Every finding on record at Sunnyview Nursing and Rehabilitation Center

Based on review of facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three of eight sampled residents (Resident R9, R12, and R90).Findings include: The facility ADL Care Mobility-Ambulation; Restorative Ambulation Program policy dated 1/27/26, indicated activities of daily living (ADL) documentation will be completed by the nurse aide that provided the assistance (and other licensed nursing personnel that provide assistance) by the end of each shift. Review of the clinical record revealed Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/1/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and depression. Review of Resident R9's clinical nurse notes and ADL documentation did not indicate that he received a haircut. During an interview and observation on 7/27/26, at 11:12 a.m. Resident R9 was observed with disheveled long hair and a long beard. Resident R90 stated I didn't get a chance to get to go down for a haircut, I never had beard before. Resident R9 stated I shaved every other day, I never had long hair. During an interview on 7/28/26, at 2:03 p.m. Staff Educator, Employee E20 confirmed Resident R9 needed hair services. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/14/26, indicated diagnoses cancer, hypertension, and depression. Review of Resident R12's clinical nurse notes and ADL documentation did not indicate that she received a nail care. During an observation on 7/27/26, at 11:52 a.m. Resident R12 was observed with long unclean nails that were curling. During an interview on 7/28/26, at 2:12 p.m. Occupational Therapist, Employee E21 confirmed Resident R12's nails were curling and needed nail services. Review of the clinical record revealed Resident R90 was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/7/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and diabetes ( occurs when your blood sugar (glucose) is too high. It develops when your pancreas doesn't make enough insulin or any at all). Review of Resident R90's clinical nurse notes and ADL documentation did not indicate that he received a haircut. During an interview and observation on 7/27/26, at 10:58 a.m. Resident R9 was observed with disheveled long hair and a long beard. Resident R90 stated I was supposed to get my haircut but no one ever showed up. Resident R90 stated he wants everything cut off. During an interview on 7/28/26, at 2:02 p.m. Social Woker, Employee E19 confirmed Resident R90 had not received hair services. During an interview on 5/19/26, at 2:23 p.m. information was disseminated to Registered Nurse, Employee E22 that the facility failed to provide Activity of Daily Living (ADL) assistance to Resident R9, R12, and R90. 28 Pa. Code: 211.12(d)(2)(5) Nursing services.

Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a timely criminal background check prior to the start of employment for three of five personnel files reviewed (Registered Nurse (RN) Employee E4, Certified Occupational Therapist Assistant (COTA) Employee E7, and Nurse Aide (NA) Employee E8.Findings include: Review of facility policy Abuse Policy- Prevention and Management dated 1/11/26, indicated that the facility must provide a safe environment and protect residents from abuse. All potential employees will be screened for a history of abuse, neglect, or mistreating residents during the hiring process. Screening will consist of, but not limited to: criminal background checks. On 7/29/26, employee personnel files were requested from the facility. Review of RN Employee E4's personnel file indicated a date of hire on 4/20/26. Review of RN Employee E4's personnel file included two criminal background check with the first Date of Request of 11/25/25, five months prior to employee's start date, and the second with a Date of Request of 7/29/26, three months after the employee's date of hire. Review of COTA Employee E7's personnel file indicated a date of hire on 5/1/26. Review of COTA Employee E7's personnel file included a criminal background check with a Date of Request of 6/25/26, more than one month after the employee's date of hire. Review of NA Employee E8's personnel file indicated a date of hire on 5/12/26. Review of NA Employee E8's personnel file included a criminal background check with a Date of Request of 10/14/26, approximately seven months prior to the employee's date of hire. During an interview on 7/30/26, at 12:06 p.m. Human Resources Employee E9 confirmed that Employee E4, and E9 had criminal background checks completed too far in advance to rule out criminal activity in a timely manner prior to the start of their employment, and that Employee E7's background checks was not completed prior to the start of employment. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(8) Personnel records.

Based on review of clinical records and staff interviews, it was determined that the facility failed to notify a physician's of a resident with a hyperglycemic episode (high blood sugar) for one of two residents (Resident R11).Findings include: Review of the facility policy Hyperglycemia Management-Diabetes Management last reviewed 1/27/26, indicated the facility will quickly and safely respond to the needs of the resident exhibiting signs and symptoms of hyperglycemia (blood sugars above target levels). The facility will manage the resident's diabetes to prevent hyperglycemia based on physician orders and monitoring. Early signs of hyperglycemia include dizziness. The charge nurse will contact the physician if blood glucose is greater than 360 (if not on sliding scale coverage) or other specific blood glucose parameters identified by the physician order or if signs and symptoms are noted. Review of the clinical record revealed Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's care plan dated 9/1/25, indicated the resident has diabetes and to administer medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/3/26, indicated diagnoses high blood pressure, anxiety, and diabetes (occurs when your blood sugar (glucose) is too high. It develops when your pancreas doesn't make enough insulin or any at all). Review of Resident R11's physician order fated 6/30/26, indicated to administer NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart-a rapid-acting insulin used to control blood sugar). Inject as per sliding scale: if 401 - 999 = 6 units call provider over 401 milligrams per deciliter (mg/dl) Review of Resident R11's July's Treatment Administration Record revealed the following blood sugar during Novolog administration:-7/2/26, Blood sugar 408 (mg/dl)-7/3/26, Blood sugar 500 (mg/dl)-7/22/26, Blood sugar 440 (mg/dl)-7/23/26, Blood Sugar 430 (mg/dl)-7/27/26, Blood Sugar 428 (mg/dl) Review of Resident R11's clinical record failed to include evidence the physician was notified of the blood glucose above 401 (mg/dl) as ordered. During an interview on 7/28/26, at 11:30 a.m. Resident R11 was asked if he ever displays signs and symptoms of low or high blood sugar and stated he sometimes feels dizzy. During an interview on 7/31/26, at 10:23 a.m. Certified registered Nurse Practitioner (CRNP), Employee E25 stated it is expected the facility notifies a physician for Resident R11 if his blood glucose is above 401. It was indicated there is a direct number staff can call to contact himself or any other provider. CRNP, Employee E25 stated he does not recall any notifications for the month of July. During an interview on 7/31/26, at 10:28 a.m. Registered Nurse, Employee E22 stated each time a physician is notified of a change in condition or parameters outside of an order, it should be documented in the clinical record. During an interview on 7/31/26, at 10:48 a.m. Registered Nurse, Employee E22 and Staff Educator, Employee confirmed no there was no evidence a physician was notified of Resident R11's elevated blood sugar as ordered on the following dates:-7/2/26, Blood sugar 408 (mg/dl)-7/3/26, Blood sugar 500 (mg/dl)-7/22/26, Blood sugar 440 (mg/dl)-7/23/26, Blood Sugar 430 (mg/dl)-7/27/26, Blood Sugar 428 (mg/dl) During an interview on 7/31/26, at 12:02 p.m. information was disseminated to the Director of Nursing and Assistant Director of Nursing, Employee E1 that the facility failed to notify a physician of a resident high blood sugar for one of two residents as ordered (Resident R11). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and review of facility documents and staff and resident interviews, it was determined that the facility failed to protect a resident from abuse for two of eight residents reviewed (Resident 92 and R201). Findings include: Review of facility policy Abuse Policy-Prevention and Management dated 1/27/26, indicated the facility prohibits the mistreatment, neglect, and abuse of residents. The facility must provide a safe resident environment and protect residents from abuse. Abuse if willful infliction of injury, intimidation resulting in physical harm, pain and/or mental anguish. Physical abuse includes spitting, roughly holding, and hitting. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE], with diagnoses that include need for assistance with quadriplegia, chronic pain, and muscle weakness. Review of Resident R92's MDS dated [DATE], revealed the diagnoses remain current. Further review of the MDS, Section C, Cognitive Patterns; Question C0500 indicated Resident R92 had a BIMS of 15, indicating cognitively intact. Review of facility documents indicated on 6/20/26, at approximately 4:00 a.m. Resident R92 reported that doors were being slammed in the hallway during the night while he was trying to sleep. He yelled to quit slamming the doors and Nurse Aide (NA), Employee E8 entered the resident's room asking who said that. When Resident R92 confirmed he yelled to quit slamming the doors, NA, Employee E8 got in the resident's face with both middle fingers in the air and told the resident f*ck you. NA, Employee E8 then stepped back pointed to his penis and told the resident to suck my d*ck. Resident R92 stated he wanted a supervisor and put the call bell on for the nurse 3-4 times but NA, Employee E8 turned it off telling him he has been doing this for 14 years. He states the aide was so close to his face he could feel spit. It was indicated the resident's roommate verified the accusations. Review of NA, Employee E8's witness statement dated 6/20/26, indicated Resident R92 yelled at him for slamming a door. NA, Employee E8 told Resident R92 this is a business, you are going to hear people shutting doors. Review of Resident R11 witness statement dated 6/20/26, stated NA, Employee E8 was slamming doors and became verbally confrontational with Resident R92. During the interaction, Resident R11 heard the nurse aide tell Resident R92 to suck his dick and state f*ck you, I don't give a sh*t. Resident R11 also stated he heard NA say It's a business here, not your home. Review of Resident R148 witness statement dated 6/20/26, indicated NA, Employee E8 had chair sitting by their room. Resident R148 had headphones in but heard two male voices yelling around 3:00 a.m. During an interview on 7/27/26, Resident R92 stated he typically leaves his door open at night when he sleeps. On 6/20/26, during the overnight shift Resident R92 told NA, Employee E8 to not shut his door the whole way and he still did. Then while everyone was sleeping, he woke up to someone slamming doors. Resident R92 then yelled out to quit slamming the doors and NA, Employee E8 entered into his room and started yelling fu*k you, fu*k you, you can suck my di*k. NA, Employee E8 told Resident R92 that this isn't his home, it's a business. It was indicated Resident R92 had been at the facility for seven years and this is the first time something like that occurred. Review of the clinical record indicated Resident R201 was admitted to the facility on [DATE], with diagnoses that include depression, cancer, and Review of Resident R201's MDS dated [DATE], revealed the diagnoses remain current. Further review of the MDS, Section C, Cognitive Patterns; Question C0500 indicated Resident R201 had a BIMS of 15, indicating cognitively intact. Review of facility documents indicated on 6/20/26, during the overnight shift, Resident R201 requested an aide to empty his urinal and place it back under his brief. She was not sure how to do this and requested help from NA, Employee E8. NA, Employee E8 told Resident R201 that aides are not taught to do that with a urinal. NA, Employee E8 was using the F word repeatedly and when Resident R201 asked him to stop, NA, Employee E8 got close to the resident's face and purposefully spit in his face. NA, Employee E8 then threw the urinal bottle at the wall across from bed. NA, Employee E8 was suspended pending outcome of investigation and other residents on aides assignment were interviewed. Review of RN Supervisor, Employee E12 witness statement dated 6/20/26, revealed at approximately 4:00 a.m. RN Supervisor, Employee E12 entered Resident R201's room and he reported he activated his call light and asked NA, Employee E14 to empty urinal and place it back under his brief. NA, Employee E14 was not sure how to proceed and requested NA, Employee E8 assistance. Resident R201 stated that NA, Employee E8 loudly told Resident R201 that NA's were not taught to do this with a urinal. It was indicated NA, Employee E8 was using the F word and Resident R201 asked him to stop. NA, Employee E8 allegedly moved his face close to the resident's and said F*ck you. NA, Employee E8 then spit in Resident R201's face and threw the urinal across the room. Review of NA, Employee E8's witness statement dated 6/20/26, indicated he entered Resident R201's room to answer call light and was mad that colored people didn't put his urinal in his brief like he wanted and eluded to calling NA, Employee E8 a nigg*r. It was indicated Resident R201 called NA, Employee E8 colored people and said you don't want me to say the other word. Review of NA, Employee E14 witness statement dated 6/20/26, revealed Resident R201 rung his call light and asked to have the urinal placed back in his brief. NA, Employee E14 told Resident R201 she couldn't do that and he got upset, so she called for another aide. NA, Employee E8 came to assist and NA, Employee E14 went back to making rounds. Review of NA, Employee E15 witness statement dated 6/20/26, indicated Resident R201 rang his call bell at 3:10 a.m. and started to tell NA, Employee E15 that some black guy refused to do anything with his urinal because they were not trained to do that. Resident R201 stated NA, Employee E8 started going off and cursing. Resident R201 stated NA, Employee E8 spit in his face twice on purpose. NA, Employee E15 then notified the RN Supervisor. During an interview on 7/27/26, at 12:55 p.m. Resident R201 confirmed the allegations of abuse that occurred on 6/20/26. It was indicated NA, Employee E8 was yelling to go fu*k yourself, and refused to urinal back under brief. NA, Employee E8 then grabbed his shoulder and spit in his face. NA, Employee E8 was then walked out once the RN Supervisor was made aware of the incident. It was indicated the next day the doctor put an order for eye drops for five days. During an interview on 7/29/26, at 10:04 a.m. RN Supervisor, Employee E16 stated she worked 7 a.m. on 6/20/26, and was notified of the incident that occurred overnight with NA, Employee E8. It was indicated RN Supervisor, Employee E12 obtained witness statements prior to sending NA, Employee E8 home and calling the police. Then in morning all residents were interviewed and Resident R92 was identified as a victim as well. NA, Employee E8 was then placed on do not return list. During an interview on 7/29/26, at 12:43 p.m. Registered Nurse Supervisor, Employee E12 stated it was approximately 3 a.m. on 6/20/26, when a NA came in for their shift and was made aware of the altercation that occurred between NA, Employee E8 and Resident R201. It was indicated NA, Employee E12 was swearing and purposely spit on the resident. RN Supervisor Employee E12 immediately went in to assess the Resident R201. NA, Employee E8 was asked to write their own statement and was notified he was suspended and was walked out of the facility. During a phone interview on 7/29/26, at 1:44 p.m. NA, Employee E14 stated she was unsure what happened once she left Resident R201's room. NA Employee E8 was unavailable for interview. Review of NA Employee E8's employee file indicated they were hired through agency. They last received Abuse training on 10/6/25. During an interview on 7/29/26, at approximately 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to protect two of eight residents from abuse (Resident 92 and R201). Pa. 28 Code 201.18(b)1)(2)Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of three residents (Resident R12).Findings include: Review of facility policy Physician Orders, Verbal and Telephone dated 1/27/26, indicated nurses are to confirm order transcription either through the electronic health record. The nurse will transcribe physician orders onto the electronic health record on the Treatment Administration Record. Review of facility policy Negative Pressure Wound Therapy, Wound Vac dated 1/27/26, indicated a physician order is necessary to provide this treatment. The facility will utilize equipment ordered by the physician. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/14/26, indicated diagnoses cancer, stage IV sacral pressure ulcer (occurs when prolonged pressure, often over bony prominences such as the heels, sacrum, hips, or tailbone, causes localized tissue damage and necrosis, but the true depth of the wound is obscured by dead tissue or other coverings), and depression. Section M: Skin Conditions indicated the resident had one stage IV pressure ulcer. Review of Resident R12's care plan dated 4/1/25, indicated the resident is at risk for pressure ulcer development and to administer treatments as ordered and monitor for effectiveness. Review of Resident R12's wound care consult dated 6/8/26, revealed Certified Nurse Practitioner (CRNP), Employee E23 assessed Resident R12's sacral pressure ulcer and it was discussed with staff that the resident's wound vac was ordered last week, still pending arrival. CRNP, Employee E23 provided an order to apply wound vac at continuous pressure at 125 mmHg, and to change twice a week. Plan of care and education discussed with facility staff. Review of Resident R12's wound care consult dated 6/11/26, revealed Certified Nurse Practitioner (CRNP), Employee E23 assessed Resident R12's sacral pressure ulcer and it was indicated the resident's wound vac arrived on 6/8/26, and was applied however nursing was having difficulty with the vac. There was an error code and the machine kept beeping throughout the night. Nursing removed the wound vac and placed saline moistened gauze and covered with a dry dressing daily since. They have asked for my assistance in looking at the wound vac today, however it is not functioning properly. Wound representative was called and it was indicated a replacement will be sent. Review of Resident R12's physician order dated 6/12/26, indicated to apply wound vac therapy dressings three times a week and as needed. Attach wound therapy at 125 mmHg every Monday for stage IV pressure ulcer. The order entered in Resident R12's clinical record was scheduled to be changed every Monday. Review of Resident R12's June 2026 Treatment Administration Record revealed Resident R12's wound vac was changed on 6/15/26, and 6/22/26. During an interview on 7/30/26, at 10:30 a.m. Wound Care Nurse, Employee E24 confirmed she is responsible for entering orders from the wound care consultant into the resident's clinical records. Wound Care Nurse, Employee E24 confirmed CRNP, Employee E23 ordered Resident R12's wound vac to be changed twice a week, and the resident's wound vac was changed only once a week. During an interview on 7/31/26, at 11:59 a.m. the Assistant Director of Nursing, Employee E1 and Director of Nursing confirmed the facility failed to provide wound care treatment as order ordered by CRNP, Employee E23. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on staff interviews it was determined that the facility failed to currently employ a qualified Registered Dietitian (RD).Findings include: Review of facility provided job description for Registered Dietitian (RD) revealed the RD must be a qualified individual whose primary purpose in this position is to plan, organize, coordinate and evaluate the nutritional components of the dietary service for the facility. Essential job functions: completes clinical duties and documentation accurately and timely. During an interview on 7/27/26, at 10:25 a.m., Food Service General Manager (FSGM) Employee E10 was unable to identify whom the current clinical RD was, that the position was employed directly by the facility and the Nursing Home Administrator would be able to identify whom was currently employed in this position. During an interview on 7/28/26, at 11:15 a.m., the Nursing Home Administrator (NHA) revealed that the facility currently does not have a RD on staff due to recent resignation of prior RD. During an follow-up interview on 7/28/26, at 1:53 p.m., the NHA confirmed that the prior RD resigned on 7/8/26 and has been unable to hire a new RD since then, with 2 full time RD positions available. NHA then confirmed that the facility failed to have a RD currently employed on staff to complete the essential job functions of the position. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201. 18(e)(1)(6) Management.

Based on review of facility policy, resident family interview and documentation, and staff interview it was determined that the facility failed to assist a resident family with forming a family group and failed to follow up on a family concern for one of two resident family (Resident Family R110). Findings include: Review of facility documentation admission Agreement - Statement of Resident Rights dated 12/16/25, indicated: A Resident has the right to have family members or other resident representatives meet in the facility with the families or resident representatives of other residents in the facility. During an interview on 7/27/26, at 1:24 p.m. Resident Family R110 indicated that in May 2026, he had been interested in attending resident group and or starting a family group for the fourth floor. Resident Family R110 indicated that he had spoken with administration about this concern and sent them an email in May regarding the concern but nothing has happened - he has tried to work with the ombudsman but he doesn't have the contact information for other families and can't be around on the unit 24/7 to catch all the families. During the interview Resident Family R110 indicated that the facility had not assisted him or given him information for starting a Resident Family group. Resident Family R110 was unaware if the facility had any responsibility in assisting family members with starting a resident family group. Review of Resident Family R110 information addressed to the NHA indicated: This letter is to inform you that I have been in contact with the [NAME] County, LTC Ombudsman, about starting a Family Council @ Sunnyview Rehabilitation and Nursing Center for the secured Nursing Care unit. [NAME] County Ombudsman has sent me several links to assist me in getting started. Again, this will only be for the secured Nursing Care unit.I have had discussions with several family members of the residents, and they are interested in forming this Council.Our goal is to positively affect quality of life improvements, an alternate to filing complaints with outside agencies, consolidate common concerns, come up with ideas for how to addressconcerns/issues, keep the facility staff from being overwhelmed by a barrage of individual complaints, and build a trusting relationship between families and the facility.Review of the concern log from May 2026 to current failed to include an above concern from Resident Family R110.During an interview on 7/31/26, at 9:24 a.m. ANHA (Assistant Nursing Home Administrator) Employee E26 indicated: the ANHA and NHA were aware of the concerns from Resident Family R110, and that the concerns about starting a family group were not included on the concern log. ANHA, indicated that the isn't a family group at the facility and they did not assist Resident Family R110 with forming a family group and the facility failed to follow up on a family concern and failed to assist a family member with forming a family group. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18( e) (4)Management.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical records, observations, staff and resident interviews, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R111 and R217).Findings Include: Review of the facility policy Oxygen Administration last reviewed 1/27/26, indicated oxygen equipment will be checked daily for: Correct set up of equipment. Date tubing when initiated, and at least every two weeks when changed, more often if malfunction or visibly soiled. All tubing will be changed and dated every two weeks or more often if malfunction or visibly soiled. Review of the clinical record indicated Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/16/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD- makes it hard to breathe), coronary artery disease (CAD- reduces blood flow to the heart) and anxiety. Review of Resident R111's physician orders dated 6/22/26, indicated home non-invasive ventilator (a device used to deliver positive pressure through a nasal mask, full face mask or mouthpiece helping to rest lung muscles and improve breathing) to be applied at night. Settings are as followed, Oxygen 5 liters, Tidal (volume of air moved into or out of the lungs) 450 milliliters (ml), max pressure 35, expiratory positive airway pressure (EPAP) min/max 5/15, Pressure Support (PS) min/max, Autotrak, Average Volume-Assured Pressure Support (AVAPS) speed 5 centimeters of water (cmH2O/min). During an observation completed on 7/28/26, at 9:22 a.m. Resident R111 was resting in bed the mask to her non-invasive ventilator was sitting on top of her bedside stand, the mask was not stored in a bag as required. During an interview completed on 7/28/26, at 9:27 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed that the mask was sitting on top of the bedside stand not stored in a bag as required and that the facility failed to provide appropriate respiratory care for Resident R111. Review of the clinical record indicated Resident R217 was admitted to the facility on [DATE]. Review of Resident R217's MDS dated [DATE], indicated diagnoses of chronic respiratory failure with hypoxia (lungs cannot maintain sufficient oxygen levels), coronary artery disease and anxiety. Review of Resident R217s physician order dated 11/13/24, indicated oxygen at 2 liters per minute continuously. Review of Resident 217's physician order dated 12/18/24, indicated change oxygen set-up and tubing every 2 weeks on night shift. During an observation completed on 7/27/26, at 11:26 a.m. Resident R217 was resting in bed an oxygen nasal cannula (thin flexible tubing with two prongs that fit into the nostrils) was visible in her nose. The nasal canula tubing was dated 6/29/26. During an interview completed on 7/27/26, at 12:28 p.m. LPN Employee E3 confirmed the oxygen tubing was dated 6/29/26, and that the facility failed to provide appropriate respiratory care for Resident R217. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of three residents (Residents R3).Findings include: Review of facility policy Bed Rails (Enabler/Assist Bars, Grab Bar, Halo/Donut)-Restraint/Non-restraint) policy dated 1/27/26, indicated the resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and if these alternatives were effective to meet the resident's assessed needs. The bed rails may be used to:Assist residents to participate in Assistance of daily living (ADL) care.Assist the resident in transfer to or from bed.Improve the residents' mobility and independent function.Assessment will be completed with admission, re-admission, quarterly, annually, with significant change in condition and if/when bed rails are added or removed. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/8/26, indicated diagnoses of diabetes (high blood sugar), hyperlipidemia (high fat in the blood) and depression. Review of physician orders dated 2/23/26, indicated side rails (right enabler) for positioning. Review of Resident R3's quarterly packet-V 14 bed rail evaluation dated 3/18/26, revealed bed rails are not recommended at this time. Review of Resident R3's quarterly packet-V 14 bed bed rail evaluation dated 6/19/26, revealed bed rails are not recommended at this time. Review of Resident R3's current comprehensive care plan revealed the resident has an ADL (activities of daily living) self-care deficit related to decline in overall function secondary to illness. Side Rails (right enabler) for positioning. During an observation on 7/26/26, at 11:21 a.m. revealed a bed rail - right enabler bar on Resident R3's bed. During an interview completed on 7/30/26, at 2:50 p.m. Registered Nurse (RN) Employee E4 confirmed that the bed rail evaluations were not accurate that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of three residents (Residents R3). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner and in two of seven medications carts (Cardinal South Hall and Cardinal East Hall) and two of four medication rooms (Cardinal Medication Room and Roseview Medication Room).Findings include: Review of the facility policy Medication Storage last reviewed 1/17/25, indicated medications and biologicals are stored safely, securely and properly, following manufacturer recommendations of those of the suppliers. The nursing staff is responsible for maintaining medication storage (medication carts and medication rooms) and preparation areas in a clean, safe and sanitary manner. Review of the facility's policy Medication Administration/Disposition last reviewed 1/27/26, indicated medications shall be administered in a safe a timely manner. When opening a multi-dose container, the date opened shall be recorded on the container. During an observation completed on 7/28/26, at 11:50 a.m. the Cardinal South Hall medication cart contained the following: 2 bottles of artificial tears opened and not labeled with a date as required.2 bottles of latanoprost eye drops opened and not labeled with a date as required.1 bottle of brimonidine eye drops opened and not labeled with a date as required. During an interview completed on 7/28/26, at 11:57 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the above findings and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Cardinal South Hall medication cart. During an observation completed on 7/28/26, at 11:58 a.m. the Cardinal East Hall medication cart contained the following: 6 bottles of artificial tears opened and not labeled with a date as required.2 bottles of latanoprost eye drops opened and not labeled with a date as required.1 bottle of miebo eye drops opened and not labeled with a date as required.2 tubes of erythromycin ophthalmic ointment opened and not labeled with a date as required.1 bottle timolol eye drops opened and not labeled with a date as required.1 package Ipratropium Bromide/albuterol opened and not labeled with a date as required.1 Stiolito Respimat inhaler opened and not labeled with a date as required.1 bottle fluticasone nasal spray opened and not labeled with a date as required.1 albuterol sulfate inhaler opened and not labeled with a date as required.1 airsupra inhaler opened and not labeled with a date as required. During an interview completed on 7/28/26, at 12:08 p.m. LPN Employee E3 confirmed the above findings and confirmed that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Cardinal East Hall medication cart. During an observation completed on 7/28/26, at 12:09 p.m. the Cardinal Units medication room refrigerators freezer contained ice build-up. During an interview completed on 7/28/26, at 12:13 p.m. LPN Employee E3 confirmed that the Cardinal Units medication room freezer contained ice build-up. During an observation completed on 7/28/26, at 12:30 p.m. the Roseview Medication rooms refrigerator contained: 1 bottle of liquid Neurontin opened and not labeled with a date as required. The area under the sink contained a blue tote. During an interview completed on 7/28/26, at 12:34 p.m. LPN Employee E13 confirmed the above findings and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Roseview Medication room. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to complete a comprehensive nutritional assessment for two of five residents (Resident R89 and R115).Findings include: Review of facility policy Nutritional Assessment, dated 1/27/26, indicated the facility will ensure that the resident maintains, to the extent possible, acceptable parameters of nutrition and hydration status and that the facility:- Provides nutritional and hydration care and services to each resident, consistent with resident's comprehensive assessment;- Recognizes, evaluates, and addressed the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration.Resident will receive an admission nutritional assessment by a registered dietitian (RD), to determine nutritional problems and risks.A nutritional assessment will be initiated within 72 hours of admission and completed by the Assessment Reference Date (ARD). Review of facility provided job description for Registered Dietitian (RD) revealed the RD must be a qualified individual whose primary purpose in this position is to plan, organize, coordinate and evaluate the nutritional components of the dietary service for the facility. Essential job functions: completes clinical duties and documentation accurately and timely. Review of Resident R89's clinical record indicated that she was admitted to the facility 7/13/26. Review of Resident 89's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/19/26, indicated diagnoses of left femur (thigh bone) fracture, falls, and pulmonary disease. Review of Resident R89's clinical record indicated an admission MDS was completed on 7/19/26. Review of Resident R89's clinical record failed to reveal that a comprehensive nutritional assessment had been completed by a RD for the MDS dated [DATE]. Review of Resident R115's clinical record indicated that she was admitted to the facility 7/11/26. Review of Resident 115's MDS dated [DATE], indicated diagnoses of dependance on renal dialysis (clinical purification of the blood, as a substitute for normal kidney function), sepsis (emergency condition caused by the body's overwhelming response to an infection), and colostomy (surgical procedure that creates an opening (stoma) in the abdomen to allow stool to exit the body when it cannot pass through the anus). Review of Resident R115's clinical record indicated an admission MDS was completed on 7/17/26. Review of Resident R115's clinical record failed to reveal that a comprehensive nutritional assessment had been completed by a RD for the MDS dated [DATE]. During an interview on 7/27/26, at 10:25 a.m., Food Service General Manager (FSGM) Employee E10 was unable to identify whom the current clinical RD was, that the position was employed directly by the facility and the Nursing Home Administrator would be able to identify whom was currently employed in this position. During an interview on 7/28/26, at 11:15 a.m., the Nursing Home Administrator (NHA) revealed that the facility currently does not have a RD on staff due to recent resignation of prior RD. During an follow-up interview on 7/28/26, at 1:53 p.m., the NHA confirmed that the prior RD resigned on 7/8/26 and has been unable to hire a new RD since then, with 2 full time RD positions available. NHA then confirmed that the facility failed to have a RD currently employed on staff to complete the essential job functions of the position. During an interview on 7/29/26, at 10:18 a.m., the Director of Nursing (DON) confirmed that an admission nutritional assessment by a RD had not been completed for Resident R89 and Resident R115 as required. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policy, resident interviews, and meal observations, it was determined that the facility failed to provide resident selected menu items for two of five residents (Residents R90 and R203). Findings include: Review of the facility policy Dining and Food Preferences last reviewed 1/27/26, indicated that the individual dining, food and beverage preferences are identified for all residents. The individual tray assembly ticket will identify allergies, food and beverage preferences or special request and adaptive equipment as appropriate. Review of the clinical record revealed Resident R90 was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/7/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and diabetes ( occurs when your blood sugar (glucose) is too high. It develops when your pancreas doesn't make enough insulin or any at all). Review of Resident 90's physician orders dated 7/31/25, indicated for a regular Consistent Carbohydrate Diet (CCHO) diet with regular texture and consistency. During a lunch observation completed on 7/27/26, at 1: 47 p.m. a review of Resident R90's lunch meal ticket indicated: -4 ounces (oz) tomato juice During observation of lunch tray, Resident R90 failed to receive 4 oz of tomato juice During an interview on 7/27/26, at 1:49 p.m. Nurse Aide, Employee E18 confirmed Resident R90 failed to receive 4 ounces of tomato juice as meal ticket indicated. Review of the clinical record revealed Resident R203 was admitted to the facility on [DATE]. Review of Resident R203's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/6/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and hyperlipidemia (high fat in the blood). Review of Resident 203's physician orders dated 11/29/25, indicated no added salt diet, regular texture, regular consistency. During a lunch observation completed on 7/27/26, at 12: 44 p.m. a review of Resident R203's lunch meal ticket indicated: Savory chicken noodle soup Barbecued beef White bread Deli ham and cheese on white Potato chips Saltine crackers Hot chocolate Pear crisp Chocolate milk Whole milk Mayonnaise Observation of lunch tray received: Deli ham and cheese sandwich on white Peanut butter and jelly sandwich on white Hot chocolate Pear crisp Chocolate milk Whole milk Mayonnaise During an interview completed on 7/27/26, at 12:47 p.m. Registered Nurse (RN) Employee E2 confirmed that Resident R203's lunch tray did not match Resident R203 requested items and stated, I will call down to the kitchen and they will send the correct items up and confirmed that the facility failed to provide resident selected menu items for Resident R203. During an interview on 7/27/26, at approximately 3:00 p.m. the Director of nursing and Nursing home Administrator confirmed the facility failed to provide resident selected menu items for two of five residents (Residents R90 and R203). 28 Pa Code: 201.18(b)(1)

Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service sanitation on one of five nursing unit nutrition pantries (Rehab Unit).Findings include: Review of facility Food and Nutrition policy Equipment; Safety dated 1/27/26, indicated that it is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. During an observation conducted 7/30/26, at 1:55 p.m. of the Rehab Unit's nutrition pantry, revealed a build-up of dried food debris splatters throughout the interior surfaces of the microwave. During an observation and interview conducted on 7/30/26, at 2:26 p.m. with Rehab Unit Manager (UM) Employee E6, she confirmed that above observation and that the facility failed to maintain food service equipment in accordance with professional standards in the Rehab unit nutrition pantry. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a medication pass for one of three resident's (Resident R33).Findings include: Review of the facility's policy Medication Administration/Disposition last reviewed 1/27/26, indicated staff shall follow established facility infection control procedures for the administration of medications. Review of the clinical record revealed Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of anemia (low iron in the blood), depression and anxiety. During a medication pass observation completed on 07/29/26, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E11 was preparing Resident R33's medications. LPN Employee E11 dropped Resident R33's Buspar tablet on to informational papers that were placed on the top of the medication cart. LPN Employee E11 placed on gloves, picked up the medication, and placed the tablet into the medication cup for administration. During an interview completed on 7/29/26, at 10:19 a.m. LPN Employee E11 confirmed dropping Resident R33's Buspar tablet onto the informational papers that were placed on the top of the medication cart. Picking the Buspar tablet up and placing it into the medication cup for administration and that the facility failed to prevent cross contamination during a medication pass for one of three residents' (Resident R33). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five units (Cardinal Unit).Findings include: Review of the facility's policy Medication Administration/Disposition last reviewed 1/27/26, indicated confidentially of the resident's health information will be maintained during the medication administration process, the electronic health record will be in privacy mode when the nurse is away from the medication cart. If paper documentation is used it will be maintained in a closed binder. During an observation on 7/29/26, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E11 left the screen up on the laptop and papers that displayed resident personal information on top of the medication cart outside of room [ROOM NUMBER]. The information was available to anyone passing by. During an interview completed on 7/29/26, at 10:19 a.m. LPN Employee E11 confirmed that laptop screen was not closed and papers that displayed resident personal information were on top of the medication cart outside of room [ROOM NUMBER] and that the facility failed to maintain the confidentiality of residents' medical information on one of five units (Cardinal Unit). 28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, where postings are available (First Floor).Findings include: During an observation on 7/30/26, at 10:30 a.m. on the First Floor had a bulletin board with required, posted information, that is conveniently located for residents and visitors. However, it failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid, and was confirmed by the Assistant Nursing Home Administrator. During an interview on 7/30/26, at 11:40 a.m. the Assistant Nursing Home Administrator Employee E26 confirmed the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, where postings are available (First Floor). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

Based on review of facility policy, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on three of six medication carts reviewed (Sunflower Unit East Hall Medication Cart, Sunflower Unit [NAME] Hall Medication Cart and Dogwood Unit East Hall Medication Cart).Findings include: Review of facility policy Drug Diversion Prevention and Narcotic Management last reviewed 1/27/26, indicated it is the policy of this facility to set forth standards related to preventing the diversion of medications. Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping; these will be addressed in this policy. Control/schedule II-V medication will be counted with two (2) professional nurses at the beginning and end of each shift. In the event of a situation where the nurse must leave the facility before the end of the shift, the DON/designee will assign a nurse to complete the inventory count with the nurse leaving prior to the end of the shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Control/schedule II -V medications will be logged into a bound book or a separate master index page/control log once received from the pharmacy as well as individual countdown records. Any discrepancy in a shift-to-shift narcotic count must be immediately communicated to the Director of Nursing. During an observation completed on 5/13/26, at 10:15 a.m. the Narcotic Count Record for the Sunflower Unit East Hall Medication Cart revealed the oncoming nurse for the afternoon shift failed to sign the sheet during shift change on 5/10/26. During an interview completed on 5/13/26, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the oncoming nurse for the afternoon shift failed to sign the sheet during shift change on 5/10/26. During an observation completed on 5/13/26, at 10:33 a.m. the Narcotic Count Record for the Sunflower Unit [NAME] Hall Medication Cart revealed the oncoming nurse for the day shift failed to sign the sheet during shift change on 5/12/26, and the oncoming nurse for the afternoon shift failed to sign the sheet during shift change on 5/12/26. During an interview completed on 5/13/26, at 10:36 a.m. Registered Nurse (RN) Employee E1 confirmed the oncoming nurse for the day shift failed to sign the sheet during shift change on 5/12/26, and the oncoming nurse for the afternoon shift failed to sign the sheet during shift change on 5/12/26. During an observation completed on 5/13/26, at 2:20 p.m. the Narcotic Count Record for the Dogwood Unit East Hall Medication Cart revealed the oncoming nurse for the day shift failed sign the sheet during shift change on 5/10/26. During an interview completed on 5/13/26, at 2:22 p.m. the Director of Nursing confirmed that the oncoming nurse for the day shift failed sign the sheet during shift change on 5/10/26, and that the facility failed to implement procedures to promote accurate accounting of controlled medications on three of six medication carts reviewed (Sunflower Unit East Hall Medication Cart, Sunflower Unit [NAME] Hall Medication Cart and Dogwood Unit East Hall Medication Cart). 28 Pa Code: 201.18 (b)(1)(3) Management.28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five floors (Rehabilitation (Rehab) floor).Findings include: Review of facility policy Resident Rights last reviewed 1/27/26, indicated Federal and State law guarantee certain basic rights to all residents of the facility. These rights include but are not inclusive of: safe and home-like environment. Be informed of safety or clinical restrictions or limitations of visitation. During an observation completed on 5/13/26, at 11:20 a.m. it was discovered that construction was being completed in the Rehab Units. The doors were blocked off with plastic sheeting and signs were up not to enter. Housekeeper Employee E5 was in the hallway and upon asking how to access the unit replied by taking the South elevator to the basement level and walking through the basement to the North elevator at the other end of the building and taking that elevator back up to the 1st floor to the Rehab Unit. During an observation completed on 5/13/26, at 11:25 a.m. Upon entering the unit it was discovered that the lounge area had plastic sheeting hanging from the ceiling. A construction crew were actively working on removing the floors in front of the nurse's station. The doorways to the resident hallways had plastic sheeting over them in front of the doors. Black foam like material was placed on the floor to the right of nursing station. It was very loud due to the equipment being used to remove the floors. The air was thick with dust. During an interview completed on 5/13/26, at 12:53 p.m. Licensed Practical Nurse (LPN) Employee E6 was sitting at a table in the lounge area with a laptop computer. Upon asking LPN Employee E6 concerning the construction replied they started today behind the nurse's station I don't want to sit out there inhaling all that dust and all the noise, it has made and impact with the residents. It is hard for the families to come in to visit. I don't want to sit out there. During an interview completed on 5/13/26, at 12:56 p.m. Resident R3 was in her room with the door shut. Upon asking Resident R3 about the construction replied Isn't all that something? It is very loud; I have been keeping the door shut it helps with the noise. During an interview completed on 5/13/26, at 1:03 p.m. Nurse Aid (NA) Employee E8 was in the hallway. (NA) Employee E8 observed utilizing a N-95 face mask. Upon asking concerning the construction and any impact on the residents replied I have asthma, so I am using a face mask. Some of the residents are having therapy in the rooms, they can go to the gym if they need to. During an interview completed on 5/13/26, at 1:10 p.m. upon asking Resident R4 concerning the construction replied, I keep the door shut because of the noise. During an interview completed on 5/13/26, at 1:15 p.m. upon asking Resident R5 concerning construction replied, We tried to go to the therapy gym, but they wouldn't let us in, so we did it in here. We were on the way and had to come back. The one therapist is wearing a mask because of the dust. During an interview completed on 5/13/26, at 1:24 p.m. upon asking Resident R6 concerning the construction replied, I'm going home on Saturday, oh the noise today, I went to the gym, I shut the door it helps keep the noise down. During an interview completed on 5/13/26, at 1:30 p.m. upon asking Resident R2 concerning the construction replied, it is a mess, the noise is bothering me it's awful and the dust is horrible you can see it. I stay mostly in my room. No gym today they can't get through, we walk in the hall or in my room. I think they should have moved the nurse's station and us out of here. I just keep the door closed. I don't care how many sheets of plastic you put up, it's still dusty. The therapist is wearing ear plugs; we should have all been moved. During an interview completed on 5/13/26, at 2:45 p.m. upon asking the Nursing Home Administrator concerning the construction replied it started on Monday, the demolition should be done today, hopefully it's all completed by next week and confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five floors (Rehab floor). 28 Pa. Code: 201.18(b)(3)

Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a midline catheter (a thin flexible tube inserted into a vein in the upper arm with the tip positioned just below the armpit) for one of two residents (Resident R2).Findings include:Review of the facility policy Midline Catheter Care and Maintenance last reviewed 1/27/26, indicated Registered Nurses and Licensed Practical Nurses who have completed a State Board Approved Basic Intravenous (IV) Certification Course that includes care and maintenance of central lines are permitted to infuse through midlines, flush midlines, perform dressing changes and change the end cap. Midline catheters need to be flushed with normal saline 10 cubic centimeters (cc) after each intermittent infusion, after discontinuing a continuous IV or every shift when not in use. Review of Resident R2's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/12/25, indicated diagnoses of hypertension (high blood pressure), diabetes (high sugar in the blood) and left tibia fracture (long bone of lower leg). Review of nursing progress notes dated 1/2/26, at 6:19 p.m. indicated IV infusion company notified for midline placement. Review of Resident R2's physician orders dated 1/3/26, at 12:00 a.m. indicated cefazolin sodium intravenous solution reconstituted 2 grams intravenously every 8 hours for wound infection for 7 Days. The orders failed to include the type of IV access, flushing the IV, dressing changes for the IV or changing the IV end cap. Review of nursing progress note dated 1/3/26, at 1:41 p.m. indicated resident tolerating IV. Midline flushing easily. During an interview on 3/6/26, at 3:40 p.m. the Director of Nursing confirmed that the Resident R2's physician orders did not include the type of IV access, flushing the IV, dressing changes for the IV or changing the IV end cap and that the facility failed to provide adequate treatment and care for a midline catheter for one of two residents (Resident R2). 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on the review of clinical records and staff interview it was determined that the facility failed to make certain that a resident received the necessary services to treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for one of two residents (Residents R1).Findings include: Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/11/26, indicated the diagnoses of high blood pressure, muscle weakness, and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R1's clinical record revealed a physician's order dated 1/13/26, stated to cleanse stage two pressure wound (pressure injury with a partial thickness loss of skin presenting as a shallow open injury with a red/pink wound bed or an intact or open/ruptured serum filled blister) to coccyx (tailbone) with wound cleanser, pat dry, triad (a paste used to treat wounds), cover with bordered gauze daily. Review of Resident R1's Treatment Administration Record (TAR) indicated that Resident R1 did not receive the above treatment on 1/15/26, or on 1/23/26. During an interview on 2/5/26, at 1:01 p.m. the Director of Nursing confirmed that the facility failed to provide pressure ulcer treatments as ordered for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision, which resulted in an elopement for two of 36 residents (Resident R12 and R37). This failure created an immediate jeopardy situation.Findings include: Review of the facility Elopement Prevention policy last revised 3/26/25, and reviewed 5/25, indicated it is the facility's policy to strive to prevent resident elopement. The facility strives to provide an environment that is free from hazards over which the facility has control and provide supervision and assistance to each resident to prevent avoidable accidents. The facility strives to reduce the risks for elopement while optimizing residents independence to safely attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility will identify residents at risk for unsafe wandering and exit seeking behavior and develop individualized prevention and management interventions based on exit seeking/elopement evaluation. Elopement represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a motor vehicle. The facility will define mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement to minimize the risk of the resident leaving a safe area without the staff awareness and/or supervision. Elopement is defined when a resident leaves the physical structure of the facility unattended and without staff knowledge and when a resident leaves the premises or a safe area without the facility's knowledge and supervision. Risk factors must be assessed and interventions implemented. Maintain door alarms and wander control systems in proper working order according to the manufacturer's recommendation. Monitor residents whereabouts of the at-risk residents during rounds. Check, through observation that the resident is wearing an electronic monitoring device as indicated. Electronic monitoring devices will be checked for placement each shift and documented on the TAR (Treatment Administration Record) or MAR (Medication Administration Record) by a licensed nurse and/or by the nursing assistant in their documentation. Electronic monitoring devices will be checked daily for function and documented on the TAR or MAR. If the electronic monitoring device is not found on resident or not working, staff will notify the charge nurse/supervisor to obtain a replacement. If a replacement is not readily available, other supervised monitoring processes will be implemented until a replacement is available. Review of the facility's Elopement-Management policy last reviewed 4/1/25, indicated the interdisciplinary team will reevaluate cognitively impaired residents who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident and/or resident representative, individualized intervention will be developed and initiated to manage the elopement behavior. Review and revise individualized interventions that may prevent further elopement attempts. Review of Resident R12's admission record indicated he was admitted on [DATE], with diagnoses of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and age-cognitive decline. Review of Resident R12's active physician order dated 1/25/25, revealed the resident required an assist of one person and a front wheeled walker. Review of Resident R12's Exit Seeking/Elopement Evaluation/Wandering assessment dated [DATE], revealed the resident was not an elopement risk. The first question asked if the resident was ambulatory or able to self-propel in a wheelchair and if no, may stop evaluation. It was documented the resident was not ambulatory and the resident's elopement assessment was not completed. Review of Resident R12's Exit Seeking/Elopement Evaluation/Wandering assessment dated [DATE], revealed the resident was an elopement risk. It was revealed the resident had exit-seeking behaviors and expressed a desire to leave. The summary and plan stated to utilize wander detection system and care plan for risk of elopement. Review of Resident R12's care plan dated 2/12/25, revealed the resident has a memory problem and tend to wander which may get me into situations where I am lost or could be injured. Interventions included I have problems with my memory. I am always asking for someone to help me and wander aimlessly. Please remind me to not go on elevator or leave the unit unless supervised by staff/family. I now wear a wander guard bracelet to keep me safe. Please make sure it is in working order. If not, please have it replaced immediately. If I do get off the unit unsupervised, please make sure the staff and family are aware. Review of Resident R12's MDS (Minimum Data Set a periodic assessment of care needs) dated 4/23/25, indicated the diagnoses were current. Section C-Cognitive Patterns revealed the resident BIMS (Brief Interview for Mental Status) was 4, severe cognitive impairment. Review of Resident R12's clinical record on 5/7/25, 5/8/25, 5/9/25, 5/12/25, and 5/27/25, revealed Resident R12 displayed exit-seeking behaviors. The facility failed to update Resident R12's care plan. Resident R12's care plan was not revised until 5/30/25, for the resident chewing off wander guard. No new interventions were added. Review of Resident R12's May 2025 TAR revealed on 5/28/25, and 5/29/25, Resident R12's electronic monitoring device was not checked on night shift. It was documented to see nurses note. Review of Resident R12's progress note dated 5/28/25, revealed wander guard not on person. Review of Resident R12's progress note dated 5/29/25, revealed Resident removed device. Review of Resident R12's clinical record revealed the resident had exit-seeking behaviors on 5/30/25. Review of Resident R12's care plan dated 5/30/25, revealed Resident R12 was an elopement risk and had been witnessed attempting to chew off band. No new interventions were implemented to prevent the resident from eloping. Review of Resident R12's progress note dated 6/1/25, at 10:27 a.m. entered by Licensed Practical Nurse, Employee E12 stated Resident found by staff in basement trying to exit outside. Resident brought back to unit and 15-minute checks started. No wander guard on. Review of Resident R12's progress note dated 6/1/25, at 10:37 a.m. entered by Registered Nurse (RN), Employee E5 stated this RN found Resident R12 in the basement. Resident R12 was wandering around. When RN, Employee E5 questioned Resident R12, Resident R12 stated I'm stretching my legs I need to walk around. When Resident R12 was asked what unit they resided on, Resident R12 replied one, and would not tell this RN what unit they were from nor would the resident tell this RN their name. Resident R12 was escorted to the elevator and taken to the second floor where staff indicated the resident was from the third floor. Review of Resident R12's progress note dated 6/1/25, at 11:15 a.m. entered by LPN, Employee E12 revealed the wander guard was placed underneath the resident's wheelchair, due to the resident continuing to remove from self. Review of Resident R12's progress note dated 6/1/25, at 3:30 p.m. revealed the resident's daughter was notified of the resident's elopement and the resident will be moving to another unit for safety reasons and this unit being more secure. Review of information submitted to the Department of Health on 6/2/25, stated on 6/1/25, at approximately 10:00 a.m. Resident R12 was found in the basement by staff ambulating with the use of their wheelchair. The resident was last seen by staff 10-15 minutes prior. A room change was completed, and the resident was moved to the secure Dementia unit. The resident stated to staff I wanted to go outside, and I will do it again. Review of Resident R12's investigation on 7/21/25, revealed Resident R12 eloped on 6/1/25, and was found in the basement trying to exit out of a door by RN, Employee E5. Resident R12 stated I wanted to go outside, and I will do it again. It was indicated the Resident did not have their wander guard on when found. A review of the facility's documentation for checking the operation of door monitors and patient wandering systems failed to reveal the Resident Monitoring System was checked on 5/30/25. It was written I was off 5/30/25. Number 2 elevator down was documented under the remarks section. A further review revealed a work order was entered on 5/30/25, at 8:17 a.m. by Maintenance Director, Employee E17 for the #2 elevator wander control. The room/area was listed as the basement. The priority was assigned medium. Service for elevator called was documented in the comment section. Review of RN, Employee E5's witness statement dated 6/1/25, revealed around 9:30 to 9:45 a.m. RN, Employee E5 went downstairs to look for supplies. Resident R12 initially was seen coming from the intermediate side towards the skilled side of the building. RN, Employee E5 was unfamiliar with Resident R12, so I didn't think much of it then. Shortly after RN Employee E5 went back towards the skilled side and went into the cage for supplies, while in there, RN, Employee E5 heard the door open and close. RN, Employee E5 heard feet shuffling. Once RN, Employee E5 came out from the cage, Resident R12 was observed looking for something and was asked what they were doing. Resident R12 stated they were exercising and needed to walk around, then Resident R12 went over to the exit door just to the left of the dock door and attempted to push on the door, which didn't open. While walking back to the elevator Resident R12 looked at RN, Employee E5's badge and said, I'm not sure I want to tell you my name. When RN, Employee E5 and Resident R12 got on the elevator, the electronic monitoring system didn't alarm at that time, and went to the 2nd floor. The door opened, still no alarm. RN, Unit Manager, Employee E18 was at the nursing station and thought the resident was a resident from the third floor who continues to take their monitor off. RN, Unit Manager, Employee E18, RN, Employee E5, and Resident R12 went to the third floor, and once there, again the alarm did not go off. LPN, Employee E12 recognized Resident R12 and was notified the resident was found in the basement. Review LPN, Employee E5's witness statement dated 6/2/25, revealed around 10:00 a.m. on 6/1/25, they were made aware Resident R12 was found in the basement trying to exit a door outside. No wander guard was on the resident due to her removing days prior. Resident was last seen in room during breakfast and medication pass around 10 minutes prior to staff bringing the resident back to the unit. Resident R12's wander guard was placed under their wheelchair, due to resident stating If you put that thing on me I will throw it in the garbage. Review of Nurse Aide (NA), Employee E15's witness statement dated 6/3/25, stated Resident R12 was last seen around at 9:15 a.m. During an interview on 7/21/25, at 10:20 a.m. NA, Employee E21 was asked how does the facility prevent residents from eloping and replied, We have wander guard, ones who wander the alarm goes off, elevator locks, and we have to put a code in. When asked if the facility has enough staff to supervise residents, NA, Employee E21 replied We have our days, some days residents can have their moments, act up, on those days we can always use more people. During an interview on 7/21/25, at 10:24 a.m. LPN, Employee E7 was asked how to prevent resident's from eloping and response They have wander guards. It was indicated they are checked daily. LPN, Employee E7 indicated they were not working when Resident R12 eloped on 6/1/25, however they were reeducated to make sure the resident's wander guards work. LPN, Employee E7 stated Resident R12 has one, I am not sure what happened, I know they turned up the sensitivity. During an interview on 7/21/25, at 1:50 p.m. Maintenance Director, Employee E17 stated there are wander guard monitoring systems in each elevator and they are checked Monday through Friday. If Maintenance Director, Employee E17 is not working, then staff would be assigned to complete the checks. In order for the wander guard system to pass a test, it must alarm, and the elevator car cannot travel. Staff must enter in a code. Maintenance Director, Employee E17 confirmed elevator #2 wander guard system was not working on 5/30/25. During an interview on 7/22/25, at 9:22 a.m. RN, Employee E5 stated if residents are identified as an elopement risk, then a wander guard bracelet is applied to the residents. The bracelets are supposed to be checked every shift that they are on, the night shift checks the function. RN, Employee E5 stated I recall all elevators were functioning when asked if any elevators were out of service on 6/1/25, the day Resident R12 was found in the basement. RN, Employee E5 stated I originally was coming down looking for supplies and walked passed Resident R12 in the basement. I didn't think a whole lot of it. Then as I was near the maintenance part of the basement, I heard feet shuffling, the resident came pass the maintenance door, trying to push it open and get out. RN, Employee E5 seen Resident R12 was looking for a way out and approached the resident. RN, Employee E5 then proceeded to take Resident R12 back onto the elevator to find out where the resident belonged. The nurse on the second floor told RN, Employee E5 maybe Resident R12 was the resident who cuts their wander guard off. Once on the third floor, LPN, Employee E12 identified the resident. It was indicated the elevator alarm did not sound on the second or third floor. RN, Employee E5 confirmed they are the nurse educator and stated, informal education was done, I don't remember doing a whole formal education. Hey, make sure you keep track of people. RN Employee E5 confirmed that the facility failed to reeducate staff on elopement. During an interview on 7/22/25, at 9:55 a.m. RN, Employee E18 stated Resident R12 had a wander guard on their chair when asked how the facility prevents residents from eloping. RN, Employee E18 stated the wander guard system did not go off. During an interview on 7/22/25, at 10:49 a.m. LPN, Employee E12 stated Resident R12 continuously tries to elope. LPN, Employee E12 stated when Resident R12 eloped on 6/1/25, the resident did not have a wander guard on. LPN, Employee E12 stated I do not recall any elevators out of service. LPN, Employee E12 stated what I believe Resident R12 took the elevator that is next to the dining room area. LPN, Employee E12 saw Resident R12 enter the dining room. The elevator must open, and Resident R12 got on. LPN, Employee E12 stated we didn't even know Resident R12 made it onto the elevator, I did not realize the wander guard was not on the resident, I assumed the resident was in the dining room. Review of Resident R37 admission record indicated they were admitted on [DATE] and readmitted on [DATE], with diagnosis of paranoid schizophrenia (mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and muscle weakness. Review of Resident R37 physician orders indicated: Place electronic monitoring device dated 7/1/25. Review of Resident R37 elopement assessment dated [DATE], indicated resident was a risk for elopement, and there was a history of wandering, and the wandering placed the resident at significant risk of getting to a potentially dangerous place. Resident R37 MDS dated [DATE], indicated the diagnosis were current. Section C cognitive patterns revealed the resident BIMS was an 8, which indicated moderately impaired. Review of MAR/TAR indicated: Check electronic monitoring device functioning every night shift. Every night shift -Start Date-07/14/2025. Review of progress note dated 7/20/25, indicated Resident R37 made 2 attempts to elope this afternoon. Staff spoke with him and was able to get him off elevator and back to his room. Resident delusional and insist he can't stay here anymore and does not have a room. Alarming device is on as ordered. Review of Resident R37's progress notes dated 7/20/25, indicated: was on the unit when a staff ran up to this writer and stated that she saw resident walking down the street with his foley catheter in hand. This writer and other staff went to where resident was seen when he was noted to be laying down on the side of the road with other passengers after they state they witnessed resident fall and hit his head. resident was noted to have a large hematoma to his forehead and several abrasions to his face and hands. Resident was assisted to a wheelchair and 911 was called and resident was taken to the hospital. Review of witness statements indicated: Nurse Aide trainee Employee E28 stated I was on the porch visiting with family member when Resident I knew had begun walking outside along with three other people. I first thought it could have been family that he was with, so I gave it a moment until they started talking about how they didn't know him. I then went inside and told the front desk, the lady at the desk ran outside to get him and I slowly followed. She then turned around and said he fell on his face. At that point she went inside to grab help and a wheelchair. I ran down to Resident R37 where two civilians driving by had stopped as I arrived. We kept Resident R37 still and a civilian caller had called 911 for medical help. Soon after a family member, and a nurse and two staff members ran down. Review of witness statement indicated: LPN Employee E29 Stated Resident R37 was seen in room at 19:37 p.m. during medication pass. Before medication pass was complete Resident R86 stated that there was a commotion downstairs concerning a black gentleman from nursing unit shortly after this LPN heard overhead call at approximately 20:25 pm after speaking with caller on the phone, this LPN sought out RN supervisors and asked about incident. RN said Resident R37 found outside and sent to hospital. Resident R86 stated to LPN Employee E29 mentioned at 22:00 p.m. he saw Resident R37 get into elevator and leave Resident R86 stated no one put code in for elevator to move, after speaking to other staff, all state alarm for elevator did not go off. Review of witness statement indicated: Front desk employee E30 stated: A gentleman came downstairs; no wander guard went off. I did not recognize him, and he walked out with a group of people. A girl from the porch came in and said a resident was out and I ran out to try to get him. As soon as he heard me yell, he sped up. I was not able to keep up with him. Review of witness statement indicated: Resident R86 stated: I saw a white gentleman get in the elevator, with Resident R37. Resident R86 saw gentleman push the elevator button. The door closed and Resident R86 Didn't think anything of it. During an interview on 7/22/25, at 10:37 a.m. the Director of Nursing and Assistant Director of Nursing (ADON), Employee E10 confirmed the facility's elopement risk assessment tool failed to include a comprehensive scoring system. ADON, Employee E10 stated if you feel a resident is at risk, then you can proceed to implement interventions such as an electronic monitoring device or locked unit. The DON confirmed the facility does not have a locked unit. The DON stated, we don't trust it either, we are looking at everyone's charting every morning. On 7/22/25, at 11:57 a.m. the NHA and DON were notified that Immediate Jeopardy was called due to the elopement of Resident R12 on 6/1/25, and Resident R37 on 7/20/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 7/22/25, at 2:30 p.m. the NHA confirmed the facility's plan of correction failed to reveal a designee and timeframe for when the elopement tool, resident-specific care plans will be completed, and that staff will be reeducated after the time the IJ was called. On 7/22/25, at 4:06 p.m. the NHA provided the facility's fourth plan of correction. On 7/22/25, at 5:21 p.m. an immediate action plan was received and accepted which included the following interventions: -The Facility is obligated to provide adequate supervision which does not rely on the Wander guard System and is based on the individual resident's assessed needs and the risks identified in the Exit Seeking Elopement Evaluation/ Wandering Tool, which does not replace an electronic monitoring device. (Wander guard System) -Will review and revise the elopement evaluation/wandering assessment to include comprehensive scoring system. To be completed by the Director of Nursing/designee within 24 hours, 7/23/25. -Current residents in-house will be reassessed for exit seeking / elopement by the Director of Nursing/designee within 24 hours, 7/23/25. -Residents will be assessed for exit seeking/elopement by the admitting RN upon admission. -Elopement binder will be revised upon completion of all assessments by the Director of Nursing/designee within 24 hours, 7/23/25. -Per results of assessments, care plans will be updated and implemented with resident-specific interventions by Director of Nursing/designee as warranted. -Elopement policies will be reviewed and revised as necessary by Nursing Home Administrator/designee within 24 hours, 7/23/25. -Wander guard system will continue to be audited by Environmental Director/designee daily. -Education of all facility staff will be conducted by Director of Nursing/designee on Elopement Risk and Supervision of residents within 24 hours, 7/23/25. -QA/QAPI was conducted 7/21 and 7/22/2025 related to plan of correction for F689. Meetings will be conducted 5 days/week until 8/5, 2x/week until 9/2, and monthly thereafter. The Elopement Risk assessment was revised on 7/22/25, to include a comprehensive scoring system. Residents with a risk greater than 12 are considered an elopement risk. Residents identified as elopement risk will have care plan updated to include individualized care interventions. On 7/23/25, 215/215 Residents were reassessed for an elopement risk, using the new Elopement. 27/215 residents were identified as an elopement risk. 4 residents were newly admitted to the facility since 7/22/25. 0/4 residents were identified as an elopement risk. Review of elopement binder on 7/23/25, included 27/27 identified elopement risks. 27/27 Residents that were identified as an elopement risk had care plans that were updated and implemented with resident-specific care interventions on 7/23/25. On 7/22/25, the Nursing Home Administrator reviewed the facility's Elopement policies. No changes were made. Review of facility documents revealed Wander guard system transmission box and all wander guards present on residents were audited on 7/23/25. Daily checks will be completed by Environmental Director Monday through Friday and the designees on the weekends. 234/255 educated Both in-person and phone. During in-person interviews on 7/23/25, from 10:36 a.m. to 11:17 a.m. 49 of 49 staff members verified education was completed on elopement risks and supervision. During phone interviews 8/8 staff members confirmed they were educated via phone. Facility conducted a QAPI meeting on 7/22/25. Meetings will be conducted 5 days/week until 8/5/25, 2x/week until 9/2/25, and monthly thereafter. Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 7/23/25, at 1:45 p.m. During an interview on 7/25/25, at 3:45 p.m., the NHA and DON confirmed that the facility failed to make certain each resident received adequate supervision, which resulted in an elopement for two of 36 residents (Resident R12 and R37), resulting in Immediate Jeopardy. 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 review of facility policies, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6) after a noted change in their condition, including a low blood sugar after receiving large doses of insulin by a registered nurse, who later confessed that she intentionally administered the insulin and/or an air bolus to harm the residents, resulting in the residents being transferred to the hospital and/or ceasing to breathe. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated [DATE], indicated that the facility prohibited the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, visitors, etc. The facility was to provide a safe resident environment and protect residents from abuse. A review of the personnel file for Registered Nurse 1 revealed that she was hired on [DATE], as a Registered Nurse/Unit Manager and worked in that position until she quit on [DATE]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], revealed that the resident was moderately cognitively impaired, required limited assistance from staff for her daily care tasks, had diagnoses that included diabetes, and did not receive insulin. A review of Resident 1's clinical record revealed that the resident was not ordered to receive any insulin. A nursing note, dated [DATE], at 12:50 p.m., revealed that Registered Nurse 1 called Resident 1's family about a fever and apnea (breathing stops). A nursing note, dated [DATE], at 1:55 p.m., revealed that Resident 1 had a fever of 100.8 degrees Fahrenheit (F), was given a bed bath, and her family was at her bedside. A nursing note, dated [DATE], at 3:17 p.m., revealed that Resident 1 had no respirations or heart beat for one minute and was pronounced dead at 3:15 p.m by Registered Nurse 1. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to 21, 2023, Registered Nurse 1, while acting as a caretaker did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted she administered 60 units of short-acting to Resident 1 while she was employed at the facility. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], and died at the facility on [DATE]. Additionally, the resident was not diagnosed with diabetes and was not ordered to receive any insulin. Review of activity notes for Resident 2, dated [DATE], indicated that the resident was independent to do self-directed leisure activities in the comfort of her room such as resting, listening to the TV, and naps. The resident had family who would call and send her items. She accepted one-on-one visits from staff and activities for conversation and current events. Review of nursing notes for Resident 2 from February 20, 2023, through [DATE], did not indicate that the resident had any significant change in condition or onset of acute (new) illness. Nursing notes for Resident 2, dated [DATE], indicated that at 8:45 a.m. staff reported the resident was not responding to them and her respirations were shallow (drawing minimal breath into the lungs). Resident 2 did not respond to tactile (touch) or verbal stimuli, radial pulse not able to be palpated (heartbeat could not be felt in the wrist), and heartbeat faint to auscultation (difficult to hear when listening with a stethoscope). Staff spoke with the resident's daughter and explained that due to the faint heartbeat and the short, shallow respirations, the resident was expected to pass in the near future. A nursing note at 9:30 a.m. indicated that staff was called to the resident's room due to it being questionable if Resident 2 had any respirations (was breathing). At 9:25 a.m. the resident was without heartbeat, without respirations, and without blood pressure (deceased ). A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE] to 21, 2023, Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 2, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 2 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 2. Resident 3's clinical record indicated that the resident was admitted to the facility on [DATE], and died on [DATE]. A nursing note for Resident 3, dated February 10, 2023, revealed that the resident was a [AGE] year old female re-admitted to the facility after a hospitalization where she developed pneumonia. A nursing note, authored by Registered Nurse 1, dated February 25, 2023, revealed that the resident was anxious, ringing her call bell every 5 to 10 minutes, and that she could not sleep. A nursing note for Resident 3, dated [DATE], at 10:11 a.m., authored by Registered Nurse 1, revealed that the nurse talked to the resident about hospice services for her difficulty breathing and that she could be medicated for her shortness of breath. A nursing note, dated [DATE], at 4:02 p.m., authored by Registered Nurse 1, revealed that the resident was having chest pain and wanted to go to the emergency room. A nursing note, dated [DATE], at 12:31 a.m., revealed that the resident returned from the hospital and that her family had chose for her to receive hospice services. A nursing note for Resident 3, dated [DATE], at 7:35 p.m., authored by Registered Nurse 1, indicated that the resident was resting with multiple family members at the bedside. A nursing note, dated [DATE], at 8:23 p.m., and authored by Registered Nurse 1 revealed that the resident was found without a pulse or respiratory rate at 8:00 p.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted that she administered 120 units of short-acting insulin to Resident 3 with the intent of killing her. A quarterly MDS assessment for Resident 4, dated [DATE], revealed that the resident was understood, could understand, required extensive assistance from staff for her daily care needs, had diagnoses that included cancer and diabetes, and did not receive any insulin during the review period. Physician's orders for Resident 4, dated [DATE], included an order for staff to flush the resident's midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medications) with 10 milliliters (ml) of Normal Saline Flush Solution 0.9 percent (to help prevent intravenous (IV) catheters from becoming blocked) intravenously every shift. Review of Resident 4's clinical record revealed that the resident was not ordered insulin. A nursing note for Resident 4, dated [DATE], at 12:33 p.m., completed by Registered Nurse 1 revealed that the resident had a left midline that is patent (an IV access port). The resident has been medicated as needed this shift. Will continue to monitor. A nursing note for Resident 4, dated [DATE], at 7:48 a.m., completed by Registered Nurse 1, revealed that she attempted to call the resident's family four times this a.m. The resident was found not breathing and with a heart rate of 30 beats per minute (a normal resting heart rate should be between 60 to 100 beats per minute). A nursing note at 8:01 a.m. completed by Registered Nurse 1 revealed that the resident had no pulse and no respiratory rate at 7:55 a.m. The time of death was called at 7:55 a.m. The resident's daughter was called back. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE], Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 4, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) and an air embolus (when one or more air bubbles enter a vein or artery and block it) to Resident 4 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 4. Registered Nurse 1 indicated that when this did not work, she administered one syringe of air into Resident 4's midline in an effort to create an air embolism. Per Registered Nurse 1, Resident 4 ceased to breathe once the air was administered. Resident 5's clinical record revealed that he was an [AGE] year old male and that he was admitted to the facility on [DATE], with Parkinson's disease (neurological disorder which causes uncontrollable moments of the limbs and memory loss). He died at the facility on [DATE]. A Certified Registered Nurse Practioner (advanced practice nurse) note for Resident 5, dated [DATE], at 2:59 p.m., revealed that the resident was alert and resting in bed comfortably. A nursing note, dated [DATE], at 5:00 a.m., revealed that the resident was found unresponsive and that his blood sugar was 55 (normal range 70-100). He was medicated with Glucagon (medication that treats very low blood sugar); however, his blood sugar decreased to 37. He then received a second dose of Glucagon and the nurse inserted an intravenous (IV) catheter to provide sugar water. At 5:30 a.m. his blood sugar was 77. At 6:45 a.m. his blood sugar was 147. A nursing note for Resident 5, dated [DATE], at 7:34 a.m., authored by Registered Nurse 1, revealed that the nurse phoned the resident's family and they did not want him sent to the hospital. At 7:05 a.m. Registered Nurse 1 phoned his daughters using her own personal cell phone to allow the resident's daughters to say goodbye to the resident. Registered Nurse 1 then pronounced Resident 5 dead at 7:10 a.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted to administering excess long-acting insulin to Resident 5. When the resident did not die, she then administered two 10 milliliter (mL) air bolus into the resident's IV, which she believed would cause an air embolism (air entered into the blood vessels to intentionally cause a blockage), with the intent to kill the resident. A quarterly MDS assessment for Resident 6, dated [DATE], revealed that the resident was cognitively impaired, required assistance from staff for his daily care tasks, had diagnoses that included diabetes, and received insulin. A care plan, dated [DATE], indicated that the resident's insulin was to be administered as ordered. A physician's order, dated [DATE], included an order for Resident 6 to receive 7 units of insulin Lispro (fast acting insulin) subcutaneously (beneath the skin) before meals for diabetes. A nursing note, dated [DATE], at 9:45 a.m., revealed that Resident 6 only ate 25 percent of his breakfast, Registered Nurse 1 checked his blood sugar and it was 380 milligrams per deciliter (mg/dL) at 7:36 a.m., and his insulin was administered. At 8:10 a.m. his blood sugar was 320 mg/dL, at 8:30 a.m. it was 310 mg/dL, at 8:45 a.m. it was 200 mg/dL, at 8:55 a.m. it was 120 mg/dL, at 9:00 a.m. it was 90, and at 9:15 a.m. was LOW. Registered Nurse 1 administered IM (intramuscular) Glucagon (used to increase blood sugar) and his blood sugar increased to 54 mg/dL at 9:30 a.m. and 120 mg/ dL at 9:45 a.m. A nursing note, dated [DATE], at 10:13 a.m. and 11:28 a.m., revealed that Resident 6's blood sugar dropped to 76 mg/dL and another dose of IM Glucagon was adminstered by Registered Nurse 1, and at 11:00 a.m. the resident's blood sugar was back down to 70 and then 55 mg/dL, and then dropped to LOW and unreadable. The resident was then transferred to the hospital. A nursing note, dated [DATE], at 12:13 p.m., revealed that the hospital called and reported that the resident was unresponsive and his blood sugar was 36 mg/dL. A nursing note, dated [DATE], at 11:32 a.m., revealed that Resident 6 returned from the hospital. On [DATE], at 4:39 a.m. Resident 6 was frothing at the mouth and very ashen in color, and CPR (cardio-pulmonary resuscitation) was started. His blood sugar was checked and was 23 mg/dL, and Glucagon was administered. His blood sugar was re-checked and was 23 mg/dL. The resident was pronounced dead at 4:30 a.m. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to [DATE], Registered Nurse 1, while acting as a caretaker did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted to administering more insulin to Resident 6 than he he should have been given, and as soon as she did, she knew she killed him. In subsequent interviews she stated that she gave Resident 6 too much insulin: he was ordered to receive 7 units of insulin and she intentionally administered 60 units. She stated that Resident 6 crashed faster than expected, which is why she provided the Glucagon and sent him to the hospital. She did not expect Resident 6 to recover and return to the facility. Following a review of the Police Criminal Complaint on [DATE], the facility's actions included: A review of the clinical records of all residents included in the indictment. The facility obtained newly run criminal background checks, Office of the Inspector General checks, and licensure/certification verification on current employees. Phone interviews were conducted with employees who had statements regarding Registered Nurse 1's conduct. Education was provided on signs and symptoms of hypo/hyperglycemia and abuse. The pharmacy initiated reports on usage and counts of insulin reorders during Registered nurse 1's employment. Medication room audits were conducted and on-site insulin was reviewed. The facility continues to educate on abuse/neglect upon hire, annually, and as necessary. Incidents of abuse and medication errors were reviewed by Quality Assurance. The facility indicated that the review was completed on [DATE]. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors after a registered nurse confessed to administering large doses of insulin, which caused a change in their conditions and/or death for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding medication administration, dated [DATE], revealed that medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required timeframe. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication must check the label three times to verify the right resident, right medication, right dose, right time, and right method of administration before giving the medication. A review of the personnel file for Registered Nurse 1 revealed that she was hired on [DATE], as a Registered Nurse/Unit Manager and worked in that position until she quit on [DATE]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], revealed that the resident was moderately cognitively impaired, required limited assistance from staff for her daily care tasks, had diagnoses that included diabetes, and did not receive insulin. A review of Resident 1's clinical record revealed that the resident was not ordered to receive any insulin. A nursing note, dated [DATE], at 12:50 p.m. revealed that Registered Nurse 1 called Resident 1's family about a fever and apnea (breathing stops). A nursing note, dated [DATE], at 1:55 p.m. revealed that Resident 1 had a fever of 100.8 degrees Fahrenheit (F), was given a bed bath, and her family was at her bedside. A nursing note, dated [DATE], at 3:17 p.m. revealed that Resident 1 had no respirations or heart beat for one minute and was pronounced dead at 3:15 p.m by Registered Nurse 1. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to 21, 2023, Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted she administered 60 units of short-acting insulin to Resident 1 while she was employed at the facility. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], and died at the facility on [DATE]. Additionally, the resident was not diagnosed with diabetes and was not ordered to receive any insulin. Nursing notes for Resident 2, dated [DATE], indicated that at 8:45 a.m. staff reported that the resident was not responding to them and respirations were shallow (drawing minimal breath into the lungs). Resident 2 did not respond to tactile (touch) or verbal stimuli, a radial pulse was not able to be palpated (heartbeat could not be felt in the wrist), and the heartbeat was faint to auscultation (difficult to hear when listening with a stethoscope). Staff spoke with the resident's daughter and explained that due to the faint heartbeat and the short, shallow respirations, the resident was expected to pass in the near future. A nursing note at 9:30 a.m. indicated that staff was called to the resident's room due to it being questionable if resident had any respirations (was breathing). At 9:25 a.m. the resident was without heartbeat, without respirations, and without blood pressure (deceased ). A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE] to [DATE], Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 2, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 2 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 2 with the intent to kill the resident. Resident 3's clinical record indicated that the resident was admitted to the facility on [DATE], and died on [DATE]. A nursing note for Resident 3, dated February 10, 2023, revealed that the resident was a [AGE] year old female re-admitted to the facility after a hospitalization where she developed pneumonia. A nursing note, authored by Registered Nurse 1, dated February 25, 2023, revealed that the resident was anxious, ringing her call bell every 5 to 10 minutes, and that she could not sleep. A nursing note for Resident 3, dated [DATE], at 10:11 a.m., authored by Registered Nurse 1, revealed that the nurse talked to the resident about hospice services for her difficulty breathing and that she could be medicated for her shortness of breath. A nursing note, dated [DATE], at 4:02 p.m., authored by Registered Nurse 1, revealed that the resident was having chest pain and wanted to go to the emergency room. A nursing note, dated [DATE], at 12:31 a.m., revealed that the resident returned from the hospital and that her family had chose for her to receive hospice services. A nursing note for Resident 3, dated [DATE], at 7:35 p.m., authored by Registered Nurse 1, indicated that the resident was resting with multiple family members at the bedside. A nursing note, dated [DATE], at 8:23 p.m. and authored by Registered Nurse 1, revealed that the resident was found without a pulse or respiratory rate at 8:00 p.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted that she administered 120 units of short-acting insulin to Resident 3 with the intent of killing her. A quarterly MDS assessment for Resident 4, dated [DATE], revealed that the resident was understood, and could understand, required extensive assistance from staff for her daily care needs, had diagnoses that included cancer and diabetes, and did not receive any insulin during the review period. Review of Resident 4's clinical record revealed that the resident was not ordered insulin. A nursing note for Resident 4, dated [DATE], at 7:48 a.m., by Registered Nurse 1 revealed that she attempted to call the resident's family four times this morning. The resident was found not breathing and with a heart rate of 30 beats per minute (a normal resting heart rate should be between 60 to 100 beats per minute). A nursing note at 8:01 a.m. by Registered Nurse 1 revealed that the resident had no pulse and no respirations at 7:55 a.m. Resident 4's time of death was called at 7:55 a.m. The resident's daughter was called back. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE], Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 4, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) and an air embolus (when air enters a vein or artery) to Resident 4 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 4. Registered Nurse 1 indicated that when this did not work, she administered one syringe of air into Resident 4's midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medications) in an effort to create an air embolism. Per Registered Nurse 1, Resident 4 ceased to breathe once the air was administered. Resident 5's clinical record revealed that the resident was an [AGE] year old male who was admitted to the facility on [DATE], with Parkinson's disease (neurological disorder which causes uncontrollable moments of the limbs and memory loss). He died at the facility on [DATE]. A Certified Registered Nurse Practioner (advanced practice nurse) note for Resident 5, dated [DATE], at 2:59 p.m., revealed that the resident was alert and resting in bed comfortably. A nursing note, dated [DATE] at 5:00 a.m., revealed that the resident was found unresponsive and that his blood sugar was 55 mg/dL (normal range 70-100 mg/dL). He was medicated with Glucagon (glucose medication that treats very low blood sugar); however, his blood sugar decreased to 37. He then received a second dose of Glucagon and the nurse inserted an intravenous (IV) catheter to provide sugar water. At 5:30 a.m. his blood sugar was 77 mg/dL, and at 6:45 a.m. his blood sugar was 147 mg/dL. A nursing note for Resident 5, dated [DATE], at 7:34 a.m., authored by Registered Nurse 1, revealed that the nurse phoned the resident's family and they did not want him sent to the hospital. At 7:05 a.m. Registered Nurse 1 phoned his daughters using her own personal cell phone to allow the resident's daughters to say goodbye to the resident. Registered Nurse 1 then pronounced Resident 5 dead at 7:10 a.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted to administering excess long-acting insulin to Resident 5. When the resident did not die, she then administered two 10 milliliter (mL) air bolus into the resident's IV, which she believed would cause an air embolism (air entered into the blood vessels to intentionally cause a blockage), with the intent to kill the resident. A quarterly MDS assessment for Resident 6, dated [DATE], revealed that the resident was cognitively impaired, required assistance from staff for his daily care tasks, had diagnoses that included diabetes, and received insulin. A care plan, dated [DATE], indicated that the resident's insulin was to be administered as ordered. A physician's order, dated [DATE], included an order for Resident 6 to receive 7 units of insulin Lispro (fast-acting insulin) subcutaneously (beneath the skin) before meals for diabetes. A nursing note, dated [DATE], at 9:45 a.m. revealed that Resident 6 only ate 25 percent of his breakfast, Registered Nurse 1 checked his blood sugar and it was 380 milligrams per deciliter (mg/dL) at 7:36 a.m., and his insulin was administered. At 8:10 a.m. his blood sugar was 320 mg/dL, at 8:30 a.m. it was 310 mg/dL, at 8:45 a.m. it was 200 mg/dL, at 8:55 a.m. it was 120 mg/dL, at 9:00 a.m. it was 90, and at 9:15 a.m. was LOW. Registered Nurse 1 administered IM (intramuscular) Glucagon (used to increase blood sugar) and his blood sugar increased to 54 mg/dL at 9:30 a.m. and 120 mg/ dL at 9:45 a.m. A nursing note, dated [DATE], at 10:13 a.m. and 11:28 a.m., revealed that Resident 6's blood sugar dropped to 76 mg/dL and another dose of IM Glucagon was adminstered by Registered Nurse 1 and at 11:00 a.m. the resident's blood sugar was back down to 70 and then 55 mg/dL, and then dropped to LOW and unreadable. The resident was then transferred to the hospital. A nursing note, dated [DATE], at 12:13 p.m., revealed that the hospital called and reported that the resident was unresponsive and his blood sugar was 36 mg/dL. A nursing note, dated [DATE], at 11:32 a.m. revealed that Resident 6 returned from the hospital. On [DATE], at 4:39 a.m., Resident 6 was frothing at the mouth and was very ashen in color, and CPR (cardio-pulmonary resuscitation) was started. His blood sugar was checked and was 23 mg/dL, and Glucagon was administered. His blood sugar was re-checked and was 23 mg/dL. The resident was pronounced dead at 4:30 a.m. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to [DATE], Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted to administering more insulin to Resident 6 than he he should have been given, and as soon as she did, she knew she killed him. In subsequent interviews she stated that she gave Resident 6 too much insulin: he was ordered to receive 7 units of insulin and she intentionally administered 60 units. She stated that Resident 6 crashed faster than expected, which is why she provided the Glucagon and sent him to the hospital. She did not expect Resident 6 to recover and return to the facility. Following a review of the Police Criminal Complaint on [DATE], the facility's actions included: A review of the clinical records of all residents included in the indictment. The facility obtained newly run criminal background checks, Office of the Inspector General checks, and licensure/certification verification on current employees. Phone interviews were conducted with employees who had statements regarding Registered Nurse 1's conduct. Education was provided on signs and symptoms of hypo/hyperglycemia and abuse. The pharmacy initiated reports on usage and counts of insulin reorders during Registered nurse 1's employment. Medication room audits were conducted and on-site insulin was reviewed. The facility continues to educate on abuse/neglect upon hire, annually, and as necessary. Incidents of abuse and medication errors were reviewed by Quality Assurance. The facility indicated that the reivew was completed on [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, it was determined that the facility failed to ensure that a registered nurse followed professional standards regarding care and the administration of medications, after the registered nurse confessed to administering large doses of insulin to residents and/or injecting an air bolus into venous access lines, which caused a change in their conditions and/or death for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6). This deficiency was cited as past non-compliance. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. A job description for a registered nurse, undated, revealed that the registered nurse was responsible for the management of an assigned unit on a specific tour of duty. The duties included collaborating, communicating, and cooperating as appropriate with other health care providers to ensure quality care, continually observing/monitoring and evaluating the quality, quantity, and timeliness of nursing care, and administering medications and treatments according to physician's orders and established policies and procedures. A review of the personnel file for Registered Nurse 1 revealed that she was hired on [DATE], as a Registered Nurse/Unit Manager and worked in that position until she quit on [DATE]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], revealed that the resident was moderately cognitively impaired, required limited assistance from staff for her daily care tasks, had diagnoses that included diabetes, and did not receive insulin. A review of Resident 1's clinical record revealed that the resident was not ordered to receive any insulin. A nursing note, dated [DATE], at 12:50 p.m. revealed that Registered Nurse 1 called Resident 1's family about a fever and apnea (breathing stops). A nursing note, dated [DATE], at 1:55 p.m. revealed that Resident 1 had a fever of 100.8 degrees Fahrenheit (F), was given a bed bath, and her family was at her bedside. A nursing note, dated [DATE], at 3:17 p.m. revealed that Resident 1 had no respirations or heart beat for one minute and was pronounced dead at 3:15 p.m by Registered Nurse 1. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to 21, 2023, Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted she administered 60 units of short-acting to Resident 1 while she was employed at the facility. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], and died at the facility on [DATE]. Additionally, the resident was not diagnosed with diabetes and was not ordered to receive any insulin. Review of activity notes for Resident 2, dated [DATE], indicated that the resident was independent to do self-directed leisure activities in the comfort of her room such as resting, listening to the TV, and naps. The resident had family who would call and send her items. She accepted one-on-one visits from staff and activities for conversation and current events. Review of nursing notes for Resident 2 from February 20, 2023, through [DATE], did not indicate that the resident had any significant change in condition or onset of acute (new) illness. Nursing notes for Resident 2, dated [DATE], indicated that at 8:45 a.m. staff reported the resident was not responding to them and her respirations were shallow (drawing minimal breath into the lungs). Resident 2 did not respond to tactile (touch) or verbal stimuli, radial pulse not able to be palpated (heartbeat could not be felt in the wrist), and heartbeat faint to auscultation (difficult to hear when listening with a stethoscope). Staff spoke with the resident's daughter and explained that due to the faint heartbeat and the short, shallow respirations, the resident was expected to pass in the near future. A nursing note at 9:30 a.m. indicated that staff was called to the resident's room due to it being questionable if Resident 2 had any respirations (was breathing). At 9:25 a.m. the resident was without heartbeat, without respirations, and without blood pressure (deceased ). A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE] to 21, 2023, Registered Nurse 1, while acting as a caretaker, did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 2, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 2 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 2. Resident 3's clinical record indicated that the resident was admitted to the facility on [DATE], and died on [DATE]. A nursing note for Resident 3, dated February 10, 2023, revealed that the resident was a [AGE] year old female re-admitted to the facility after a hospitalization where she developed pneumonia. A nursing note, authored by Registered Nurse 1, dated February 25, 2023, revealed that the resident was anxious, ringing her call bell every 5 to 10 minutes, and that she could not sleep. A nursing note for Resident 3, dated [DATE], at 10:11 a.m., authored by Registered Nurse 1, revealed that the nurse talked to the resident about hospice services for her difficulty breathing and that she could be medicated for her shortness of breath. A nursing note, dated [DATE], at 4:02 p.m., authored by Registered Nurse 1 revealed that the resident was having chest pain and wanted to go to the emergency room. A nursing note, dated [DATE], at 12:31 a.m. revealed that the resident returned from the hospital and that her family had chose for her to receive hospice services. Nursing note for Resident 3, dated [DATE], at 7:35 p.m., authored by Registered Nurse 1, indicated that the resident was resting with multiple family members at the bedside. A nursing note, dated [DATE], at 8:23 p.m. and authored by Registered Nurse 1, revealed that the resident was found without a pulse or respiratory rate at 8:00 p.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted that she administered 120 units of short-acting insulin to Resident 3 with the intent of killing her. A quarterly MDS assessment for Resident 4, dated [DATE], revealed that the resident was understood, understands, required extensive assistance from staff for her daily care needs, had a diagnosis which included cancer and diabetes, and did not receive any insulin during the review period. Physician's orders for Resident 4, dated [DATE], included an order for staff to flush the resident's midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm to administer medications) with 10 milliliters (ml) of Normal Saline Flush Solution 0.9 percent (to help prevent intravenous (IV) catheters from becoming blocked) intravenously every shift. Review of Resident 4's clinical record revealed that the resident was not ordered insulin. A nursing note for Resident 4, dated [DATE], at 12:33 p.m., completed by Registered Nurse 1, revealed that the resident has a left midline that is patent (open, unobstructed, affording free passage). The resident has been medicated as needed this shift. Will continue to monitor. A nursing note for Resident 4, dated [DATE], at 7:48 a.m., completed by Registered Nurse 1, revealed that she attempted to call the resident's family four times this a.m. The resident was found not breathing and with a heart rate of 30 beats per minute (a normal resting heart rate should be between 60 to 100 beats per minute). A nursing note at 8:01 a.m., completed by Registered Nurse 1, revealed that the resident had no pulse and no respiratory rate at 7:55 a.m. The time of death was called at 7:55 a.m. The resident's daughter was called back. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed neglect of a care dependent person: That on or about [DATE], Registered Nurse 1, while acting as a caretaker did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 4, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) and an air embolus (when one or more air bubbles enter a vein or artery and block it) to Resident 4 without medical justification. Interview with Registered Nurse 1 revealed that she admitted to administering insulin to Resident 4. Registered Nurse 1 indicated that when that did not work, she administered one syringe of air into Resident 4's midline in an effort to create an air embolism. Per Registered Nurse 1, Resident 4 ceased to breathe once the air was administered. Resident 5's clinical record revealed that he was a [AGE] year old male and that he was admitted to the facility on [DATE], with Parkinson's disease (neurological disorder which causes uncontrollable moments of the limbs and memory loss). He died at the facility on [DATE]. A Certified Registered Nurse Practioner (advanced practice nurse) note for Resident 5, dated [DATE], at 2:59 p.m., revealed that the resident was alert and resting in bed comfortably. A nursing note, dated [DATE], at 5:00 a.m., revealed that the resident was found unresponsive and that his blood sugar was 55 (normal range 70-100). He was medicated with Glucagon (medication that treats very low blood sugar); however, his blood sugar decreased to 37. He then received a second dose of Glucagon and the nurse inserted an intravenous (IV) catheter to provide sugar water. At 5:30 a.m. his blood sugar was 77 mg/dl, and at 6:45 a.m. his blood sugar was 147 mg/dl. A nursing note for Resident 5, dated [DATE], at 7:34 a.m., authored by Registered Nurse 1 revealed that the nurse phoned the resident's family and they did not want him sent to the hospital. At 7:05 a.m. Registered Nurse 1 phoned his daughters using her own personal cell phone to allow the resident's daughters to say goodbye to the resident. Registered Nurse 1 then pronounced Resident 5 dead at 7:10 a.m. A police criminal complaint, dated [DATE], revealed that Registered Nurse 1 admitted to administering excess long-acting insulin to Resident 5. When the resident did not die, she then administered two 10 milliliter (mL) air bolus into the resident's IV, which she believed would cause an air embolism (air entered into the blood vessels to intentionally cause a blockage), with the intent to kill the resident. A quarterly MDS assessment for Resident 6, dated [DATE], revealed that the resident was cognitively impaired, required assistance from staff for his daily care tasks, had diagnoses that included diabetes, and received insulin. A care plan, dated [DATE], indicated that the resident's insulin was to be administered as ordered. A physician's order, dated [DATE], included an order for Resident 6 to receive 7 units of insulin Lispro (fast-acting insulin) subcutaneously (beneath the skin) before meals for diabetes. A nursing note, dated [DATE], at 9:45 a.m., revealed that Resident 6 only ate 25 percent of his breakfast, Registered Nurse 1 checked his blood sugar and it was 380 milligrams per deciliter (mg/dL) at 7:36 a.m., and his insulin was administered. At 8:10 a.m. his blood sugar was 320 mg/dL, at 8:30 a.m. it was 310 mg/dL, at 8:45 a.m. it was 200 mg/dL, at 8:55 a.m. it was 120 mg/dL, at 9:00 a.m. it was 90, and at 9:15 a.m. was LOW. Registered Nurse 1 administered IM (intramuscular) Glucagon (used to increase blood sugar) and his blood sugar increased to 54 mg/dL at 9:30 a.m. and 120 mg/ dL at 9:45 a.m. A nursing note, dated [DATE], at 10:13 a.m. and 11:28 a.m., revealed that Resident 6's blood sugar dropped to 76 mg/dL and another dose of IM Glucagon was adminstered by Registered Nurse 1 and at 11:00 a.m. the resident's blood sugar was back down to 70 and then 55 mg/dL, and then dropped to LOW and unreadable. The resident was then transferred to the hospital. A nursing note, dated [DATE], at 12:13 p.m. revealed that the hospital called and reported that the resident was unresponsive and his blood sugar was 36 mg/dL. A nursing note, dated [DATE], at 11:32 a.m., revealed that Resident 6 returned from the hospital. On [DATE], at 4:39 a.m. Resident 6 was frothing at the mouth and very ashen in color, and CPR (cardio-pulmonary resuscitation) was started. His blood sugar was checked and was 23 mg/dL, and Glucagon was administered. His blood sugar was re-checked and was 23 mg/dL. The resident was pronounced dead at 4:30 a.m. A Commonwealth of Pennsylvania Police Criminal Complaint, dated [DATE], revealed that on or about [DATE] to [DATE], Registered Nurse 1, while acting as a caretaker did intentionally, knowingly or recklessly cause serious bodily injury and/or death by failing to provide treatment, care, goods, or services necessary to preserve the health, safety or welfare of a care-dependent person for whom she was responsible to provide care. Registered Nurse 1 did intentionally, knowingly or recklessly cause serious bodily injury and/or death to a care-dependent person, Resident 1, by failing to provide treatment, care, goods or services necessary to preserve her health when she administered medication (insulin) to Resident 1 without medical justification. An interview with Registered Nurse 1 on [DATE], revealed that she admitted to administering more insulin to Resident 6 than he he should have been given, and as soon as she did, she knew she killed him. In subsequent interviews she stated that she gave Resident 6 too much insulin: he was ordered to receive 7 units of insulin and she intentionally administered 60 units. She stated that Resident 6 crashed faster than expected, which is why she provided the Glucagon and sent him to the hospital. She did not expect Resident 6 to recover and return to the facility. Following a review of the Police Criminal Complaint on [DATE], the facility's actions included: A review of the clinical records of all residents included in the indictment. The facility obtained newly run criminal background checks, Office of the Inspector General checks, and licensure/certification verification on current employees. Phone interviews were conducted with employees who had statements regarding Registered Nurse 1's conduct. Education was provided on signs and symptoms of hypo/hyperglycemia and abuse. The pharmacy initiated reports on usage and counts of insulin reorders during Registered nurse 1's employment. Medication room audits were conducted and on-site insulin was reviewed. The facility continues to educate on abuse/neglect upon hire, annually, and as necessary. Incidents of abuse and medication errors were reviewed by Quality Assurance. The facility indicated that the reivew was completed on [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, the facility contract for hairdresser services, clinical records, facility reports and staff interviews, it was determined that the facility failed to provide the required supervision to prevent an accident that resulted in harm that included a fractured hip for one of 12 residents reviewed (Resident R1). Findings include: The facility Resident, Family Care Plan Conferences policy dated 5/1/16, indicated that the plan of care (care plan) was developed for the resident by the interdisciplinary team and identified the needs, strength and problems of the resident and identified goals which included the care and services that must be provided to meet those goals. The Agreement for Hairdresser Services identified duties and obligations of the hairdresser as complying with the policies and procedures of the facility which included prompt notification of the nursing staff when unable to attend to the needs of the resident. Resident R1's admission record indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. lack of coordination. The quarterly Minimum Data Set assessment (MDS-a periodic assessment of care needs) dated 11/2/16, indicated that Resident R1 required the extensive assistance of two people for transfers, the extensive assistance of one person when ambulating off the nursing unit and was severely impaired cognitively for making decisions with a Brief Interview for Mental Status (BIMS - test given that helps determine a person's cognitive understanding) score of 2 (score of 0-7 severely impaired). The current care plan indicated that on 8/14/16, the facility staff initiated interventions that Resident R1 required supervision when off of the nursing unit, the extensive assistance of staff to move between surfaces and that the resident required a chair alarm (a device attached to a chair that alarms when person exits the chair). These same interventions were in place for Resident R1 when the facility reviewed and updated the care plan on 12/9/16. The December 2016 recapitulation orders (a summary of the physician's orders [REDACTED]. A nursing progress note dated 12/19/16, at 5:46 p.m. indicated that the Hairdresser Employee E1 called the nursing station and asked for nurse assistance. The note stated, RN (Registered Nurse), LPN (Licensed Practical Nurse) and 2 CNAs (Certified Nursing Aides) found (Resident R1) lying on floor (of the salon) on right side .RN moved resident away from wall while maintaining resident's neck and body alignment and position. Head laceration noted to right temporal/parietal region (area on side of head directly in front and above the ear); pressure applied to reduce bleeding. Resident R1's physician was notified, ambulance transportation was arranged and the resident was transferred to the hospital. The results of an X-ray completed at the hospital on [DATE], revealed that Resident R1 had an, acute intertrochanteric (located in the region between the greater and lesser trochanters which form the hip bone) fracture of the right femur (long bone running through the thigh). A hospital operation report indicated that on 12/20/16, Resident R1 had an open reduction internal fixation (ORIF-surgical repair using implants to repair fractured bones) of the right intertrochanteric hip fracture. The facility investigation that concluded on 12/21/16, noted that Employee E1 left Resident R1 unattended in the beauty salon. During Employee E1's absence, Resident R1 got up off the chair, grabbed a broom and fell while attempting to sweep hair clippings off the floor. During interviews on 1/11/17, at 9:15 a.m. and at 9:30 a.m. the Director of Nursing (DON), the Assistant Director of Nursing, Employee E3 and the Nursing Home Administrator (NHA) confirmed that Resident R1 required supervision and was not to be left unattended in the beauty salon. During a phone interview on 1/12/17, at 10:45 a.m. Employee E1 reported that Resident R1's hair was getting dyed on 12/19/16, so the resident was transferred from the wheelchair to the beauty salon chair. The chair sensor alarm was attached to the wheelchair but not placed on the beauty salon chair. Employee E1 confirmed knowing that Resident R1 was not to be left alone, described the resident as a helper and realized from past behaviors, the potential for Resident R1 to see the hair clippings on the floor and help by sweeping them up and Employee E1 reported, I knew not to leave (Resident R1) alone and made a mistake when I did. During an interview on 1/12/17, at 2:45 p.m. the NHA and the DON confirmed that the facility failed to provide Resident R1 with the required supervision needed to keep the resident safe and that Resident R1 subsequently incurred harm. 42 CFR 483. 25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/supervision/devices. Previously cited 4/27/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/27/16, 6/12/15. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/19/16, 4/27/16, 6/12/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/19/16, 6/12/15.