Every finding on record at Transitions Healthcare Gettysburg

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 24 residents reviewed (Resident 2, 7, 14, and 55).Findings include: Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills) and bipolar disorder (unusual shifts in mood, ranging from extreme highs to lows). Review of Resident 2's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with an ARD (Assessment Reference Date - last day of the assessment period) of May 8, 2026, indicated Resident 2 was receiving an anticoagulant. Review of Resident 2's current and discontinued physician orders failed to reveal an order for anticoagulant medication use. An interview on August 19, 2026 at 1:15 PM, with Employee 1 (MDS Coordinator) revealed that Resident 2's aforementioned MDS was incorrect and should not have been coded for anticoagulant use. During an interview on August 20, 2026, at 10:59 AM, with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), revealed that it was the expectation of the facility that MDS assessments be correct. Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 7's physician orders revealed an order for a no added salt diet pureed diet dated July 14, 2025. Review of Resident 7's Annual MDS with an ARD of July 22, 2026, revealed in Section K. Nutrition and Swallowing that he was not coded for receiving a therapeutic diet. During a staff interview with Employee 1 on August 19, 2026, at 1:11 PM, Employee 1 confirmed that Resident 7's MDS was coded inaccurately for his therapeutic diet. During a staff interview with the NHA and DON on August 20, 2026, at 10:44 AM, both confirmed that they would expect resident assessments to be coded accurately. Review of Resident 14's clinical record revealed diagnoses that included benign prostatic hyperplasia (noncancerous enlargement of the prostate gland causing trouble urinating) and obstructive (functional blockage of urine flow which causes damage to the kidneys) and reflux (urine flows backward into the kidneys) uropathy (any condition affecting that affects the urinary system). Review of Resident 14's Annual MDS with an ARD of April 25, 2026, revealed in Section I. Active Diagnoses at question I2300. Urinary Tract Infection (UTI) (Last 30 days) was not marked. Review of Resident 14's clinical record progress notes, physician orders, and medication administration records revealed that he was treated for a UTI from March 13, 2026, through April 22, 2026. During a staff interview with the NHA and DON on August 20, 2026, at 10:48 AM, both confirmed that Resident 14's UTI should have been coded on his MDS and that they would expect resident assessments to be coded accurately. Review of Resident 55's clinical record revealed diagnoses that included paroxysmal atrial fibrillation (a type of irregular and fast heart rhythm where episodes start and stop suddenly on their own), ischemic cardiomyopathy (a heart muscle disorder where the heart cannot pump blood well), and long term (current) use of anticoagulants (a substance that prevents or slows down the blood's ability to clot). Review of Resident 55's orders revealed an order for Eliquis 5 mg every 12 hours for Paroxysmal Atrial Fibrillation; long term (current) use of anticoagulants written on March 3, 2026, at 6:20 PM. Review of Resident 55's Medicare-5 Day MDS with an ARD of March 9, 2026, revealed anticoagulant usage was not marked yes. Review of Resident 55's medication administration record revealed she had taken Eliquis 5 mg on March 3, 2026, through March 9, 2026. Review of Resident 55's MDS with an ARD of July 24, 2026, revealed anticoagulant usage was not marked yes. Review of Resident 55's medication administration record revealed she had taken Eliquis 5 mg twice a day during her assessment period. During a staff interview with Employee 1 on August 19, 2026, at 1:20 PM, she stated, she missed documenting that and she should have marked them. She revealed her expectation was the anticoagulant should have been marked yes as the Resident was taking it during the assessment period. During a staff interview with the NHA and DON on August 20, 2026, at 10:33 AM, the DON expressed her expectation would be that the MDS would be coded accurately for anticoagulant usage on the MDS with ARD of March 9, 2026, and July 24, 2026. Further review of Resident 55's clinical record revealed the MDS with ARD of March 9, 2026 and July 24, 2026, had been modified to show anticoagulant usage during the assessment period. 28 Pa. Code 211.5(f) Medical records.28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for four of 24 residents reviewed (Residents 6, 7, 12, and 55).Findings include: Review of facility policy, titled OPS 351a Care Plan-Comprehensive, with a last review date of July 20, 2026, revealed, in part, Each resident will have a comprehensive care plan developed that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. Review of the clinical record for Resident 6 revealed diagnoses that included primary generalized osteoarthritis (cartilage breakdown happens in multiple joints) and upper end left humerus fracture (fracture of upper arm). Review of Resident 6's current medication administration record revealed prophylactic daily administration of an anticoagulant (blood thinner) for deep vein thrombosis (clot forms in deep vein). Review of Resident 6's care plan failed to include a care plan for pain or for receiving an anticoagulant. During an interview with the Director of Nursing (DON) on August 19, 2026, at 9:50 AM, the DON agreed that Resident 6's care plans should reflect his status, and agreed that pain and anticoagulant medication should be present on the care plan. Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 7's Annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with an ARD (Assessment Reference Date - last day of the assessment period) of July 22, 2026, revealed in Section V. Care Area Assessment (CAA) Summary that Resident 7 triggered for cognitive loss, visual function, and dental care. The accompany CAA worksheets indicated that all of these identified triggers would be care planned. Review of Resident 7's current care plan failed to reveal any focus for cognitive loss, visual function, or dental care. During a staff interview with the DON on August 20, 2026, at 12:12 PM, the DON confirmed that she would expect Resident 7's comprehensive care plan to have included his triggered cognitive loss, visual function, and dental care. She said that would be revising Resident 7's care plan. Review of Resident 12's clinical record revealed diagnoses that included urinary retention and history of lung cancer. Review of Resident 12's admission MDS with an ARD of April 8, 2026, revealed in Section V. Care Area Assessment (CAA) Summary that Resident 12 triggered for cognitive loss and visual function. The accompany CAA worksheet indicated that both of these identified triggers would be care planned. Review of Resident 12's current care plan failed to reveal any focus for cognitive loss or visual function. During a staff interview with the NHA and DON on August 20, 2026, at 10:43 AM, the DON confirmed that Resident 12's care plan should have included his cognitive loss and visual function concerns. She also confirmed that Resident 12's care plan had now been revised. Review of Resident 55's clinical record revealed diagnoses of obstructive sleep apnea (a common sleep disorder where throat muscles relax and block the airway during sleep) and chronic systolic (congestive) heart failure (heart failure occurring when the main pumping chamber of the heart, which is the left ventricle, loses its ability to contract normally), paroxysmal atrial fibrillation (a type of irregular and fast heart rhythm where episodes start and stop suddenly on their own), ischemic cardiomyopathy (a heart muscle disorder where the heart cannot pump blood well), and long term (current) use of anticoagulants (a substance that prevents or slows down the blood's ability to clot). Review of Resident 55's order revealed a current order for continuous oxygen at two liters per minute via nasal cannula every bedtime written on March 3, 2026, upon return from a hospital stay. Review of Resident 55's discontinued orders revealed an order for continuous oxygen at two liters per minute via nasal cannula every shift written on January 24, 2026, which was her admission date to the facility. Review of Resident 55's care plan did not reveal a focus, goal or interventions for oxygen use. Review of Resident 55's resolved/cancelled areas of care plan did not reveal oxygen goal, focus or interventions having been added during development of the comprehensive care plan at admission. During a staff interview with the NHA and the DON on August 20, 2026, at 10:34 AM, the DON revealed her expectation is the care plan would be updated for oxygen use upon admission to the facility. Review of Resident 55's orders revealed an order for Eliquis 5 mg every 12 hours for Paroxysmal Atrial Fibrillation; long term (current) use of anticoagulants written on March 3, 2026, at 6:20 PM. Review of Resident 55's care plan failed to reveal a focus, goal, or interventions for use of anticoagulant medication or monitoring of skin condition or bleeding. During a staff interview with the NHA and DON on August 20, 2026, at 10:32 AM, the DON revealed her expectation is that the care plan would include an anticoagulant when the order is received. 42 CFR 483.21(b) Comprehensive Care Plans.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the kitchen, and failed to maintain sanitary conditions in the kitchen and in one of two nourishment rooms (Annex 1).Findings include: Review of facility policy, titled Food Storage, with a last review date on July 20, 2026, revealed, in part, Food will be stored in an area that is clean, dry, and free from contaminants. 7. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, food should be consumed, sold, or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready foruse. 8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 9. Scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis.10. Racks and other storage surfaces should be clean and protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. 13. Refrigerated food storage: a. All refrigerator units should be kept clean and in good working condition at all times. f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 14. Frozen Foods: c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Tour of the kitchen on August 17, 2026, at 9:56 AM, with Employee 2 (Dietary Manager) revealed the following concerns:1) Walk-in Refrigerator 2 - three pans of peach crisp which were not dated2) Dry storage room - two plastic food storage bins stored upright; an open box of cornstarch with bag open and not sealed; an open packet of tortilla shells which was not dated; and there was a brown powdery substance noted on the floor near the door; 3) Prep Refrigerator - food debris and spillage noted on the inside base of the refrigerator4) Juice machine - a plastic bag containing lemonade, which was connected to the machine, was laying on the floor; and on the counter directly beside the juice machine was a purse and beverage cup which Employee 2 identified as a dietary staff members;5) Ice cream cooler - an open bag of chicken tenders that was not dated or sealed and a box of pork egg rolls that was not dated;6) Microwave - heavy amount of food splatter;7) Prep area counter - an unsealed plastic bin of brown sugar with a measuring spoon placed inside8) Tray line reach-in refrigerator with food debris and the reach-in warming unit on the end also had food debris and splatter;9) Small prep area counter - there was a peeler noted in a basket with a blue colored substance noted in the bin and on the peeler;10) Cook's table - all three drawers were noted to have food spillage on the top ledge and there was an unsealed plastic bin of liquid butter with pastry brush sitting inside; scoops for the flour, sugar, and thickener bins were laying on top of the bins with no covering and the scoop for the rice was noted to be stored inside the bin. Observations of Annex 1 nourishment room on August 17, 2026, at 10:34 AM, revealed a brown colored spill in the drawers where lids and cups are stored. Follow-up observation of the kitchen with Employee 2 on August 18, 2026, at 1:10 PM, revealed the following:1) presence of a black colored substance on ceiling over the two-compartment and three-compartment sinks and the air vents in these two areas were noted to have a large amount of black colored fuzzy appearing substance; and2) Dish room - presence of a black colored substance on ceiling; a water pipe located over the clean dish counter that had cracked paint and a rust colored substance noted; two fans one of which was blowing in the direction of the clean dishes that had a large amount of gray fuzz noted. Review of Monthly Cleaning Calendars for the kitchen for July 2026 and August 2026 revealed that the tray line hot and cold reach-in units were last cleaned on July 12, 2026; and that the sweeping and mopping of walk-ins and pantry was completed on August 15, 2026. Follow-up observation of the kitchen on August 19, 2026, at 10:30 AM, revealed that all areas of concern had been cleaned. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on August 19, 2026, at 11:20 AM, the NHA confirmed that she would expect food to be stored properly and sanitary conditions be maintained. She said that maintenance does do preventative checks of the kitchen and that, if staff notice cleanliness issues that maintenance needs to complete such as the fans, vents, ceiling, they should put in a TELS (facility maintenance work order program) to get the task completed. 28 Pa code 211.6(f) Dietary services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 24 residents reviewed (Residents 12, 13 and 115).Findings include: Review of facility policy, titled OPS 351a Care Plan-Comprehensive, with a last review date of July 20, 2026, revealed, in part, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 12's clinical record revealed diagnoses that included urinary retention and history of lung cancer. Review of Resident 12's care plan revealed a care plan focus for an urinary tract infection dated July 22, 2026. Review of Resident 12's clinical record revealed that he had completed his course of treatment for his urinary tract infection on July 27, 2026. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 20, 2026, at 10:43 AM, the DON confirmed that Resident 12's care plan should have been revised when his urinary tract infection resolved. She also confirmed that Resident 12's care plan had now been revised. Review of Resident 13's clinical record revealed diagnoses that included anxiety disorder (mental health disorder that causes intense ongoing fear and worry) and generalized weakness (reduction in muscle strength). Review of Resident 13's physician orders revealed orders with a start date of December 23, 2025, for left and right hand splints and left and right elbow braces to be applied every day shift for two hours or as tolerated, then remove and apply a washcloth to the left and right hands. Review of resident 13's comprehensive care plan failed to reveal any mention of Resident 13's use of hands splints and elbow braces. During an interview on August 20, 2026, at 10:57 AM, with the NHA and DON, it was revealed that Resident 13's care plan had been updated to include the hand splints and elbows braces, and that it was the expectation of the facility that care plans be updated timely. Review of Resident 115's clinical record revealed a diagnoses that included neuromuscular dysfunction of bladder (happens when damage or disease interrupts the nerve and muscle signals that control how the bladder stores and empties urine) and polyneuropathy (a medical condition where many peripheral nerves all over the body are damaged at the same time). Review of Resident 115's orders revealed an order to cleanse Suprapubic catheter (a flexible tube placed directly into the bladder through a small cut in the lower belly to drain urine when you cannot urinate normally) stoma site with normal saline solution then apply drain sponge every day and prn (as needed). Review of Resident 115's care plan revealed an intervention to receive suprapubic catheter care every shift. During a staff interview with the NHA and the DON on August 20, 2026, at 10:41 AM, the DON revealed her expectation is for current orders and care plan to match.42 CFR 483.21(b) Comprehensive Care Plans.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of two residents reviewed (Resident 12).Findings include: Review of Resident 12's clinical record revealed diagnoses that included history of lung cancer and chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 12's physician orders revealed an order for continuous oxygen at 2 liters per minute via nasal cannula dated July 7, 2026. Observation of Resident 12 on August 19, 2026, at 10:39 AM, revealed Resident 12's oxygen concentrator was running, but his nasal cannula dated August 15, 2026, was noted to be on the floor. Observation was shared with Employee 3 (Nurse Aide) on August 19, 10:39 AM, the aforementioned observation was shared. Employee 3 was observed to immediately enter Resident 12's room. Follow-up observation of Resident 12 on August 19, 2026, at 10:40 AM, revealed that the oxygen tubing dated August 15, 2026, had been removed from the floor and was in place on Resident 12's face. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on August 19, 2026, at 11:05 AM, the DON confirmed that Employee 3 should not have placed the O2 from the floor onto Resident 12. 28 Pa code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to discard expired stock medications in one of two medication storage areas observed (Annex 1).Findings include: Review of facility policy, titled Storage of Medications, with a revision date of [DATE] and policy review date of [DATE], revealed, in part, outdated.medications.are immediately removed from inventory, disposed of according to procedures for medication disposal. Observation of the Annex 1 Med Storage room on [DATE], at 10:45 AM, revealed six bottles of Iron 27 mg with an expiration date of [DATE]. During an immediate staff interview with Employee 4 (Registered Nurse Supervisor), Employee 4 revealed that the six bottles of Iron 27 mg were expired and discarded them per facility protocol. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on [DATE], at 10:34 AM, the DON confirmed that she expected stock medications to be discarded when expired according to policy or manufacturer guidelines. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident. Resident 1 was found by security staff at a nearby college campus as she was attempting to enter a locked building. This failure placed an additional 14 residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15).Findings include: Review of facility policy, titled Elopement/Wandering Resident, revised August 27, 2025, revealed, Managing elopement risk is crucial for ensuring the safety and well-being of residents in nursing homes, particularly those with cognitive impairments .The facility will determine which residents have significant wandering behavior and enhance staff awareness as well as educate them on how to deal with such residents .Based on individual resident needs, staff may increase supervision and monitoring of residents at risk of elopement, especially during high-risk times. Review of Resident 1's clinical record revealed diagnoses that included bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior). Review of Resident 1's elopement assessment dated [DATE], revealed that she was identified as an elopement risk. Review of physician orders revealed an order, dated May 30, 2025, to check for placement of code alert bracelet each shift. Review of Resident 1's care plan revealed that she is at risk for exit seeking because she wanders aimlessly. The care plan notes an intervention of a code alert bracelet which staff are to check for functioning and placement each shift, effective July 8, 2024. Review of Resident 1's census information revealed that she has resided on the second-floor secured dementia care unit since her admission on [DATE]. Review of Resident 1's July 9, 2026, quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that she had severe cognitive impairment. Review of reported incident revealed that Resident 1 was discovered to be missing from her nursing unit at approximately 5:12 PM on August 3, 2026, while staff were distributing dinner trays. A search of the facility and grounds was conducted with no success. Interviews with staff were conducted, and it was determined that the Resident was last seen around 3:00 PM in the activity room. Resident 1 was not observed leaving the unit, so the exact time of departure was unknown. At 6:00 PM the local police department was notified that Resident 1 was missing. At 7:15 PM, Emergency Medical Services (EMS) contacted the facility and notified them that Resident 1 was located at a nearby college campus. College security staff were alerted when an unknown individual set off an alarm by trying to enter a locked facility door at the campus. It was determined that the individual was Resident 1. EMS responded to evaluate Resident 1 onsite. Resident 1 was assessed by EMS and was found to have no acute injuries or medical concerns. Resident 1 was returned to the facility via staff transport at 7:28 PM. At the time of the elopement, it was noted that Resident 1 was not wearing shoes and exited the building in her socks. She was found at a college campus, approximately 1 mile away from the facility. To arrive at her destination, Resident 1 would have crossed a busy two-lane main road. Additionally, Resident 1 likely walked down two flights of stairs before exiting the building. Following Resident 1's return, the facility began an investigation, and it was determined that Resident 1 most likely exited the building during the time when the facility alarm system was powered down for repairs to the fire panel, which resulted in the code alert system being offline and the door locks disengaging.Review of Resident 1's progress notes dated August 3, 2026, revealed that she was assessed for injury upon return to the facility. She was found to be incontinent of bowel and bladder. The soles of her feet were noted to be reddened. During an interview with Employee 1 (Facility Service Director) on August 6, 2026, at 10:27 AM, he revealed that on August 3, 2026, repairs were being performed on the fire panel, and the system was powered down from approximately 11:00 AM to 3:55 PM. Prior to this happening, Employee 1 stated that he made an announcement over the intercom that work was being done on the fire panel and that the system would be disconnected. He revealed that he felt it was common knowledge that when the system was down, there was no power to anything. During an interview with the Nursing Home Administrator (NHA) on August 6, 2026, at 12:27 PM, she revealed that she conducts elopement training quarterly during, which she reviews what is to happen when the fire/alarm system goes down. She further revealed that she was not able to confirm who was monitoring the doors on Resident 1's unit during the system outage on August 3, 2026. During an interview with Employee 3 on August 6, 2026, at approximately 11:20 AM, she stated that prior to Resident 1's elopement, she was aware that the doors are vulnerable when the fire alarm system is powered down, but that she was unaware of any particular assignment for monitoring the doors. During an interview with Employee 4 on August 6, 2026, at 11:31 AM, she stated that prior to Resident 1's elopement, she did not recall receiving training on what to do when the fire/alarm system is offline. During an interview with Employee 5 on August 6, 2026, at 11:39 AM, she stated that prior to Resident 1's elopement, she was not aware that the doors unlocked when the fire/alarm system is off. During a later interview with the NHA on August 6, 2026, at 3:57 PM, she revealed the expectation that Resident 1's elopement never should have happened. Clinical record review for Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 revealed that they had been identified as an elopement risk and had orders for a code alert bracelet. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement. The NHA was provided the immediate jeopardy template on August 6, 2026, at 12:50 PM, and an immediate action plan was requested. On August 6, 2026, at 3:57 PM the facility's immediate action plan was reviewed and accepted, which included: On 8/3/2026 at 5:30 PM, staff conducted a second thorough search of the building and surrounding grounds, secured all exits, and secured all residents in their rooms appropriately to see if any other residents were missing from the facility. After the second search was concluded, the only resident that was not accounted for was Resident 1. On 8/3/2026 at 7:28 PM, Resident 1 arrived at facility. Upon arrival, the Director of Nursing (DON) completed a comprehensive head-to-toe assessment, including evaluation for injuries, skin integrity, neurological status, vital signs, and overall condition. No injuries or significant changes in the Resident's condition were identified. Upon interviewing the Resident, Resident 1 was asked if she was ok and was asked how she exited the facility grounds; Resident stated, that was fun. Resident 1 was returned to her unit, and the code alert was checked to ensure it was in proper working order, no issues identified. Resident 1 was provided a meal upon return to unit in which she pleasantly consumed with no issues noted. The practitioner and Resident 1's Responsible Party were notified of the Resident 1's return and assessment findings. Resident 1 was seen by the practitioner on 8/4/2026 for follow-up, no new concerns noted. On 8/3/2026, the Maintenance Director conducted a comprehensive inspection of all facility doors to verify that each door was functioning properly, all door code alert systems were operational, and all doors were properly secured. The inspection confirmed that all doors were in proper working order, all door code alerts were functioning as intended, and all doors were appropriately secured. No additional concerns or deficiencies were identified during the inspection. On 8/3/2026, all residents' code alert devices were audited by the DON/Designee to verify that they were properly in place on each identified resident and functioning as intended. In addition, all resident care plans were reviewed to ensure they accurately reflected each resident's code alert status and were in compliance with facility policy. Education was completed with facility staff in regard to knowledge pertaining to Elopement Training and Down Fire Systems, highlighting on how the Code Alert system will be temporarily offline during this interruption by in-person education conducted by the NHA/Designee. Additional in-person education was completed prior to start of the shift for those staff members that were not present in the building at the time of the incident. Education was additionally sent via text/phone via Cliniconex on 8/4/2026. Through the investigation process, it was identified that when the facility's fire panel goes down, the code alert system goes down as well. A system change has been put into place to reflect that when the fire alarm is activated or if there is testing on the fire panel/breaker box in the facility, the facility's active security alarm system will be offline. During this process, instructions will be given to select facility personnel to man stairwell doors, exit doors, and elevators during the fire watch process. These assigned positions are intended to enhance resident safety by preventing unauthorized use of stairwells and elevators during an emergency, fire alarm event, or testing event. To monitor and maintain ongoing compliance, the facility will conduct a down fire system drill audit weekly for four weeks to ensure compliance. Findings will be reviewed in monthly Quality Assurance/Performance Improvement meeting. An Ad Hoc QAPI meeting was held on 8/4/2026 with IDT (Inter-disciplinary) Team to discuss the series of events that led up to the occurrence that happened on 8/3/2026 involving Resident 1. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. The Immediate Jeopardy was lifted on August 6, 2026, at 3:57 PM, after ensuring that the immediate action plan had been implemented. The facility demonstrated past non-compliance by initiating immediate interventions starting August 3, 2026, following the incident. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed on August 6, 2026, during the onsite survey and included: - An in-house resident head count was completed on August 3, 2026. - All doors in facility were checked to ensure they were properly secured on August 3, 2026. - Resident 1 was assessed for injury upon return to the facility on August 3, 2026. - Resident 1 was placed on 15-minute checks from the time of her return through 7:00 AM on August 4, 2026. - An audit was conducted of all residents with code alert bracelets to ensure proper placement, function, and care planning on August 3, 2026. - A blast email and text message was sent to all staff persons to educate them on fire alarm, security system and elopement process updates on August 3, 2026. - In-person education was completed on the fire alarm, security system and elopement process with all staff present during the incident. Staff who were not present were educated prior to the start of their shift. Education was completed by August 4, 2026. - An ad hoc QAPI meeting was conducted on August 4, 2026, to discuss the elopement and next steps. During the onsite survey on August 6, 2026, no additional concerns related to elopement were identified based on observations, clinical record review, interviews with staff, review of audits, and review of education provided to staff. It was determined that the facility was in compliance as of August 4, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was revealed that the facility failed to ensure that one of 3 residents reviewed received a therapeutic diet per physician order (Resident 1).Findings include: Review of facility provided extension sheet revealed residents on a low sodium diet should receive scrambled eggs in place of ham. Review of Resident 1's clinical record revealed clinical diagnoses that included cerebral infarction (stroke- blood flow to an area of the brain is blocked, depriving brain tissue of oxygen and glucose) and hypertension (elevated blood pressure). Review of Resident 1's current physician orders stated Resident 1 should receive a Low Sodium Diet, Regular texture, Regular/Thin consistency 2 Gram Sodium related to Essential (Primary) Hypertension. During an interview with Resident 1 on July 20, 2026, at 11:30 AM, Resident 1 stated that he received ham at breakfast and no scrambled eggs. Resident 1 stated that he asked where the scrambled eggs were and that he was told there are no scrambled eggs on Mondays. During an interview with Resident 2 on July 20, 2026, at 1:10 PM, who also receives a low sodium diet, he was asked if he received scrambled eggs for breakfast, and he replied no but he was unable to recall if he received ham. During an interview with Employee 1 (Nurse Aide) she confirmed that Resident 1 received ham for breakfast and remembered cutting the ham for the Resident. Employee 1 said that she didn't know he shouldn't have received the ham. Employee 1 denied telling Resident 1 the facility doesn't serve scrambled eggs on Mondays, and said the Resident didn't request scrambled eggs and was enjoying the ham. During an interview with Employee 2 (Dietary Manager) on July 20, 2026, at 1:00 PM, after Employee 2 reviewed the error in Resident 1's therapeutic diet, she stated that the person who calls out the diet during tray line meal preparation made the mistake in Resident 1's diet. Employee 1 added that scrambled eggs are available every morning. During an interview with Resident 1 on July 20, 2026, Resident 1 stated that he received ham at breakfast and no scrambled eggs. During an interview with the Director of Nursing (DON) on July 20, 2026, at 3:00 PM, the DON agreed that residents should receive the diet prescribed by the physician. 28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 211.6(a) Dietary Services.

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident's right to file a grievance anonymously was honored on three of three resident living areas.Findings include: Review of facility, titled OPS-352 Grievance Policy, with a last review date of August 27, 2025, revealed, in part, 1. A concern/grievance may be made in person, in writing, by telephone or by mail and may be reported anonymously. The facility may not require the signature of the resident, the resident's representative or concerned party on a concern/grievance. 2. Grievance forms are located at each nursing station, the receptionists' office and outside the Social Service office. Forms may be returned to the receptionists' office, the Social Service department and/or to facility staff and management. During a Resident group meeting with Residents 30, 51, 55, 66, and 76 on September 23, 2025, at 10:30 AM, Residents 30, 51, 66, and 76, all indicated that they did not know how to file a grievance or how to do it anonymously. Resident 51 indicated that she just tells the facility Social Worker if she has an issue. Residents 30, 66, and 76 concurred that they just tell the Social Worker, their nurses, or others in management if they have concern. Resident 55 offered no comments in the discussion. Observation of grievance process information posted on a bulletin board on all three living areas of the facility on September 23, 2025, between 1:00 PM and 1:30 PM, revealed a posting that indicated If you have a concern or a grievance to file, you may complete a grievance form. Please return this form to the RN Supervisor or Nurse Manager. You may also contact: Nursing Home Administrator [name, email, and phone number provided] or Grievance Coordinator/Director of Social Services [name, email, and phone number provided]. There was no drop box or any location noted in which a resident could file/place an anonymous grievance. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on September 25, 2025, at 11:12 AM, the NHA confirmed that there should have been a process in place for residents to be able to submit grievances anonymously. She also confirmed that the facility revised their process on September 24, 2025, after the concern was brought to their attention by the surveyor. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (b)(1)(2) Management.28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of two residents reviewed (Resident 5).Findings include: Review of facility policy, titled CLIN-157 CPAP/BIPAP, with a last review date of August 27, 2025, revealed, in part, orders must include pressure and hours of use and may include supplemental oxygen and mask size. The policy failed to indicate how the mask was to be stored when not in use. Review of Resident 5's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, and legal blindness. Review of Resident 5's current physician orders revealed an order for CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps; used to treat sleep apnea) on at bedtime and remove in the morning, dated February 2, 2025. The order failed to include any ordered settings for the CPAP. Review of Resident 5's care plan failed to reveal a respiratory care plan or any documentation of Resident 5's use of a CPAP. Observation of Resident 5 on September 22, 2025, at 1:21 PM, revealed a CPAP machine on her bedside stand. Her mask was observed hanging on a hook on the wall above the head of her bed. The mask was directly touching the wall. Follow-up observations of Resident 5 on September 23, 2025, at 9:32 AM; September 24, 2025, at 9:51 AM; and September 25, 2025, at 9:05 AM, all revealed the same observation of her CPAP mask hanging on the hook directly touching the wall. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on September 25, 2025, at 11:17 AM, the DON confirmed that Resident 5's CPAP order did not include the machine settings and that she would expect that information to have been included in the order. She confirmed that Resident 5's care plan should have included her respiratory diagnosis and all appropriate care interventions. She said that she has read mixed recommendations on how the masks should be stored when not in use (placed in a protective bag or stored in open air) but confirmed that the facility policy did not include guidance on how masks should be stored when not in use. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for four of 24 residents reviewed (Residents 5, 75, 99, and 118).Findings include:Review of the facility policy, titled OPS Minimum Data Set Submission/Accuracy, with a last review date of August 27, 2025, stated, Each Minimum Data Set Submission (MDS) [an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] will be completed accurately and timely and in accordance with RAI (Resident Assessment Instrument) guidelines and requirements.Review of Resident 5's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, muscle weakness, and moderate protein-calorie malnutrition (the state of inadequate food intake which leads to changes in body composition and function). Review of Resident 5's quarterly MDS dated [DATE], revealed in Section M. Skin Conditions at question M0100A that she was coded as not having a pressure ulcer. Further review of this section revealed at question M0210 that she was coded as having one or more unhealed pressure ulcers/injuries; and at question M0300C1 she was coded as having one Stage 3 pressure ulcer (a full-thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed). During a staff interview with the Director of Nursing (DON) on September 24, 2025, at 2:00 PM, she confirmed Resident 5's MDS was coded inaccurately at question M0100A and that a correction would be submitted. She further indicated that she would expect a resident's MDS to be an accurate reflection of the Resident. Review of Resident 75's clinical record revealed diagnoses that included nicotine dependence (cigarettes daily) and hypertension (high/elevated blood pressure). Review of Resident 75's care plan revealed the Resident is evaluated regularly for smoking safely. The care plan for smoking was initiated June 7, 2018.A review of Resident 75's Annual MDS dated [DATE], Section J1300, Current Tobacco Use was marked no and should have been marked yes. Section I - Active Diagnoses, Subtitled Other failed to show that Resident 118 is nicotine dependent.During an interview with Resident 75 on September 22, 2025, the Resident stated that he is permitted to smoke daily in the courtyard at 10:00 AM, 1:30 PM, 4:00 PM, and 7:00 PM. The Resident also said that he is supervised by staff and wears a safety apron.A review of Resident 75's Annual MDS dated [DATE], revealed a BIMS (brief interview of mental status) score of 14, indicating cognition intact.During an interview with the DON on September 25, 2025, at 11:00 AM, she confirmed the error with Section J1300 and said a modification had been completed for that MDS.Review of Resident 99's clinical record revealed diagnoses that included expressive aphasia (partial loss of the ability to produce language), atherosclerotic heart disease (a disease in which plaque builds up inside your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood), and cerebral infarction (stroke).Review of Resident 99's Quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating cognition was intact. Further review of Section B. - Hearing, Speech, and Vision, Subsection B0600. Speech Clarity was coded a 0, indicating speech was clear.During the screening process on September 22, 2025, the surveyor introduced themself to Resident 99 and attempted to have a conversation asking the Resident if there were any concerns with the care or services being provided. The Resident gave eye contact and tried to speak but a response could not be understood, and then the Resident just nodded her head indicating a response of no concerns.Review of Resident 99's care plan revealed a focus with communication related to diagnosis of Expressive Aphasia, initiated March 14, 2024.Observation of Employee 5 (Registered Nurse) on September 5, 2025, who attempted to interview Resident 99, revealed Employee 5 had to clarify any response provided by Resident 99. Resident 99 appeared to struggle to speak and picked up a whiteboard and began to write all her responses to Employee 5. Resident 99's whiteboard appeared to be used frequently based on previous responses observed on the whiteboard, and having to erase previous responses to continue interaction with Employee 5.Review of Resident 99's progress notes, sub-titled Plan of Care dated December 27, 2024; March 10, 2025; June 15, 2025; and July 30, 2025, all stated speech is slurred.During an interview with the DON on September 25, 2025, at 11:00 AM, the DON confirmed that Section B. - Hearing, Speech, and Vision, Subsection B0600. Speech Clarity should be coded a 1, indicating speech was unclear based on status and the Plan of Care progress notes through lookback period. Review of Resident 118's clinical record revealed diagnoses that included nicotine dependence (cigarettes daily) and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin).Review of Resident 118's care plan revealed the Resident was evaluated regularly for smoking safely. The care plan for smoking was initiated May 12, 2019. The care plan had a focus for Resident 118 desiring to smoke and was permitted to smoke daily in the courtyard at 10:00 AM, 1:30 PM, 4:00 PM, and 7:00 PM.A review of Resident 118's Annual MDS dated [DATE], revealed a BIMS score of 15, indicating cognition is intact. A review of Section J1300, Current Tobacco Use was marked no and should have been marked yes. Section I - Active Diagnoses, subtitled Other failed to show that Resident 118 is nicotine dependent.During an interview with the DON on September 25, 2025, at 11:00 AM, the DON confirmed the error with Resident 118's MDS at Section J1300 and added that a modification has been completed for that MDS. The DON added that there is not enough space to add nicotine dependence in the active diagnoses Section I. 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services.

Based on facility policy review, observation, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 24 residents reviewed (Residents 5 and 116).Findings include: Facility policy, titled Care Plan - Comprehensive, last reviewed August 27, 2025, read, in part, Each resident will have a comprehensive care plan developed that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. Review of Resident 5's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, and legal blindness. Observation of Resident 5 on September 22, 2025, at 1:21 PM, revealed a CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps; used to treat sleep apnea) machine on her bedside stand. Review of Resident 5's current physician orders revealed an order for CPAP on at bedtime and remove in the morning, dated February 2, 2025. Review of Resident 5's annual comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident, such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 4, 2025, revealed in Section O. Special Treatments, Procedures, and Programs that Resident 5 utilized a non-invasive ventilator during the assessment reference period. Review of Resident 5's quarterly MDS with the assessment reference date of August 29, 2025, revealed in Section O. Special Treatments, Procedures, and Programs that Resident 5 continued to utilize a non-invasive ventilator (CPAP) during the assessment reference period. Review of Resident 5's care plan failed to reveal a respiratory care plan or any documentation of Resident 5's use of a CPAP. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 25, 2025, at 11:17 AM, the DON indicated that she would expect Resident 5's CPAP use to be on her care plan. Review of Resident 116's clinical record revealed diagnoses that included dementia with behavioral disturbance (cognitive decline accompanied by significant changes in behavior) and delusional disorders (serious mental illness where a person cannot tell what is real from what is imaginary). Review of Resident 116's physician orders revealed orders for Seroquel (an antipsychotic medication) 100 mg twice daily and Seroquel 25 mg twice daily for dementia with delusional disorder. Review of Resident 116's annual comprehensive MDS with an assessment reference date of November 27, 2024, revealed Resident 116 was coded as receiving antipsychotic medication. In addition, the care area assessment summary worksheet completed in conjunction with this MDS indicated Resident 116 had triggered for antipsychotic medication use and that it would be care planned. Review of Resident 116's quarterly MDS with an assessment reference date of September 4, 2025, revealed Resident 116 was coded as receiving antipsychotic medication. Review of Resident 116's comprehensive care plan failed to reveal any care planning for antipsychotic medication use. During a staff interview on September 25, 2025, at 10:03 AM, with the NHA and DON, the DON stated it was the expectation of the facility that comprehensive care plans be developed accurately. 28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for one of 24 residents reviewed (Resident 5).Findings include: Review of facility policy, titled Care Plan - Comprehensive, last reviewed August 27, 2025, read, in part, Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; d. At least quarterly. Review of Resident 5's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, muscle weakness, and moderate protein-calorie malnutrition (the state of inadequate food intake which leads to changes in body composition and function). Review of Resident 5's clinical record revealed that she had a Stage 3 pressure ulcer from July 2, 2025, to August 12, 2025. Review of Resident 5's clinical record revealed that she had a quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of August 29, 2025, which indicated that she had no pressure ulcers. Review of Resident 5's care plan revealed an active care plan focus for altered skin integrity related to limited mobility and incontinence open area to coccyx, with an initiated date of July 2, 2025. During a staff interview with the Director of Nursing on September 24, 2025, at 2:00 PM, she confirmed that Resident 5's care plan should have been revised when the pressure ulcer was resolved or at least after her most recent MDS was completed. 28 Pa. Code 211.12(d)(2)(5) Nursing services.

Based on observation, food committee meeting minutes, grievance review, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature.Findings include:Review of Food Committee Meeting Minutes from July 29, 2025, revealed under complaints/concerns veggies are cold.Review of May 2025 Grievance Log revealed Resident 34 filed a grievance on May 6, 2025, that she feels she should be able to have her tea served hotter. Residents 30, 51, 66, and 76 who attended a group meeting on September 23, 2025, at 10:40 AM, revealed food temperatures are sometimes cold and they have to ask staff to reheat their food, and that coffee is often not hot enough. During an interview with Resident 4 on September 23, 2025, at 10:40 AM, he revealed his food isn't always served hot. Observation during meal tray line service on September 23, 2025, at 11:51 AM, revealed staff were placing two mugs with handles on the trays. Interview with Employee 1 (Dietary Manager) on September 23, 2025, at 11:52 AM, revealed she was not sure why they serve mugs for both hot and cold beverages but that has been the facility process since she has been employed there. During an interview with Employee 1 on September 23, 2025, at 12:03 PM, she revealed the expectation that hot foods and hot beverages should be served above 135 degrees F, and cold foods and beverages should be served below 50 degrees F. A test tray was completed on September 23, 2025, at 12:04 PM, utilizing a lunch tray served from the tray line in the main facility kitchen. The test tray was served and placed in a closed food cart approximately two minutes prior to being delivered to the East Hall (other trays for room service were being delivered there also at that time). The test tray included: Open faced roast turkey sandwich, mashed potatoes with gravy, creamed corn, cherry crisp dessert, coffee and iced tea. Test tray temperatures were taken by Employee 1, and revealed:Creamed corn was 115 degrees F (Fahrenheit-unit of measure), not acceptable.Iced tea was served in a hot beverage mug, the mug was only half full with tea without ice, and the temperature was 57 degrees F, not acceptable.Coffee was 115 degrees F, not acceptable.Interview with Employee 1 on September 23, 2025, at 12:07 PM, the surveyor revealed the concern with the test tray temperatures and serving cold beverages in a warm beverage mug. Employee 1 revealed they are working to improve meal service, and she has ordered new carafes for hot beverages, but the one on the cart that had the coffee for the test tray was an old carafe. Interview with the Nursing Home Administrator (NHA) on September 24, 2025, at 2:27 PM, the surveyor revealed the concern with the test tray temperatures and service of cold beverages. The NHA revealed she would expect palatable and appetizing food and beverage temperatures, and the facility will inquire about ordering cold beverage cups. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of five residents reviewed (Resident 108). Findings Include: Review of facility policy, titled Pressure Ulcer Prevention and Management, revised September 13, 2019, revealed in a section Pressure relief: Elevate/float heels or obtain a device to provide pressure relief. Review of Resident 108's clinical record revealed diagnoses of muscle weakness (weakness in the muscles that makes movement difficult) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). Review of Resident 108's current physician order on August 12, 2024, at 2:35 PM, revealed a physician's order for Blue off-loading boots to B/L (bilateral) heels, with an order date of July 22, 2024. Observation of Resident 108 on August 12, 2024, at 1:48 PM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Observation of Resident 108 on August 13, 2024, at 9:57 AM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Observation of Resident 108 on August 14, 2024, at 10:59 AM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Interview with the Nursing Home Administrator on August 15, 2024, at 11:45 AM, revealed that Resident 108 should have been wearing the off-loading boots at the time of the above observations and the order has been changed to a pressure reducing mattress. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, product label review, facility policy review, and staff interview, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for two of three medication carts observed (Annex 1 North medication cart and Annex 1 South medication cart). Findings Include: Review of facility provided policy, Storage of Medications, effective September 2018, revealed, Medication and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Observation of the Annex 1 North medication cart on August 15, 2024, at 9:40 AM, revealed one Ozembic (a prescription injectable medication used to treat type 2 diabetes) that was currently in use and was not labeled with a date that it was opened. The observation at that time also revealed a Levemir pen (a prescription injectable medication used to treat type 2 diabetes) that was unopened, not refrigerated, and was not labeled with the date it had been removed from refrigeration. Also, noted was one Basaglar pen (a prescription injectable medication used to treat type 2 diabetes) that was open and not labeled with a date of opening. Observation of the Annex 1 South medication cart on August 15, 2024, at 9:50 AM, revealed one vial of Lantus insulin (a prescription injectable medication used to treat type 2 diabetes) that was labeled with an open date of June 25, 2024 (51 days prior). A second vial of Lantus insulin was labeled with an open date of July 15, 2024 (31 days prior). Further observation revealed two insulin Aspart pens (a prescription injectable medication used to treat type 2 diabetes) labeled with open dates of July 15, 2024 (31 days prior). Review of Ozembic product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 56 days. Review of Levemir product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 42 days. Review of Basaglar product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Review of Lantus product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Review of insulin aspart product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Interview with Nursing Home Administrator on August 15, 2024, at 1:35 PM, revealed an expectation that the medication would have been labeled, stored, and disposed of as per the manufacture's guidelines. 28 Pa. Code 201.18(b)(1) Management

Based on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 24 residents reviewed (Resident 59). Findings include: Review of facility provided policy, titled Restorative Adaptive Equipment, with a revision date of March 28, 2016, revealed, Restorative adaptive equipment and assistive devices will be used to promote individual resident functional level and to prevent decline. Review of Resident 59's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hemiplegia (one-sided weakness caused by brain or spinal cord problems). Review of Resident 59's care plan revealed a focus area of, [Resident 59] is on a therapeutic, mechanically altered diet, with a date initiated of May 29, 2019, and a revision date of January 5, 2022. Further review of this care plan revealed an intervention of, Dycem on side table with meals in dining room, with a revision date of April 23, 2024. Review of Resident 59's current physician's orders on August 12, 2024, revealed an order for Dycem (non-slip rubber mat) in the dining room on table with meals, ordered September 11, 2023. Observation of Resident 59 on August 12, 2024, at 11:29 AM, revealed he was sitting in his room eating lunch and there was no Dycem present. Observation of Resident 59 on August 13, 2024, at 12:04 PM, revealed he was sitting in his room eating lunch and there was no Dycem present. Observation of Resident 59 on August 14, 2024, at 11:46 AM, revealed he was sitting in his room eating lunch and there was no Dycem present. Interview with the Nursing Home Administrator revealed that he would have expected that Resident 59 would have had his ordered adaptive equipment, as ordered, at all meals. 28 Pa Code 211.12(d)(5) Nursing services

Based on resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to follow the facility policy for reporting an allegation of neglect to the Nursing Home Administrator (NHA) immediately for one of 24 residents reviewed (Resident 5). Findings include: A review of the facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, last revised June 14, 2024, stated, any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor. The Administrator or the Director of Nursing who receives the report are to be notified immediately by the charge nurse/supervisor who receives the report. A review of the clinical record for Resident 5 on August 13, 2024, revealed diagnoses that included obstructive and reflux uropathy (obstructive or functional impediment of urine flow and back-up of urine flow) and bullous pemphigus (a rare autoimmune skin disease that causes blisters to form between the skin's epidermal and dermal layers of the skin). A review of Resident 5's Quarterly MDS (periodic assessment of resident needs) revealed a BIMS (brief interview of mental status) score of 13, indicating Resident 5 is cognitively intact. During an interview with Resident 5 on August 13, 2024, at 9:30 AM, the Resident informed the surveyor that a nurse on night shift August 11, 2024, didn't change her soiled brief. During an interview with Employee 4 (Licensed Practical Nurse) on August 13, 2024, at 9:35 AM, Employee 4 confirmed that Resident 5 stated the same allegation of neglect on the morning of August 12, 2024. Employee 4 stated that she reported the allegation of neglect immediately to the dayshift supervisor on August 12, 2024. During an interview with Employee 5 (Registered Nurse Supervisor) on August 13, 2024, at 10:55 AM, the Employee confirmed being informed about the allegation of neglect that Resident 5 had made to staff on August 12, 2024. Employee 5 was asked if the allegation was reported to the NHA, and Employee 5 confirmed there was no additional reporting of the allegation at the time. On August 13, 2024, at approximately 12:00 PM, the NHA confirmed that he was made aware of the allegation of neglect by Employee 5 on August 13, 2024, and that the facility is in the process of investigating and obtaining statements from staff and Resident 5. On August 13, 2024, at 1:43 PM, statements were received from the staff working on August 11, 2024, and a statement from Resident 5. Resident 5's statement indicated that she was changed, but staff were slow to change her. Resident 5 required the assistance of two staff. No specific times were provided by Resident 5 indicating a delay. Staff documented care was provided. Staff stated that Resident 5 had frequent episodes of loose stools and was changed frequently with assistance due to those issues. The facility unsubstantiated neglect. During an interview with the NHA on August 14, 2024, at approximately 11:15 AM, the NHA confirmed that policy should have been followed by staff and the allegation of neglect made by Resident 5 should have been reported immediately to the NHA on August 13, 2024. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 27 residents reviewed (Residents 14, 20, and 51). Findings Include: Review of Resident 14's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and history of traumatic brain injury (injury to the brain caused by an external force). Review of Resident 14's physician orders revealed an order for Insulin Glargine, inject 6 units at bedtime for type 2 diabetes, hold for blood sugar level less than 150, starting May 10, 2024. Further review indicated an administration time of 9:30 PM. Review of Resident 14's physician orders also revealed an order to check blood sugar levels before meals and at bedtime, starting May 10, 2024. Further review revealed scheduled times for blood sugar monitoring were 6:30 AM, 11:00 AM, 4:30 PM, and 8:00 PM. Review of Resident 14's July 2024 and August 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed that a blood sugar level of less than 150 was recorded at 8:00 PM and Resident 14's insulin administration was not held at 9:30 PM on the following dates: July 1-3, 7-8, 10-11, 14-16, 18-23, 25-28, and 31, 2024; and August 3-6 and 9-13, 2024. Further review of Resident 14's July 2024 and August 2024 MARs failed to reveal that blood sugar levels were recorded specifically in correspondence with administration of Resident 51's insulin at 9:30 PM. During an interview with the Nursing Home Administrator (NHA) and Regional Nurse on August 15, 2024, at 1:15 PM, they revealed that they had no additional information regarding the aforementioned insulin administration concern, and that Resident 14's insulin order was updated to include a corresponding blood sugar level check. Review of Resident 20's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (high blood pressure). Review of Resident 20's clinical record revealed a physician's order for Humalog Kwik Pen Subcutaneous Solution Pen-Injector 200 Unit/milliliters (insulin Lispro) inject as per sliding scale: If 100-150 = 2 units; 151-200 = 3 units; 201-250 = 4 units; 251-300 = 5 units; 301-350 = 6 units; 351-400 = 7 units above 400 call Medical director/nurse practitioner, subcutaneously before meals for diabetes, with a start date of May 20, 2024. Review of Resident 20's May 2024 MAR (Medication Administration Record) revealed the following: On May 23, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 142, and was not administered any insulin. On May 27, 2024, at 7:00 AM, the Resident had a blood sugar level of 146, and was not administered any insulin. On May 28, 2024, at 7:00 AM, the Resident had a blood sugar level of 148, and was not administered any insulin. Review of Resident 20's June 2024 MAR revealed the following: On June 1, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 101, and was not administered any insulin. On June 1, 2024, at 11:00 AM, the Resident had a blood sugar level of 133, and was not administered any insulin. On June 15, 2024, at 7:00 AM, the Resident had a blood sugar level of 100, and was not administered any insulin. On June 17, 2024, at 7:00 AM, the Resident had a blood sugar level of 115, and was not administered any insulin. Review of Resident 20's July 2024 MAR revealed on July 3, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 101, and was not administered any insulin. Review of Resident 20's August 2024 MAR revealed the following: On August 5, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 103, and was not administered any insulin. On August 10, 2024, at 7:00 AM, the Resident had a blood sugar level of 148, and was not administered any insulin. During an interview with the NHA on August 15, 2024, at 11:04 AM, he revealed he would have expected Resident 20 to have been administered insulin as ordered by the physician. Review of Resident 51's clinical record revealed diagnoses that included cerebral infarction (brain injury caused by a lack of oxygen to a group of brain cells) and hemiplegia and hemiparesis following cerebral infarction (inability to move, severe weakness, or rigid movement on either the right or left side of the body). Review of Resident 51's physician orders revealed an order for Trolamine Salicylate External Cream (treats minor aches and pains of the muscles/joints), apply topically to legs every 8 hours as needed for muscle pain, starting March 3, 2023. Observation on August 13, 2024, at 9:50 AM, revealed Resident 51 in bed with his overbed table in front of him. Two small plastic medication administration cups partially filled with a white cream were present on his overbed table. Additional observation at 10:04 AM, revealed Employee 1 (Licensed Practical Nurse) inquiring with Resident 51 about the contents of the medication cups on his table. Resident 51 was observed stating that it was Aspercreme (Trolamine Salicylate), that the nurse puts it on but left the cups there, and that he didn't know why the cups were left there. Employee 1 removed the cups from Resident 51's room at that time. During an interview with the Regional Nurse on August 15, 2024, at 11:15 AM, she confirmed that the cream should not have been left in Resident 51's room since he does not self-administer that medication. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed for respiratory care (Resident 9). Findings include: Review of facility policy, titled Clin - 157 CPAP/BIPAP, last reviewed March 2024, revealed that when cleaning the system: clean the unit weekly. Review of Resident 9's clinical record revealed diagnoses that included stage 3 chronic kidney disease (when your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood) and pulmonary fibrosis (a lung disease that occurs when lung tissue become damaged and scarred). During an observation of Resident 9 on August 12, 2024, at 1:57 PM, revealed a CPAP (continuous positive airway pressure) machine and mask sitting on Resident 9's night stand beside their bed, not dated. Review of Resident 9's clinical record revealed a physician's order for CPAP on at bedtime, remove in the AM every shift, and encourage use during naps, with an active date of July 17, 2024. Review of Resident 9's July 2024 and August 2024 MAR (Medication Administration Record) revealed that Resident 9 uses the CPAP daily. Review of Resident 9's clinical record on August 13, 2024, revealed there was no order or documentation indicating the CPAP mask, tubing, filter, and water supply has been cleaned or changed. Review of Resident 9's clinical record on August 15, 2024, at 9:15 AM, revealed new CPAP orders were put in place that included: CPAP/BiPAP - wash headgear/straps, tubing, and humidifying chamber with solution of mild soapy water weekly, and allow to air dry; CPAP/BiPAP filter - weekly, remove from back of device, rinse under running water while squeezing filter to ensure dust is removed. Blot dry with clean towel and place back into machine; CPAP/BiPAP use: check distilled water supply every week. Replace and write date on bottle if: supply depleted, supply not dated, supply dated over 30 days prior, all with an active date of August 20, 2024. During an interview with the Nursing Home Administrator on August 15, 2025, at 11:05 AM, revealed they would have expected Resident 9 to have cleaning orders for their CPAP in place prior to the active date above, and would expect the CPAP to be cleaned weekly. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical record, facility documentation review, facility policy review, hospital records review, and staff and resident interviews, it was determined that the facility failed to ensure that residents were protected from neglect during provision of care for one of four residents reviewed (Resident 1). The facility staff member failed to verify the resident and transfer status, which resulted in actual harm to Resident 1 who sustained a laceration to the right lower leg, transfer to the hospital, and received 13 sutures to the right lower leg. Findings Include: Review of the facility's policy, titled Abuse Prohibition-Abuse, Neglect, and Misappropriation of Resident's Property, revised June 14, 2023, revealed that neglect is defined at 483,5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Review of Resident 1's clinical record revealed that the Resident was admitted to the facility on [DATE], with diagnoses that included anorexia nervosa (an eating disorder causing people to obsess about weight and what they eat) and failure to thrive (doesn't gain weight normally). A review of Resident 1's Quarterly Minimum Data Set (MDS - a periodic review of a resident's assessment and care needs), dated May 2, 2024, revealed that Resident 1 needed two persons' physical assistance with staff for transfer to move between surfaces including to and from bed, chair, and wheelchair. A review of Resident 1's current care plan revealed that Resident 1 had an activity of daily living self-care performance deficit related to weakness. The care plan was revised on June 6, 2024, to reflect Resident 1 transfers via a full mechanical lift. During an interview with the Director of Nursing (DON), she stated that Resident 1 was a 2-person transfer with a rolling walker prior to the revision on June 6, 2024. Review of Resident 1's physician orders revealed that on October 25, 2023, the physician order was to transfer with assistance of 2-persons and a rolling walker. On June 6, 2024, the physician orders were revised to transfer via mechanical lift. Concluding that, at the time of the incident, the Resident was to be transferred with 2-persons assisting and her rolling walker. Review of facility reported incident, submitted on June 6, 2024, revealed that when Resident 1 was being transferred from bed to wheelchair by Employee 1 (Nursing Assistant) she noticed a laceration to the right lower leg when pulling Resident 1 back in wheelchair. Per resident's care plan, resident transfers with 2 assist and rolling walker. It is reported that Employee 1 transferred Resident 1 with 1 assist. The facility substantiated neglect and told the staffing agency that Employee 1 is a Do Not Return to facility. Review of Resident 1's nursing notes dated June 4, 2023, at 6:04 AM, stated that she was transferred to the hospital emergency department for right leg shin wound, physician and Resident Representative were made aware. A review of Employee 1's telephone statement obtained by the Nursing Home Administrator on June 5, 2024, revealed Resident 1 sustained a skin tear when re-positioning her in the wheelchair during a transfer. Employee 1 stated, Resident 1 pushed up on the wheelchair via arm rest and I pulled, hitting her leg on the piece of her wheelchair where the leg rest go. I reported the incident to the Registered Nurse immediately. Employee 1 stated that she was given instruction to weigh a resident, but went into the wrong room and proceeded to transfer Resident 1 out of bed independently to obtain a weight. Resident 1 was not supposed to be weighed that shift and had no orders to be out of bed to be weighed. A review of Employee 1's personnel file on June 10, 2024, revealed her most recent completion of training on abuse, neglect, and misappropriation was on July 7, 2023. During an interview with Resident 1 on June 10, 2024, at approximately 10:15 AM, she was asked if she could recall what happened when she injured her leg she replied, yes. Resident 1 added, I asked the nurse why she was getting me out of bed to be weighed and she told me, that's how we weigh people. Resident 1 also confirmed there was only one staff person who assisted her out of bed. Resident 1 stated, when she pulled me back in the wheelchair my leg was caught by the metal piece on the wheelchair. A written statement by Employee 2 (LPN-Licensed Practical Nurse) on June 4, 2024, revealed that she overheard the LPN charge nurse inform Employee 1 that the transfer status for all residents is on the back of their closet door. She also stated that Resident 1 told Employee 2 and the EMT that she sustained the skin tear during the transfer to her wheelchair from her bed. A review of the written statement by Employee 3 (Nurse Aide) on June 4, 2024, stated that Employee 1 was told to wash and dress Resident 1 only and NOT to get her out of bed. The statement also said that Employee 3 reviewed with Employee 1 the residents who needed washed up and dressed and not to get out of bed; and also the residents who needed weighed. During a phone interview with Employee 3 on June 10, 2024, at 10:30 AM, it was confirmed that Employee 1 was told by Employee 3 to wash and dress Resident 1 only, and not to get her out of bed. A review of hospital records for Resident 1 dated June 4, 2024, stated, Resident 1 sustained an L-shaped laceration to the lateral aspect of the right lower extremity, there is a flap of skin evident, adipose tissue exposed, no muscle belly exposure (fleshy part of the skeletal muscle); L-shape approximately 7 cm x 6 cm (total laceration 13 cm). Resident 1 received 13 sutures to repair the laceration. A non-adherent (non-stick) dressing and antibiotic ointment was applied. An interview with the DON on June 10, 2024, at 11:00 AM, confirmed that the facility failed to follow the transfer status and provide 2-person assistance during the transfer for Resident 1. The facility failed to ensure a Resident was protected from neglect during the provision of care by transferring the Resident from the bed to the wheelchair with the assistance of only one staff. Employee 1 neglected to follow the transfer status and failed to confirm the resident care needs. This failure resulted in actual harm to Resident 1 who sustained a laceration, transfer to the hospital, and required 13 sutures. 28 Pa Code 211.10(d) Patient care policies 28 Pa Code 211.12 (c) Nursing Services 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on review of clinical records, facility policy review, review of facility investigation reports, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide the assistance required for a safe transfer for one of four residents reviewed (Resident 1), resulting in actual harm as evidenced by a laceration that required transfer to the hospital and 13 sutures. Findings Include: A review of the facility policy, titled Transfer/Lift Policy, stated, all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. Review of Resident 1's clinical record revealed that the Resident was admitted to the facility on [DATE], with diagnoses that included anorexia nervosa (an eating disorder causing people to obsess about weight and what they eat) and failure to thrive (doesn't gain weight normally). A review of Resident 1's Quarterly Minimum Data Set (MDS-a periodic review of a resident's assessment and care needs), dated May 2, 2024, revealed that Resident 1 needed 2-persons' physical assistance with staff for transfer to move between surfaces including to and from bed, chair, wheelchair, and some aspects of toilet use. A review of Resident 1's current care plan revealed that Resident 1 had an activity of daily living self-care performance deficit related to weakness. The care plan was revised on June 6, 2024, to reflect Resident 1 transfers via a full mechanical lift. During an interview with the Director of Nursing (DON), she stated that Resident 1 was a 2-person transfer with a rolling walker prior to the revision on June 6, 2024. A review of Resident 1's physician order summary on June 10, 2024, revealed that on October 25, 2023, the physician order was to transfer with assistance of 2-person assist and a rolling walker. On June 6, 2024, the physician orders were revised to transfer via mechanical lift. A review of the incident report for June 4, 2024, revealed Resident 1 sustained a laceration to the right shin area and it was cleaned with normal saline (salt) solution, bandage applied, and physician notified. An order was obtained to send the Resident to the hospital emergency department for evaluation and treatment. The Resident was transferred by ambulance on June 6, 2024, at 6:25 AM. The laceration was repaired with 13 sutures. Resident 1 returned to the facility on [DATE], at 8:14 AM. A review of hospital records for Resident 1 dated June 4, 2024, stated that Resident 1 sustained an L-shaped laceration to the lateral aspect of the right lower extremity, there is a flap of skin evident, adipose tissue exposed, no muscle belly exposure (fleshy part of the skeletal muscle); L-shape approximately 7 cm x 6 cm (total laceration 13 cm). Resident 1 received 13 sutures to repair the laceration. A non-adherent (non-stick) dressing and antibiotic ointment was applied. During an interview with Resident 1 on June 10, 2024, at approximately 10:15 AM, she was asked if she could recall what happened when she injured her leg she replied, yes. Resident 1 added, I asked the nurse why she was getting me out of bed to be weighed and she told me, that's how we weigh people. Resident 1 also confirmed there was only one staff person who assisted her out of bed. Resident 1 stated, when she pulled me back in the wheelchair my leg was caught by the metal piece on the wheelchair. Review of facility reported incident, submitted on June 6, 2024, revealed that when Resident 1 was being transferred from bed to wheelchair by Employee 1 (Nursing Assistant) she noticed a laceration to the right lower leg when pulling Resident 1 back in wheelchair. Per resident's care plan, resident transfers with 2 assist and rolling walker. It is reported that Employee 1 transferred Resident 1 with 1 assist. A review of Employee 1's statement obtained by the Nursing Home Administrator on June 5, 2024, reveals Resident 1 sustained a skin tear when re-positioning her in the wheelchair during transfer. Employee 1 stated, Resident 1 pushed up on the wheelchair via arm rest and I pulled, hitting her leg on the piece of her wheelchair where the leg rest go. I reported the incident to the Registered Nurse immediately. An interview with the DON on June 10, 2024, at 11:00 AM, confirmed that the facility failed to provide a two- person assist with rolling walker during a transfer, to provide adequate supervision and assistance, to prevent harm to Resident 1. During an interview on June 10, 2024, at 11:00 AM, the DON confirmed the facility failed to prevent injury while transferring a Resident, resulting in actual harm for Resident 1. Employee 1 failed to provide the two person assistance needed for a safe transfer for Resident 1. This failure resulted in harm to Resident 1 who sustained a laceration to the lower leg during the transfer from the bed to the wheelchair. Resident 1 required hospitalization and 13 sutures. 28 Pa Code 211.10(d) Patient care policies 28 Pa Code 211.12 (c) Nursing Services 28 Pa Code 211.12 (d)(3) Nursing Services

Based on observations, review of facility policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from physical abuse for two of four residents reviewed (Residents 1 and 2), resulting in Resident 2 being physically abused and placed all residents' safety in Immediate Jeopardy. Findings include: Review of the facility's policy titled OPS-346 Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, with a revision date of September 11, 2017, revealed that Residents shall not be subject to abuse by anyone including but not limited to Facility staff, other residents, consultants or volunteers, agency staff, family members, legal guardians, friends, or others. Physical abuse includes hitting, slapping, pinching, kicking, etc Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. The facility will ensure that prevention techniques are implemented to identify, correct, and intervene in situations where abuse and/or neglect are more likely. Proper assessment, care planning, and monitoring of residents with needs and behavioral symptoms which might lead to conflict or neglect. Examples include residents with a history of aggressive behaviors . If a resident is observed being aggressive or exhibiting any form of verbal, physical, or sexual abuse behavior toward another resident, immediate action will be taken to stop alleged abuse and remove the resident from danger. The resident will receive measures to ensure his or her immediate safety and well being following the incident and during the investigation process. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's most recent comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated August 7, 2017, revealed that the resident had a Brief Interview for Mental Status (BIMS - a standardized interview to determine a resident's mental status) score of 15, which means cognitively intact. Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. to think, feel, and behave clearly) and mood disorder symptoms). Review of Resident 2's quarterly MDS dated [DATE], revealed that he was unable to complete the BIMS interview. A staff assessment for mental status was completed which revealed his cognitive skills for daily decision making is modified independence (some difficulty in new situations only). Review of Resident 2's current care plan revealed that Resident 2 is impatient with staff and other residents and he is impulsive which can cause confrontations with staff, visitors, and other residents. Further review of Resident 2's current care plan revealed interventions to make sure the environment and situation is safe for both Resident 2 and others around him. If Resident 2 is becoming agitated and if needed, remove all others around and/or move Resident 2 so that everyone is safe. Review of Resident 1's progress notes revealed a social service note dated April 27, 2017, in which Resident 1 voiced concerns about his roommates' (Resident 2) behaviors getting worse and requesting Resident 2 be relocated. Review of Resident 1's grievance form dated April 27, 2017, at 3:30 p.m. revealed that Resident 1 is concerned for his safety and well being in his room due to Resident 2 having negative verbalizations towards Resident 1. Further review of the grievance form revealed that Resident 1 was offered a room change but Resident 1 refused. Review of Resident 1's progress notes revealed a nursing note dated April 28, 2017, which stated that Resident 1 initiated a verbal confrontation with his roommate (Resident 2), and residents were separated. Review of social service progress note dated April 28, 2017, revealed that Resident 1 yelled at Resident 2 for being in front of the room. Review of Resident 1's social service note dated May 17, 2017, revealed that Resident 1 called Resident 2 an inappropriate name. Review of Resident 1's social service note dated June 15, 2017, revealed that Resident 1 voiced concerns about Resident 2 placing his clothing on top of Resident 1's property. Review of Resident 1's social service note dated June 28, 2017, revealed that Resident 2 wanted to get at Resident 1 and Resident 2 attempted to get out of his chair to get to Resident 1. Resident 1 told a staff member that Resident 2 said get out of my room and that Resident 2 was going to beat him. Review of Resident 2's nursing progress note dated June 28, 2017, revealed that Resident 2 was observed on the floor in the middle of the room. Resident 2 stated he was 'trying to get rid of him' (referring to his roommate). Further review of the progress note revealed that Resident 2 was agitated and repeatedly stated in a profane manner that he wanted 'him' (Resident 1) out of his room. Review of Resident 2's Incident/Accident Report, dated June 28, 2017, at 10:50 a.m. revealed that Resident 2 was observed on the floor in the middle of the room and stated he was going to get rid of roommate. Review of Resident 2's current physician orders [REDACTED]. Further review of Resident 2's current physician orders [REDACTED]. Review of Resident 2's Medication Administration Record [REDACTED] Review of Resident 2's nursing progress note dated July 9, 2017, at 10:30 a.m. revealed that Resident 2 became angry with another resident (Resident 4), blocked her wheelchair with his chair, cursed and verbally threatened her. Then Resident 2 stood up from his chair and drew his fist towards Resident 4. Further review of the progress note revealed that staff intervened and separated the residents. Review of incident/accident reports revealed that there was not an incident report completed regarding this incident on July 9, 2017. Review of Resident 2's MAR indicated [REDACTED] Review of Resident 1's facility form titled Incident/Accident Report dated September 24, 2017, revealed that Resident 1 was engaged in an altercation with Resident 2. Resident 1 was observed sitting on his bed with wet clothes and blood was noted on Resident 1's bed, walls and on Resident 1's clothing. Review of Resident 1's facility form titled Investigation of Incident/Accident Form revealed that Resident 1 first stated Resident 2 fell , but then Resident 1 stated that he hit Resident 2. Review of witness statement by Certified Nursing Assistant (CNA) 2 revealed that upon entering the resident's room, Resident 2 was noted to be on the floor between both beds and had cuts all over his face. Resident 1 was sitting on his bed acting like nothing happened, and covered in blood from head to toe. It was noted that Resident 1's dumbbell (a short bar with a weight at each end, used typically in pairs for exercise or muscle-building) was sitting on the nightstand. Further review of CNA 2's witness statement revealed that Resident 1 stated he lives in fear of Resident 2 and his moodiness. Review of witness statement by Licensed Practical Nurse (LPN) 1 revealed that Resident 1 stated he hit Resident 2 and then Resident 1 took a dumbbell from under his pillow and put it on his bedside table. Review of witness statement by Registered Nurse (RN) 1 revealed that Resident 1 stated Resident 2 was going to beat him up. Further review of RN 1's witness statement revealed that Resident 2 was still agitated after the incident and he wanted to go back at Resident 1. Review of Resident 2's facility form titled Incident/Accident Report dated September 24, 2017, revealed that staff were called into Resident 2's room as Resident 2 was engaging in an altercation with Resident 1. When staff entered the room, Resident 2 was observed on the floor, in between the two beds in the room, with facial bleeding, lacerations, abrasions, and bruising to eyes. Resident 1 was observed laying on his bed with splatters of blood on him. Review of witness statement by LPN 1 revealed that Resident 2 was agitated most of the morning. Review of witness statement by CNA 1 revealed that Resident 2 was observed laying on the floor with cuts and blood on his face and Resident 1 was laying on the bed acting fine with blood on him and his bed sheets and a dumbbell under his arm. Review of witness statement by RN 1 revealed that upon entering the room, Resident 2 was still agitated and wanting to go back for more. Further review of the witness statement revealed that RN 1 observed Resident 2 stating he wanted to kick Resident 1's butt. Review of Resident 2's nursing progress note dated September 24, 2017, revealed that Resident 2 was sent to the emergency department for evaluation and treatment. Review of Resident 2's Emergency Department physician progress notes [REDACTED]. Resident 2 also had a three centimeter Y-shaped laceration through the medial (middle) portion of the right eyebrow and a one centimeter laceration on his right cheek. Resident 2 also had other superficial (at the surface) wounds which included a minor laceration of the mucosa (tissue) of his upper lip with some ecchymosis (bruising) in that area. Resident 2 also had an old-looking, blush ecchymosis of the right middle abdomen. Resident 2 had two of the lacerations repaired with five sutures (stitches). Resident 2 was discharged from the Emergency Department on September 24, 2017, and returned to the facility. During an interview with Resident 1 on September 26, 2017, at 1:22 p.m., he stated that on the day of the incident of September 24, 2017, Resident 2 came at him from the side of Resident 1's bed, hit his bedside table and spilled his drinks. Resident 1 stated that Resident 2 told me he was going to beat me up-not his exact words. Resident 1 stated that Resident 2 grabbed his shirt and Resident 1 pushed Resident 2 to get him away and that is all he remembers until staff came into the room. When surveyor asked Resident 1 if he currently felt safe, he stated that he feels safe with Resident 2 gone, but it is only a matter of time until it happens again. When surveyor asked Resident 1 if he felt safe prior to the incident on September 24, 2017, Resident 1 stated no, He (Resident 2) is dangerous. Resident 1 stated that approximately three to four months ago, Resident 2 came into their room and said that he hated Resident 1 and wanted him out of their room and that he would kill Resident 1 if he had to do it himself. Resident 1 told the surveyor that the facility offered him a room change but his response was Why should I move? I'm settled in here. Resident 1 stated that when he was offered the room change, the only available room was on the Alzheimer's (a progressive disease that destroys memory and other important mental functions) unit. Resident 1 stated that he shouldn't have to move rooms because he was not the problem; Resident 2 was the problem. Resident 1 stated that the facility told him they couldn't move Resident 2 but they would not provide him an explanation of why. During an interview with the Director of Nursing (DON) on September 26, 2017, at 2:23 p.m. when asked if any interventions were put into place related to Resident 1 and 2's prior altercations, the DON stated that Resident 1 was offered a room change but he refused and Resident 2 is re-directed and given his [MEDICATION NAME] to calm him down. Resident 2 was not offered a room change. At that time, surveyor asked the DON how Resident 1 and 2 are now being protected, as well as how are other residents in the facility being protected. She stated that they are keeping Resident 1 and 2 separated and staff are observing Resident 2, but there was no direction given to staff in regards to how often they were to be observing him. Surveyor observation on September 26, 2017, at 10:55 a.m. revealed Resident 2 in the lobby, in front of the dining room, wheeling his Rock 'N Go (type of wheelchair) up to another resident. No staff were present at this time. Surveyor observation on September 26, 2017 at 1:15 p.m. and September 26, 2017 at 1:50 p.m. revealed Resident 2 in the doorway of his room, with no staff members around either of those times. Review of Resident 1's current care plan revealed an intervention added on September 24, 2017 to attempt to keep separated from other residents when agitated. Review of Resident 2's care plan revealed an intervention on September 24, 2017 for a room change after an altercation with his roommate. On September 26, 2017, at 4:06 p.m. the Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy, due to the lack of supervision for physical abuse and safety, reporting and monitoring of Residents 1 and 2. The facility submitted and implemented an immediate plan to ensure residents' safety that included a facility sweep to ensure the safety of all residents, placing Residents 1 and 2 on every 15 minute checks for two months, after which will then be reevaluated for continued need. Education will be provided to staff including that Resident 1 and 2 must be visualized by a staff member every 15 minutes and they must be kept separate from one another. Education will also include how to handle other residents who may become aggressive or hostile. Audits of the 15 minute safety checks will be completed daily for two months and will then be submitted to the Quality Assurance Performance Improvement Committee. The Immediate Jeopardy was removed on September 27, 2017, at 10:45 a.m. when it was confirmed that Residents 1 and 2 were under 15 minute observation checks, and the majority of the facility's staff were educated regarding the reporting of physical abuse. The facility failed to ensure that residents were free from physical abuse for two of four residents reviewed (Residents 1 and 2), resulting in Resident 2 being physically abused with injuries and placed all residents' safety in Immediate Jeopardy. 42 CFR 483.12(a)(1) Freedom from Abuse, Neglect, Exploitation 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations, facility policy review, clinical record review, and interviews with residents and staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who was threatened, which resulted in harm to another resident when Resident 2 grabbed Resident 1 resulting in Resident 2 being struck by Resident 1. Resident 2 sustained bruises and two lacerations that required sutures, creating an Immediate Jeopardy situation for two of four residents reviewed (Residents 1 and 2). Findings include: Review of facility policy titled CLIN-006 Incident Investigations, with a revision date of August 10, 2017, revealed The goal of an accident or incident investigation is to recognize, gather, and analyze relevant facts that will support a positive resolution and follow-up. It is also important in order to eliminate pre-existing hazards that may result in future harm to patients. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's most recent comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated August 7, 2017, revealed that the resident had a Brief Interview for Mental Status (BIMS - a standardized interview to determine a resident's mental status) score of 15, which means cognitively intact. Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. to think, feel, and behave clearly) and mood disorder symptoms). Review of Resident 2's quarterly MDS dated [DATE], revealed that he was unable to complete the BIMS interview. A staff assessment for mental status was completed which revealed his cognitive skills for daily decision making is modified independence (some difficulty in new situations only). Review of Resident 2's current care plan revealed that Resident 2 is impatient with staff and other residents and he is impulsive which can cause confrontations with staff, visitors, and other residents. Further review of Resident 2's current care plan revealed interventions to make sure the environment and situation is safe for both Resident 2 and others around him. If Resident 2 is becoming agitated and if needed, remove all others around and/or Resident 2 so that everyone is safe. Review of Resident 1's progress notes revealed a social service note dated April 27, 2017, in which Resident 1 voiced concerns about his roommates' (Resident 2) behaviors getting worse and requesting Resident 2 be relocated. Review of Resident 1's grievance form dated April 27, 2017, at 3:30 p.m. revealed that Resident 1 is concerned for his safety and well being in his room due to Resident 2 having negative verbalizations towards Resident 1. Further review of the grievance form revealed that Resident 1 was offered a room change but Resident 1 refused. Review of Resident 1's progress notes revealed a nursing note dated April 28, 2017, which stated that Resident 1 initiated a verbal confrontation with his roommate (Resident 2), and residents were separated. Review of social service progress note dated April 28, 2017, revealed that Resident 1 yelled at Resident 2 for being in front of the room. Review of Resident 1's social service note dated May 17, 2017, revealed that Resident 1 called Resident 2 an inappropriate name. Review of Resident 1's social service note dated June 15, 2017, revealed that Resident 1 voiced concerns about Resident 2 placing his clothing on top of Resident 1's property. Review of Resident 1's social service note dated June 28, 2017, revealed that Resident 2 wanted to get at Resident 1 and Resident 2 attempted to get out of his chair to get to Resident 1. Resident 1 told a staff member that Resident 2 said get out of my room and that Resident 2 was going to beat him. Review of Resident 2's nursing progress note dated June 28, 2017, revealed that Resident 2 was observed on the floor in the middle of the room. Resident 2 stated he was 'trying to get rid of him' (referring to his roommate). Further review of the progress note revealed that Resident 2 was agitated and repeatedly stated in a profane manner that he wanted 'him' (Resident 1) out of his room. Review of Resident 2's Incident/Accident Report, dated June 28, 2017, at 10:50 a.m. revealed that Resident 2 was observed on the floor in the middle of the room and stated he was going to get rid of roommate. Review of Resident 2's current physician orders [REDACTED]. Further review of Resident 2's current physician orders [REDACTED]. Review of Resident 2's Medication Administration Record (MAR) dated June 2017, revealed that Resident 2 received lorazepam tablet, 0.5 mg on June 28, 2017, at 11:12 a.m. Review of Resident 2's nursing progress note dated July 9, 2017, at 10:30 a.m. revealed that Resident 2 became angry with another resident (Resident 4), blocked her wheelchair with his chair, cursed and verbally threatened her. Then Resident 2 stood up from his chair and drew his fist towards Resident 4. Further review of the progress note revealed that staff intervened and separated the residents. Review of incident/accident reports revealed that there was not an incident report completed regarding this incident on July 9, 2017. Review of Resident 2's MAR dated July 2017, revealed that Resident 2 received lorazepam tablet 0.5 mg at 5:42 p.m. Review of Resident 1's facility form titled Incident/Accident Report dated September 24, 2017, revealed that Resident 1 was engaged in an altercation with Resident 2. Resident 1 was observed sitting on his bed with wet clothes and blood was noted on Resident 1's bed, walls and on Resident 1's clothing. Review of Resident 1's facility form titled Investigation of Incident/Accident Form revealed that Resident 1 first stated Resident 2 fell , but then Resident 1 stated that he hit Resident 2. Review of witness statement by Certified Nursing Assistant (CNA) 2 revealed that upon entering the resident's room, Resident 2 was noted to be on the floor between both beds and had cuts all over his face. Resident 1 was sitting on his bed acting like nothing happened, and covered in blood from head to toe. It was noted that Resident 1's dumbbell (a short bar with a weight at each end, used typically in pairs for exercise or muscle-building) was sitting on the nightstand. Further review of CNA 2's witness statement revealed that Resident 1 stated he lives in fear of Resident 2 and his moodiness. Review of witness statement by Licensed Practical Nurse (LPN) 1 revealed that Resident 1 stated he hit Resident 2 and then Resident 1 took a dumbbell from under his pillow and put it on his bedside table. Review of witness statement by Registered Nurse (RN) 1 revealed that Resident 1 stated Resident 2 was going to beat him up. Further review of RN 1's witness statement revealed that Resident 2 was still agitated after the incident and he wanted to go back at Resident 1. Review of Resident 2's facility form titled Incident/Accident Report dated September 24, 2017, revealed that staff were called into Resident 2's room as Resident 2 was engaging in an altercation with Resident 1. When staff entered the room, Resident 2 was observed on the floor, in between the two beds in the room, with facial bleeding, lacerations, abrasions, and bruising to eyes. Resident 1 was observed laying on his bed with splatters of blood on him. Review of witness statement by LPN 1 revealed that Resident 2 was agitated most of the morning. Review of witness statement by CNA 1 revealed that Resident 2 was observed laying on the floor with cuts and blood on his face and Resident 1 was laying on the bed acting fine with blood on him and his bed sheets and a dumbbell under his arm. Review of witness statement by RN 1 revealed that upon entering the room, Resident 2 was still agitated and wanting to go back for more. Further review of the witness statement revealed that RN 1 observed Resident 2 stating he wanted to kick Resident 1's butt. Review of Resident 2's nursing progress note dated September 24, 2017, revealed that Resident 2 was sent to the emergency department for evaluation and treatment. Review of Resident 2's emergency department physician progress notes [REDACTED]. Resident 2 also had a three centimeter Y-shaped laceration through the medial (middle) portion of the right eyebrow and a one centimeter laceration on his right cheek. Resident 2 also had other superficial (at the surface) wounds which included a minor laceration of the mucosa (tissue) of his upper lip with some ecchymosis (bruising) in that area. Resident 2 also had an old-looking, blush ecchymosis of the right middle abdomen. Resident 2 had two of the lacerations repaired with five sutures (stitches). Resident 2 was discharged from the emergency department on September 24, 2017, and returned to the facility. During an interview with Resident 1 on September 26, 2017, at 1:22 p.m., he stated that on the day of the incident of September 24, 2017, Resident 2 came at him from the side of Resident 1's bed, hit his bedside table and spilled his drinks. Resident 1 stated that Resident 2 told me he was going to beat me up-not his exact words. Resident 1 stated that Resident 2 grabbed his shirt and Resident 1 pushed Resident 2 to get him away and that is all he remembers until staff came into the room. When surveyor asked Resident 1 if he currently felt safe, he stated that he feels safe with Resident 2 gone, but it is only a matter of time until it happens again. When surveyor asked Resident 1 if he felt safe prior to the incident on September 24, 2017, Resident 1 stated no, He (Resident 2) is dangerous. Resident 1 stated that approximately three to four months ago, Resident 2 came into their room and said that he hated Resident 1 and wanted him out of their room and that he would kill Resident 1 if he had to do it himself. Resident 1 told the surveyor that the facility offered him a room change but his response was Why should I move? I'm settled in here. Resident 1 stated that he was offered a room change but the only available room was on the Alzheimer's (A progressive disease that destroys memory and other important mental functions) unit. Resident 1 stated that he shouldn't have to move rooms because he was not the problem; Resident 2 was the problem. Resident 1 stated that the facility told him they couldn't move Resident 2 but they would not provide him an explanation of why. During an interview with the Director of Nursing (DON) on September 26, 2017, at 2:23 p.m. when asked if any interventions were put into place related to Resident 1 and 2's prior altercations, the DON stated that Resident 1 was offered a room change but he refused and Resident 2 is re-directed and given his lorazepam to calm him down. Resident 2 was not offered a room change. At that time, surveyor asked the DON how Resident 1 and 2 are now being protected, as well as how are other residents in the facility being protected. She stated that they are keeping Resident 1 and 2 separated and staff are observing Resident 2, but there was no direction given to staff in regards to how often they were to be observing him. Surveyor observation on September 26, 2017, at 10:55 a.m. revealed Resident 2 in the lobby, in front of the dining room, wheeling his Rock 'N Go (type of wheelchair) up to another resident. No staff were present at this time. Surveyor observation on September 26, 2017 at 1:15 p.m. and September 26, 2017 at 1:50 p.m. revealed Resident 2 in the doorway of his room, with no staff members around either of those times. Review of Resident 1's current care plan revealed an intervention added on September 24, 2017 to attempt to keep separated from other residents when agitated. Review of Resident 2's care plan revealed an intervention on September 24, 2017 for a room change after an altercation with his roommate. On September 26, 2017, at 4:06 p.m. the Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy, due to the lack of supervision for physical abuse and safety, reporting and monitoring of Residents 1 and 2. The facility submitted and implemented an immediate plan to ensure residents' safety that included a facility sweep to ensure the safety of all residents, placing Residents 1 and 2 on every 15 minute checks for two months, after which will then be reevaluated for continued need. Education will be provided to staff including that Resident 1 and 2 must be visualized by a staff member every 15 minutes and they must be kept separate from one another. Education will also include how to handle other residents who may become aggressive or hostile. Audits of the 15 minute safety checks will be completed daily for two months and will then be submitted to the Quality Assurance Performance Improvement Committee. The Immediate Jeopardy was removed on September 27, 2017, at 10:45 a.m. when it was confirmed that Residents 1 and 2 were under 15 minute observation checks, and the majority of the facility's staff were educated regarding the reporting of physical abuse. The facility failed to provide adequate and safe supervision for two residents resulting in Resident 2 being struck by Resident 1, which resulted in harm and required Resident 2 to be transported to the hospital for evaluation and treatment. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(a)(b)(2) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of select facility policies, observation, and staff interview, it was determined that the facility failed to provide the necessary care and services to prevent the development of pressure ulcers for one of two residents reviewed (Resident R 2). Findings include: Review of the facility policy for the "24 Hour Report" dated December 2010, that the Licensed Practice Nurse (LPN) would communicate resident clinical information to the interdisciplinary team both written and verbal on each unit. The oncoming LPN will give a verbal report to Nurse Aides (NA) on that unit at shift change. There will be a walking shift to shift report between the NA's prior to the start of their shift. Nursing staff will provide any pertinent information regarding direct resident care. Review of Resident R2's Braden Scale assessment (an indicator of pressure ulcer risk), revealed that the assessments were performed on November 18 and 25, 2011. Resident R 2 is at moderate risk for developing pressure ulcers. Resident R 2's admission Minimum Data Set (MDS, an assessment completed at specific intervals to determine care needs) dated November 25, 2011, revealed that Resident R 2's care area summary for pressure ulcers triggered for further development a plan of care. Resident R 2 is on low air mattress (air pressure of the bed drops on the area where the pressure from each body parts applies). Resident R 2's toilet status is total dependence with two person physical assist. The bed mobility is total dependence with two person physical assist. Resident R 2 is frequently incontinent of Bowel. Resident R 2 has Foley urinary catheter (a tool to drain urine from the bladder) for his urination. Review of Resident R 2's clinical records revealed that the facility admitted him on November 18, 2011. Resident R 2 has a spinal cord injury and he was admitted for rehabilitation on his waist and area below. His mobility for both lower extremities is hardly noticeable for most of the time. He has some limited sensation on his waist and below. Review of the Resident R 2's incident investigation report and interview with the Director of Nursing on December 18, 2011, at 9:58 a.m., revealed that NA 8 placed Resident R 2 on the bedpan on December 15, 2011, for a bowel movement around 2:30 p.m. NA 8 went out to the dumpsite area, located outside of the facility, soon after she gave the bedpan to Resident R 2, to discard trash. The second shift NA 12, assigned to Resident R 2's care, arrived on the floor at 2:45 p.m., and started to work without receiving the report from the previous shift. NA 8's shift ended at 3:15 p.m. and she went home without communicating to other staff on the floor that Resident R 2 was on the bedpan. On December 15, 2011, at 8:45 p.m., NA 12 went to Resident R 2's room to provide his evening care. NA 12 discovered that Resident R 2 was on the bedpan and that he has "cuts" on his buttock area. Observation on December 18, 2011, between 10:20 a.m. and 11:40 a.m. during the pressure ulcer treatment, revealed that Resident R 2's buttock area has a 23 centimeter (across the buttock area) by 15 centimeter (width) Stage II Pressure Ulcer (partial thickness skin loss presenting as a shallow open ulcer with a red or pink wound bed) where the area was likely to have a direct contact with the upper part of bed pan. The surrounding tissue was intact. The open area had small amount of bloody serosanguinous drainage and was reddish in color. There was a 12 by one centimeter reddened [MEDICATION NAME] abraded area that was likely to be caused by the same bedpan incident on his left lower buttock area. Interview with the Director of Nursing on December 18, 2011, at 9:58 a.m., revealed that staff should have followed the shift to shift report as stated on the policy. Interview with the Chief Executive Officer on December 20, 2011, at 11 a.m., revealed that Resident R 2 already had Stage I Pressure Ulcer (intact skin with non-blanchable redness) on the buttock area on his admission assessment. However, based on the surveyor's observation on December 18, 2011, between 10:20 a.m. and 11:40 a.m., most of the surrounding open area caused by the bedpan was intact and a normal healthy skin color. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 1/31/2011 28 Pa. Code 211.12 (e) Nursing services.