents to prevent physical and psychological injury. This failure resulted in actual harm to Residents R8 and R9. 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/6/15, 12/4/14 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 5/24/16, 3/22/16, 11/6/15, 2/5/15, 12/4/14 28 Pa Code 201.18(a) Management Previously cited 2/24/16, 2/5/15 28 Pa Code 201.18(b)(1) Management Previously cited 5/24/16, 2/24/16, 11/6/15, 12/04/14 28 Pa Code 201.18(b)(2) Management Previously cited 5/24/16, 2/24/16 28 Pa Code 201.18(b)(3) Management Previously cited 3/22/16, 2/5/15, 12/4/14 28 Pa Code 201.18(e)(1) Management Previously cited 5/24/16, 6/18/15, 12/4/14 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.29(a) Resident rights Previously cited 5/24/16, 11/6/15 28 Pa Code 201.29(c) Resident rights Previously cited 5/24/16, 11/06/15 28 Pa Code 201.29(d) Resident rights Previously cited 5/24/16 28 Pa Code 211.5(f) Clinical records Previously cited 12/04/14 28 Pa Code 211.10(d) Resident care policies Previously cited 5/24/16, 2/24/16, 12/4/14 28 Pa Code 211.12(d)(1) Nursing services Previously cited 5/24/16, 11/6/15, 12/4/14 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(3)(5) Nursing services Previously cited 5/24/16, 11/6/15, 6/18/15, 12/4/14

Based on review of clinical records and facility documentation, and interviews with staff, and as evidenced by the deficient practice cited in this report, the facility failed to ensure sufficient nursing staff was available to provide effective nursing services. The facility failed to ensure that two residents (Residents R8 and R9) with documented behaviors were adequately supervised to prevent injury, causing actual physical harm to one resident (Resident R8) and psychosocial harm to the other resident (Resident R9). Findings include: Review of the information dated July 9, 2016, submitted by the facility, revealed that on July 8, 2016, around 9:00 p.m. both Residents R8 and R9 were in a dining room when the staff observed Resident R9 approach Resident R8. The two residents began to argue, hit each other, and fell to the floor. Review of a nursing progress note from Employee E4, a Registered Nurse Supervisor, dated July 8, 2016, at 9:15 p.m. revealed that Employee E4 was notified of an altercation between residents. The note indicated that upon Employee E4's arrival to the second floor dining room, Resident R8 was on the floor in a sitting position, with the resident's nose bleeding and Resident R8's nasal bone, appeared (and) noted to be crooked on lateral side of nose. Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). The nurses' note stated, PCP (Primary Care Physician) notified & new order for X-ray to nasal bones to R/O (rule out) fracture was ordered stat (immediately.) Review of a radiology report for Resident R8 dated July 8, 2016, indicated, fracture is seen at the tip of the nasal bones (broken nose). Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). Review of the facility's investigation documentation into the incident on July 8, 2016, revealed a statement from Resident R8, dated July 9, 2016. The statement indicated that while Resident R8 was in the dining room, Resident R9 walked over to Resident R8, a verbal exchange ensued (regarding if Resident R8 was still angry about the altercation that took place between the two residents on July 1, 2016). Resident R8 asked Resident R9 to move out of the resident's way and Resident R9 would not move. The statement further revealed that Resident R8 rolled the wheelchair towards Resident R9 since Resident R9 wouldn't move, and Resident R9 hit Resident R8 from behind, hit Resident R8 several times in the nose, and, staff ran in to break them up and they (Residents R8 and R9) fell on the floor. Further review of the facility's investigation documentation revealed Resident R9 remained on 1:1 supervision until the resident was transferred to an acute care psychiatric hospital for evaluation on July 10, 2016. Review of the staffing for the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, there were three nursing assistants (NA's) that called off work and the facility failed to provide other staff to fill in for the three NA's. Further interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with the Director of Nursing (DON), in the presence of the Nursing Home Administrator (NHA), on July 19, 2016, at approximately 4:00 p.m. confirmed the three NA call offs on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016. Further interview with the DON and NHA, when asked where the 1:1 staff member was when both residents were found on the floor, the DON and NHA indicated they were unable to confirm that Resident R9 was on 1:1 supervision at the time of the incident. The facility failed to provide adequate staffing to supervise residents to prevent physical and psychological injury. This failure resulted in actual harm to Residents R8 and R9. Refer to F323 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 5/24/16, 3/22/16, 11/6/15, 2/5/15, 12/4/14 28 Pa Code 201.18(a) Management Previously cited 2/24/16, 2/5/15 28 Pa Code 201.18(b)(1) Management Previously cited 5/24/16, 2/24/16, 11/6/15, 12/04/14 28 Pa Code 201.18(b)(2) Management Previously cited 5/24/16, 2/24/16 28 Pa Code 201.18(b)(3) Management Previously cited 3/22/16, 2/5/15, 12/4/14 28 Pa Code 201.18(e)(1) Management Previously cited 5/24/16, 6/18/15, 12/4/14 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.29(a) Resident rights Previously cited 11/6/15 28 Pa Code 201.29(c) Resident rights Previously cited 5/24/16, 11/06/15 28 Pa Code 201.29(d) Resident rights Previously cited 5/24/16 28 Pa Code 211.5(f) Clinical records Previously cited 12/04/14 28 Pa Code 211.10(d) Resident care policies Previously cited 5/24/16, 2/24/16, 12/4/14 28 Pa Code 211.12(d)(1) Nursing services Previously cited 5/24/16, 11/6/15, 12/4/14 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(3)(5) Nursing services Previously cited 5/24/16, 11/6/15, 6/18/15, 12/4/14

Based on clinical record reviews, facility documentation and staff interviews, it was determined that the facility failed to provide adequate monitoring and supervision for a resident with a history of behaviors including sexually abusing cognitively impaired residents (Resident R1), resulting in actual harm for one of seven residents reviewed (Resident R6). Findings include: According to the, American Psychological Association, sexual abuse is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent. According to, The Technical Assistance Manual for Pennsylvania's Sexual Violence Centers, a working definition of elder sexual abuse is, Anytime a person 60 and over is forced, tricked, coerced, or manipulated into unwanted sexual contact. It also includes sexual contact with elders who are unable to grant informed consent . Review of Resident R1's clinical record revealed a quarterly Minimum Data Set assessment (MDS-a periodic comprehensive assessment of needs) dated April 14, 2016, that indicated Resident R1 was cognitively intact with a BIMS score of 15 (Brief Interview of Mental Status - a brief screener that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0 to 7 severe impairment) and had [DIAGNOSES REDACTED]. Review of Resident R6's clinical record revealed an annual MDS assessment dated [DATE], indicating that Resident R6 was severely cognitively impaired with a BIMS Score of 6, required assistance of one staff for ambulation, had [DIAGNOSES REDACTED]. Review of the interdisciplinary plan of care meeting summaries, dated November 12, 2015, December 3, 2015, and February 9, 2016, noted that Resident R1 was abusive to the staff and was inappropriate to female staff and female residents. Review of Resident R1's behavior plan of care for inappropriate behaviors (sexually touching residents and staff) and aggression, such as grabbing female staff's breast and buttocks while they are trying to provide care as well as being sexually inappropriate towards female residents and staff included interventions such as separation from residents, not to corner the resident, psychiatric services and routine monitoring. Review of nursing documentation dated February 25, 2016, for the 11:00 p.m. to 7:00 a.m., nursing shift, noted that Resident R1 had been sexually inappropriate with the nurse aide, as Resident R1 had touched the nurse aide's buttocks while the nurse aide was providing care. Review of a written statement that was dated March 3, 2016, by Resident R3 who was alert and oriented, with a BIMS score of 15 according to her most recent annual MDS assessment dated [DATE], revealed that on March 1, 2016, she was sitting in front of the nursing station when Resident R1 had come over to her and, .proceeded to put his hand up my leg to my vaginal area, I pushed his hand away. A nursing note on March 30, 2016, at 4:00 p.m., stated that Resident R1 was, having a behavior with staff and another resident. There was no description of the behavior or indication of how staff addressed the behavior. On April 3, 2016, nursing documentation at 4:00 p.m. stated that the resident's physician had been informed during a telephone conversation that there were increased behaviors. There was no further description of what the behaviors were or what interventions were added. On April 25, 2016, the Director of Social Services had documented that Resident R1 had been found in his room with his hand up Resident R6's shirt fondling her breast, that staff had interrupted this, and Social Services had advised him this was unacceptable behavior and he should not do it again. A written statement dated May 4, 2016 at 3:15 p.m., by Employee E12, a member of the nursing staff, revealed that she had observed that Resident R1 had his hands up Resident R6's shirt. Resident R6 was observed, at the time, to have a riblet (a small cut of rib meat) that Resident R1 had given her off of his lunch tray. Employee E12 revealed that Resident R6 was ordered a pureed diet (consists of foods that do not require chewing). Employee E4, the Second Floor Nursing Unit Manager, stated in an interview on May 24, 2016 at approximately 11:30 a.m., that she told the Social Worker, (Employee E11) about the incident that occurred on April 25, 2016, that Resident R1 had enticed Resident R6, with food that Resident R6 was not supposed to have in his room, and Employee E11 did not really do any follow up after the incident, that basically Resident R1 would just be moved away from other residents and staff. The Second Floor Nursing Unit Manager added that she had not immediately put anything in place to consistently monitor Resident R1 after this event, and that she probably should have, that Resident R1 was being checked on by staff every 15 minutes, stating that, a lot can happen in 15 minutes. There was no evidence available at the time of the survey that the facility had completed an investigation of this event and no evidence that the facility had put in place interventions at that time to prevent future occurrences and to protect Resident R6 and other residents. A nursing note dated April 30, 2016, (no time indicated), stated that the nurse aide had reported that Resident R1, had inappropriate sexual behavior, that Resident R1, had been seen with his hand inside the resident's (Resident R6) incontinence brief, that the nurse aide removed Resident R6 from the room, that the nurse interviewed Resident R1, that Resident R1, admitted to touching, Resident R6's leg and that the physician and social services would be notified on Monday, (May 2, 2016, two days later). On May 2, 2016, Resident R1 was moved to the First Floor Nursing Unit. On May 2, 2016, the physician ordered a psychiatric consultation due to hyper sexual urges. Nursing documentation for May 2, 2016 at 1:00 p.m., reported that the local law enforcement agency had been notified of the inappropriate sexual behavior, that Resident R1 did not want to speak with the police officer, that Resident R1 had admitted to the Assistant Director of Nursing and the Nursing Home Administrator that he, had touched (the resident's) breast a few times. Resident R1 was moved to another nursing unit and continued to be checked every 15 minutes. Nursing documentation dated May 4, 2016 at 6:20 p.m., revealed that Resident R1 had been transferred to a hospital psychiatric unit. This was confirmed by the Director of Nursing in an interview at approximately 11:00 a.m. on May 24, 2016. The resident returned to the facility on [DATE]. Nursing documentation for May 19, 20, 21, and 22, 2016, continued to report that Resident R1 was verbally abusing staff, propositioning staff and stated he wanted to touch their breasts, was touching staff buttocks and that the resident was not easily redirected. Facility documentation regarding the events of April 30, 2016, included an undated written statement made by Employee E13, a Registered Nurse, that noted, I am aware of other incidents that involved (Resident R1) touching female residents, that (Resident R1) had an incident of touching and kissing (Resident R5) , an [AGE] year old, cognitively impaired resident. Resident R5 had a BIMS score of 5 according to her March 5, 2016 quarterly MDS. At the time of the survey there was no evidence that this incident had been investigated or documented. Employee E13 further stated that she had been in clinical meetings (attended by the Nursing Home Administrator, the Director of Nursing and other department directors) where Resident R1's, inappropriate sexual behavior had been discussed, and that the, inappropriate behavior has been occurring over the past year. Resident R1 was observed on May 24, 2016 at approximately 11:00 a.m., sitting in his wheelchair, by himself, in front of the first floor dining room. The facility failed to insure the safety of cognitively impaired female residents, protecting them from sexual abuse from a cognitively intact male resident with documented repeated displays of inappropriate verbal and physical sexual behaviors and aggression resulting in actual harm. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/06/15, 12/04/14 28 Pa. Code 201.18(b)(1) Management Previously cited 02/24/16, 11/06/15, 12/04/14 28 Pa. Code 201.29(a) Resident rights Previously cited 11/06/15 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/06/15, 12/04/14 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/06/15, 06/18/15, 12/04/14

Based on observation, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that two residents (Residents R8 and R9) with documented behaviors were adequately supervised to prevent injury, causing actual physical harm to one resident (Resident R8) and psychological harm to the other resident (Resident R9). Findings include: Review of the clinical record for Resident R9 revealed a social service progress note dated March 10, 2016, indicating the resident was admitted to the facility from an acute care hospital on March 9, 2016, with [DIAGNOSES REDACTED]. The social service progress note further revealed that Resident R9 was alert and oriented to self only (knowledge of person, not place or time) but was able to make basic needs known, had both short term and long term memory impairment and was moderately to severely impaired in decision making tasks. The social service progress note went on to state that Resident R9, at times presents as pleasant, yet unpredictable and demonstrates at times, verbal aggression and explosive behaviors. The social service progress note additionally indicated that Resident R9 required long term care services due to the need for 24 hour care and supervision. Review of a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated May 3, 2016, revealed that Resident R9 had additional [DIAGNOSES REDACTED].) and restlessness. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in determining cognitive impairment) score of 4, indicating that the resident was severely cognitively impaired. Additionally, the resident did not utilize any mobility devices (cane/crutch, walker, wheelchair or limb prosthesis), the resident could ambulate (how a resident walks) with supervision in the resident's room, in a corridor and on the nursing unit, and the resident exhibited wandering behavior (walking around without purpose) one to three days during the seven day MDS assessment period. Further review of the social service progress notes revealed that on April 11, 2016, Resident R9, attacked a staff member, by punching a nurse after the resident asked for a cigarette and the nurse told the resident there were no cigarettes available. On April 14, 2016, Resident R9, asked another resident for a cigarette (and) when (Resident R9) was told that the other resident did not have cigarettes, (Resident R9) punched the other resident. On April 16, 2016, social services noted that Resident R9 was being discharged from the facility to an acute care psychiatric hospital for evaluation. Review of the MDS tracking information in the facility's electronic medical record system confirmed that Resident R9 was out of the facility from April 15, 2016, through April 27, 2016. Review of the nursing progress notes revealed that on May 16, 2016, Resident R9 was confused and standing by the elevator waiting for the facility's established smoking time. The note stated that Resident R9 attempted to get on the elevator with the resident's roommate who informed Resident R9 that Resident R9 could not go down on the elevator alone. The note revealed that Resident R9, turned around and punched roommate in the chest, which was witnessed by a staff member. The note also indicated Resident R9 was verbally abusing staff and calling them a derogatory curse word. On June 19, 2016, Resident R9 was observed with aggressive behavior to another resident. Review of a social service progress note clarified that on June 19, 2016, Resident R9 was, becoming increasingly verbally aggressive, with residents and staff, insisting the resident has cigarettes when Resident R9 does not. The social service progress note further clarified that Resident R9's demeanor was, also becoming aggressive, with the resident clenching the fists and the resident's body, is becoming very tense as (Resident R9) is upset, and yelled and cursed at residents in the dining room at lunch. On June 21, 2016, the nursing progress notes revealed that after Resident R9 went out for the designated smoking time, the resident tried to get on the elevator to try to go to smoke more cigarettes. As another resident was coming off the elevator, Resident R9, grabbed (the other resident's) arm and tried to pull (the other resident) out (of) the wheelchair. On June 22, 2016, the nursing progress notes indicated that Resident R9 was placed on one-to-one supervision (1:1-staff member specifically assigned to closely watch and guard one resident). Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from June 22, 2016, through July 1, 2016. Review of a social service progress note dated July 1, 2016, revealed that while Resident R9 was being monitored on the 1:1 assignment at the nurses' station, another resident in a wheelchair (Resident R8) came behind Resident R9 and hit Resident R9 with the wheelchair and indicated, resident believes it was intentional. The social service progress note went on to reveal that Resident R9 punched Resident R8 in retaliation. Further review of the nursing progress notes revealed that Resident R9 remained on 1:1 supervision from July 1, 2016, through July 8, 2016. Review of the social service progress notes dated July 8, 2016, revealed that a social worker witnessed Resident R9 in a, minor verbal altercation with another resident, requiring the social worker to separate Resident R9 from the other resident. Review of the information dated July 9, 2016, submitted by the facility, revealed that on July 8, 2016, around 9:00 p.m. both Residents R8 and R9 were in a dining room when staff observed Resident R9 approach Resident R8. The two residents began to argue, hit each other and both residents fell to the floor. Review of a nursing progress note from Employee E4, a Registered Nurse Supervisor, dated July 8, 2016, at 9:15 p.m. revealed that Employee E4 was notified of an altercation between residents. The note indicated that upon Employee E4's arrival to the second floor dining room, Resident R8 was on the floor in a sitting position, with the resident's nose bleeding and Resident R8's nasal bone, appeared (and) noted to be crooked on lateral side of nose. The nurses' note stated, PCP (Primary Care Physician) notified & new order for X-ray to nasal bones to R/O (rule out) fracture was ordered stat (immediately.) Review of a radiology report for Resident R8 dated July 8, 2016, indicated, fracture is seen at the tip of the nasal bones (broken nose). Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). Review of the facility's investigation documentation into the incident on July 8, 2016, revealed a statement from Resident R8 which was dated July 9, 2016. The statement indicated that while Resident R8 was in the dining room, Resident R9 walked over to Resident R8, a verbal exchange ensued (regarding if Resident R8 was still angry about the altercation that took place between the two residents on July 1, 2016). Resident R8 asked Resident R9 to move out of the resident's way and Resident R9 would not move. The statement further revealed that Resident R8 rolled the wheelchair towards Resident R9 since Resident R9 wouldn't move, and Resident R9 hit Resident R8 from behind, hit Resident R8 several times in the nose, and staff ran in to break them up and they (Residents R8 and R9) fell on the floor. Further review of the facility's investigation documentation revealed Resident R9 remained on 1:1 supervision until the resident was transferred to an acute care psychiatric hospital for evaluation on July 10, 2016. During an interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:30 p.m., Resident R9's behavior was described as being like a, pressure cooker, that the resident's aggression would gradually build over time and suddenly, without warning, Resident R9 would expel verbal and or physical aggression towards others, and then will be fine for a while. Review of the clinical record for Resident R8 revealed an annual MDS assessment dated [DATE], indicating that the resident had [DIAGNOSES REDACTED]. Review of a psychiatric consultation for Resident R8 dated July 15, 2016, revealed that the staff members reported the resident exhibited sexually inappropriate speech and innuendo, of which the resident denied. The consultation went on to report that Resident R8, does not accept limits/social norms, and had, no cognitive/social filter. No remorse. Verbally aggressive. Believe (Resident R8) will engage in physical altercation if provoked. Additional review of the clinical record for Resident R8 revealed no documentation regarding assessment or interventions to prevent any further behavioral issues with Resident R8. Observation of Resident R8 on July 19, 2016, at approximately 2:00 p.m. revealed the resident self-propelled in the wheelchair and addressed the assigned medication nurse, the facility's ADON, Assistant Director of Nursing, in the hallway near the medication cart, asking questions about the resident's medications. Further observation revealed Resident R8's voice escalated in a harsh tone towards the ADON, with Resident R8 swiftly and angrily self-propelling away from the ADON. During an interview with the ADON after the observation, the ADON stated that Resident R8 was upset that the ADON would not administer the resident's medications directly in the hallway, and was not happy when the ADON said the resident's medications needed to be administered in a private area, not out in the hallway. Interview with the Director of Nursing (DON) on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that the facility staff addressed the assessment made by the psychiatric consult. Review of the staffing for the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, there were three nursing assistants (NA's) that called off work and the facility failed to provide other staff to fill in for the three NA's. Further interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with Employee E6 on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with the DON, in the presence of the Nursing Home Administrator (NHA), on July 19, 2016, at approximately 4:00 p.m. confirmed the three NA call offs on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016. Further interview with the DON and NHA, when asked where the 1:1 staff member was when both residents were found on the floor, the DON and NHA indicated they were unable to confirm that Resident R9 was on 1:1 supervision at the time of the incident. Review of a facility care plan audit related to resident behaviors (created as part of the facility's plan of correction for the deficiencies cited on May 24, 2016) dated July 12, 2016, acknowledged that Resident R9 hit another resident (Resident R8) on both July 1, 2016, and July 8, 2016, and that there were, 1:1 blanks on many days on the resident's, Observation Worksheets (documentation that NA's complete when they are assigned to 1:1 duty). Further review of the care plan audits revealed no documentation that the facility addressed the failure of the staff to complete the 1:1 observation worksheets, or that an investigation was initiated to determine the reason for the incomplete documentation. Interview with the DON on July 19, 2016, at approximately 4:00 p.m. confirmed there was no documentation that facility staff addressed the incomplete 1:1 documentation. Further review of clinical and facility documentation revealed no evidence that the facility had an established policy or protocol regarding 1:1 supervision of residents, including definition of what a 1:1 entails, how physically close a staff member needs to be located to a resident on 1:1 supervision, and regarding what the 1:1 staff member needs to document while performing the 1:1 duty. There was no documentation that the facility staff addressed how Resident R8 was able to get so physically close to Resident R9, a resident on 1:1 supervision, causing the incident with the wheelchair on July 1, 2016, or if any new interventions needed to be implemented after this incident. There was no documentation that the facility determined how Resident R9 (a resident with long-standing documented behaviors of physical and verbal aggression, severe cognitive impairment, and a history of a physical altercation with Resident R8), attacked and broke Resident R8's nose on July 8, 2016, while Resident R9 was on 1:1 supervision. Additionally, there was no documentation that the facility staff addressed Resident R8's (a resident with severe cognitive impairment, who freely self-propels throughout the facility without supervision, and was identified as not able to accept limits and will engage in physical altercation if provoked) own potential to harm other residents based on the professional psychiatric evaluation dated July 15, 2016. The facility failed to adequately supervise residents to prevent physical and psychological injury. This failure resulted in actual harm to Residents R8 and R9. 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/6/15, 12/4/14 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 5/24/16, 3/22/16, 11/6/15, 2/5/15, 12/4/14 28 Pa Code 201.18(a) Management Previously cited 2/24/16, 2/5/15 28 Pa Code 201.18(b)(1) Management Previously cited 5/24/16, 2/24/16, 11/6/15, 12/04/14 28 Pa Code 201.18(b)(2) Management Previously cited 5/24/16, 2/24/16 28 Pa Code 201.18(b)(3) Management Previously cited 3/22/16, 2/5/15, 12/4/14 28 Pa Code 201.18(e)(1) Management Previously cited 5/24/16, 6/18/15, 12/4/14 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.29(a) Resident rights Previously cited 5/24/16, 11/6/15 28 Pa Code 201.29(c) Resident rights Previously cited 5/24/16, 11/06/15 28 Pa Code 201.29(d) Resident rights Previously cited 5/24/16 28 Pa Code 211.5(f) Clinical records Previously cited 12/04/14 28 Pa Code 211.10(d) Resident care policies Previously cited 5/24/16, 2/24/16, 12/4/14 28 Pa Code 211.12(d)(1) Nursing services Previously cited 5/24/16, 11/6/15, 12/4/14 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(3)(5) Nursing services Previously cited 5/24/16, 11/6/15, 6/18/15, 12/4/14

Based on review of clinical records and facility documentation, and interviews with staff, and as evidenced by the deficient practice cited in this report, the facility failed to ensure sufficient nursing staff was available to provide effective nursing services. The facility failed to ensure that two residents (Residents R8 and R9) with documented behaviors were adequately supervised to prevent injury, causing actual physical harm to one resident (Resident R8) and psychosocial harm to the other resident (Resident R9). Findings include: Review of the information dated July 9, 2016, submitted by the facility, revealed that on July 8, 2016, around 9:00 p.m. both Residents R8 and R9 were in a dining room when the staff observed Resident R9 approach Resident R8. The two residents began to argue, hit each other, and fell to the floor. Review of a nursing progress note from Employee E4, a Registered Nurse Supervisor, dated July 8, 2016, at 9:15 p.m. revealed that Employee E4 was notified of an altercation between residents. The note indicated that upon Employee E4's arrival to the second floor dining room, Resident R8 was on the floor in a sitting position, with the resident's nose bleeding and Resident R8's nasal bone, appeared (and) noted to be crooked on lateral side of nose. Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). The nurses' note stated, PCP (Primary Care Physician) notified & new order for X-ray to nasal bones to R/O (rule out) fracture was ordered stat (immediately.) Review of a radiology report for Resident R8 dated July 8, 2016, indicated, fracture is seen at the tip of the nasal bones (broken nose). Review of another nursing progress note, dated July 8, 2016, at 10:10 p.m. revealed that while Resident R9 was on 1:1 supervision, the nurse was notified of an altercation with Resident R9 and another resident (Resident R8). Review of the facility's investigation documentation into the incident on July 8, 2016, revealed a statement from Resident R8, dated July 9, 2016. The statement indicated that while Resident R8 was in the dining room, Resident R9 walked over to Resident R8, a verbal exchange ensued (regarding if Resident R8 was still angry about the altercation that took place between the two residents on July 1, 2016). Resident R8 asked Resident R9 to move out of the resident's way and Resident R9 would not move. The statement further revealed that Resident R8 rolled the wheelchair towards Resident R9 since Resident R9 wouldn't move, and Resident R9 hit Resident R8 from behind, hit Resident R8 several times in the nose, and, staff ran in to break them up and they (Residents R8 and R9) fell on the floor. Further review of the facility's investigation documentation revealed Resident R9 remained on 1:1 supervision until the resident was transferred to an acute care psychiatric hospital for evaluation on July 10, 2016. Review of the staffing for the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, there were three nursing assistants (NA's) that called off work and the facility failed to provide other staff to fill in for the three NA's. Further interview with Employee E6, the Social Service Director, on July 19, 2016, at approximately 2:35 p.m. revealed that on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016, when the altercation between Residents R8 and R9 occurred, the facility, did not have enough staff to cover the 1:1 that night. Further interview with the Director of Nursing (DON), in the presence of the Nursing Home Administrator (NHA), on July 19, 2016, at approximately 4:00 p.m. confirmed the three NA call offs on the 3:00 p.m. to 11:00 p.m. shift on July 8, 2016. Further interview with the DON and NHA, when asked where the 1:1 staff member was when both residents were found on the floor, the DON and NHA indicated they were unable to confirm that Resident R9 was on 1:1 supervision at the time of the incident. The facility failed to provide adequate staffing to supervise residents to prevent physical and psychological injury. This failure resulted in actual harm to Residents R8 and R9. Refer to F323 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 5/24/16, 3/22/16, 11/6/15, 2/5/15, 12/4/14 28 Pa Code 201.18(a) Management Previously cited 2/24/16, 2/5/15 28 Pa Code 201.18(b)(1) Management Previously cited 5/24/16, 2/24/16, 11/6/15, 12/04/14 28 Pa Code 201.18(b)(2) Management Previously cited 5/24/16, 2/24/16 28 Pa Code 201.18(b)(3) Management Previously cited 3/22/16, 2/5/15, 12/4/14 28 Pa Code 201.18(e)(1) Management Previously cited 5/24/16, 6/18/15, 12/4/14 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.29(a) Resident rights Previously cited 11/6/15 28 Pa Code 201.29(c) Resident rights Previously cited 5/24/16, 11/06/15 28 Pa Code 201.29(d) Resident rights Previously cited 5/24/16 28 Pa Code 211.5(f) Clinical records Previously cited 12/04/14 28 Pa Code 211.10(d) Resident care policies Previously cited 5/24/16, 2/24/16, 12/4/14 28 Pa Code 211.12(d)(1) Nursing services Previously cited 5/24/16, 11/6/15, 12/4/14 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(d)(3)(5) Nursing services Previously cited 5/24/16, 11/6/15, 6/18/15, 12/4/14