Every finding on record at Transitions Healthcare Washington PA

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure dressing changes were delivered by a licensed nurse, who has the skills, experience and knowledge to administer wound care treatments for four of thirteen residents reviewed (Resident R3, R4, R5, and R12).Findings Include: Review of facility policy Dressing Changes dated 1/6/26, indicated dressing changes will be completed per physician order and documented on the resident's treatment record and weekly wound progress report. Verify the current treatment orders by checking the Treatment Record and the Physician's Orders in the electronic health record. Review previous wound documentation to obtain information on where/how wound measurements were taken. Confirm orders for pain medication and administer prior to dressing change. Explain the procedure to the resident. Complete all appropriate documentation in the electronic health record. Review of the facility Registered Nurse Supervisor (RN) job description indicated the RN supervisor primary purpose in this position is to supervise, coordinate the activities of nursing personnel engaged in nursing services, and be the charge nurse during their assigned tour of duty. Assists the physician during rounds or special treatments and examinations of residents by preparing necessary equipment, notifying physician of significant changes in resident's condition and evaluates resident's condition and takes orders as needed. Review of the facility Licensed Practical Nurse (LPN) job description indicated the LPN provides care and treatment in accordance with physician orders and works under the direction of physicians and registered nurses within the scope of practice as defined by the state. Order, administer and record medications and treatments in accordance with physician orders and nursing policies and procedures. Ensure all medications and treatments are signed for and completed in the appropriate allotted time frames and according to policies and procedures. Review of the facility Certified Nursing Assistant (CNA) job description indicated the CNA primary purpose is to perform direct resident care duties under the supervision of a licensed nursing personnel. Provide personal care (i.e., grooming, bathing, dressing, oral care etc.) of residents daily and as needed. Change bed linen and maintain appropriate grooming supplies in resident rooms. Take and record vital signs (temperature, blood pressure, etc.), weights and measurements, intake and output, food consumption, and other information as assigned. Routinely turn and position residents as necessary. Review of an anonymous complaint revealed a reported concern on 7/7/26 related to wound care. The complaint alleged that CNA Employee E1 does wound care, and the nurses are told to sign off on the wound care treatments completed by CNA Employee E1. Interview with CNA Employee E1 on 7/8/26 at approximately 10:30 AM and 5:00 p.m. confirmed she did independently do resident wound care without oversite, supervision or other staff in the room for Residents R3, R4, R5, and R12 on 6/26/26. She stated she is the CNA assigned to round with the wound care nurse and the wound care provider. CNA Employee E1 stated she did this because the wound care nurse was off this day and everyone was busy. When asked how she reviewed the orders to know what dressing was required and which residents, the CNA stated she cannot access the orders, so she changed the dressing based off memory from prior rounding with the wound care nurse and wound care provider. When asked what her role was when rounding with the wound care nurse and wound care provider the CNA replied, I only assist with positioning the resident rolling, lifting, and holding the resident so they can do the treatment. CNA Employee E1 confirmed she has not provided or completed wound care or dressing changes prior or since this date. During an interview on 7/8/26, at 11:00 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the surveyor interview with CNA Employee E1. The NHA and DON developed and started staff education on 7/8/26 at approximately 12:00 p.m., titled Licensed Nursing Staff Education: Wound Care Responsibilities and Certified Nursing Assistant Education: Scope of Practice and Wound Care. Review of the Treatment Administration Record (TAR) reveals dressing changes were signed off as completed by a licensed nurse for Resident R3, R4, R5, and R12 on 6/26/26. Interviews attempted with Residents R3, R4, and R5 (R13 non-interviewable) on 7/8/26 between 1:30 p.m. and 4:30 p.m. the residents could not answer if the CNA Employee E1 or any CNA completed dressing/wound care independently on 6/26/26 or any other day. Telephone interview was conducted between LPN Employee E8 and Director of Nursing (DON), on 7/8/26 between 12:00 p.m. LPN Employee E8 who confirmed she does her own wound care when the wound care nurse isn't there. A CNA has never offered to do her wound care and should would not let them, she does it all herself. She confirmed she did all her wound care treatments when she worked on 6/26/26. Telephone interview was conducted between LPN Employee E9 and DON, on 7/8/26 between 12:00 p.m. and 2:00 p.m. LPN Employee E9 confirmed she does her own wound care when the wound care nurse isn't there. A CNA has never offered to do her wound care (did not work on 6/26/26). Telephone interview was conducted between LPN Employee E10 and DON, on 7/8/26 between 12:00 p.m. and 2:00 p.m. LPN Employee E10 confirmed sometimes there is a nurse dedicated to doing wound care. One CNA offers to do wound care and I tell her no. On 6/26/26 when I worked, I did my own wound care. Telephone interview was conducted between LPN Employee E11 and DON, on 7/8/26 between 12:00 p.m. and 2:00 p.m. LPN Employee E11 confirmed she does her own wound care when the wound care nurse isn't there. A CNA has never offered to do her wound care. On 6/26/26 when I worked, I did all my wound care. During an interview between LPN Employee E7 and DON on 7/8/26 between 12:00 p.m. and 2:00 p.m. LPN Employee E7 signed a statement stating 6/26/26 the wound care nurse was off. I do not remember asking CNA Employee E1 to do my treatments. During an interview between LPN Employee E12 and DON on 7/8/26 between 12:00 p.m. and 2:00 p.m. LPN Employee E12 wound care nurse, signed a statement stating, upon arriving back to the building 6/29/26 there we no changes to any wound in the building. During an interview on 7/8/26 at approximately 4:00 p.m. LPN Employee E13 stated she has never asked for or had wound care completed on residents by a CNA. During interviews on 7/8/26, between 2:14 p.m. and 4:30 p.m. CNA's Employee's E2, E3, E4, E5 and E6 stated, I do not do wound care/dressing changes, I am not trained to do that, I am not permitted to do that, nurse do wound care/dressing changes. During an interview on 7/8/26, at 5:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that residents received necessary treatment and services provided by a qualified person. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of an impacted right femur fracture (thigh bone) for one of four residents (Resident R1). Findings include: Review of the facility policy Transfer/Lift Policy, dated 1/6/26, indicated it is the facility's policy to provide safe care for each resident and staff when having to physically transfer/lift a resident and all resident care will be provided in accordance with the individual resident's care plan.Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/31/26 included diagnoses of anxiety, chronic ischemic heart disease (plaque buildup restricts blood flow and oxygen to the heart), muscle weakness, and abnormal gait and mobility. Review of Section GG: Functional Abilities indicated that Resident R1 required substantial/maximal assistance for chair/bed-to-chair transfers. Review of a physician order dated 7/28/24 indicated Resident R1 transfer with a mechanical lift with the assist of two staff members. Review of a rehabilitation communication, dated 3/3/26, indicated that the resident has bed mobility with an assist of two members. Review of Resident R1's care plan revealed transfer and mobility status was not updated until after the incident. Review of a progress note dated 5/30/26 at 11:01 a.m. indicated, while [NA] (nursing assistant) was doing care, resident yelling out when right leg is touched. A telehealth visit was completed and an Xray was ordered and scheduled. Review of facility submitted information on 5/30/26 at 6:30 p.m., indicated Received a call from RN (registered nurse) Supervisor at approximately 0630 PM with a report that the x-ray on Resident R1 was positive for a femur fracture above the knee. No reports of any falls or trauma noted with the resident for the previous shift. Resident's son was notified and did not want his mother transported to the hospital for any treatment for the fracture, to leave her at the facility. Resident was left in bed for the day, pain medication ordered and administered. Review of a facility investigation completed on 5/31/26, indicated that incident occurred on 5/29/26 during the 7 a.m. to 3 p.m. shift. Timeline of events obtained through interviews with all staff that cared for resident in the last 24 hours confirmed that there was no hoyer lift sling under the resident during this shift. It was determined that NA Employe E1 was responsible for resident during this shift. Review of an employee written statement by NA Employee E1, dated 5/31/26 at 9:30 a.m. indicated, I lifted the resident into her chair by standing her up using a bear hug and pivoting her into the chair. NA Employee E1 also stated that she did have the resident information sheet with transfer status but did not look before transferring resident and admitted to not using a hoyer lift. NA Employee E1 was an agency staff member and no longer allowed to work at the facility. State Surveyor attempted to reach NA Employee E1 by phone but unsuccessful. During interviews with staff to include Registered Nurses (RN), LPNs and NAs on 6/22/26, at approximately 12:00 p.m., indicated that transfer status is printed on the information sheets. During an interview on 6/22/26 at approximately 1:32 p.m., the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of an impacted right femur fracture for one of three residents (Resident R1).

Based on review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility failed to protect residents from neglect that resulted in actual harm of an impacted fracture of the right femur (thigh bone) for one of four residents (Resident R1). Findings include: Review of the facility policy dated 1/6/26, Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary. Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/31/26 included diagnoses of anxiety, chronic ischemic heart disease (plaque buildup restricts blood flow and oxygen to the heart), muscle weakness, and abnormal gait and mobility. Review of Section GG: Functional Abilities indicated that Resident R1 required substantial/maximal assistance for chair/bed-to-chair transfers. Review of a physician order dated 7/28/24 indicated Resident R1 transfer with a mechanical lift with the assist of two staff members. Review of a rehabilitation communication, dated 3/3/26, indicated that the resident has bed mobility with an assist of two members. Review of Resident's care plan revealed that transfer status and mobility were only added after the incident. Review of a progress note dated 5/30/26 at 11:01 a.m. indicated, while [NA] (nursing assistant) was doing care, resident yelling out when right leg is touched. A televisit was completed and an Xray was ordered and scheduled. Review of facility submitted information on 5/30/26 at 6:30 p.m., indicated Received a call from RN (registered nurse) Supervisor at approximately 0630 PM with a report that the x-ray on Resident R1 was positive for a femur fracture above the knee. No reports of any falls or trauma noted with the resident for the previous shift. Resident's son was notified and did not want his mother transferred to the hospital for any treatment for the fracture, to leave her at the facility. Resident was left in bed for the day, pain medication ordered and administered. Review of a facility investigation completed on 5/31/26, indicated that incident occurred on 5/29/26 during the 7 a.m. to 3 p.m. shift. Timeline of events obtained through interviews with all staff that cared for resident in the last 24 hours confirmed that there was no hoyer lift sling under the resident during this shift. It was determined that NA Employe E1 was responsible for resident during this shift. Review of an employee written statement by NA Employee E1, dated 5/31/26 at 9:30 a.m. indicated, I lifted the resident into her chair by standing her up using a bear hug and pivoting her into the chair. NA Employee E1 also stated that she did have the resident information sheet with transfer status but did not look before transferring resident and admitted to not using a hoyer lift. NA Employee E1 was an agency staff member and no longer allowed to work at the facility. State Surveyor attempted to reach NA Employee E1 by phone but unsuccessful. During interviews with staff to include Registered Nurses (RN), LPNs and NAs on 6/22/26, at approximately 12:00 p.m., indicated that transfer status is printed on the information sheets. During an interview on 6/22/26, at approximately 1:32 p.m. the Director of Nursing confirmed the facility failed to protect residents from neglect which resulted in actual harm for one of four residents (Resident R1).

Based on review of facility policy, facility records, resident and staff interviews, it was determined that the facility failed to make certain call lights are answered timely, for fourteen of twenty residents as required (Resident R15, R16, R14, R22, R62, R79, R82, R122, R123, R500, R501, R502, R503, and R504). Findings include: The facility policy Call Bells dated 1/6/26 with a previous review date of 1/6/25, indicated the purpose of this procedure is to respond to the resident's requests and needs when using the call bell system for assistance. If answering the call light from the nurse's station, please ensure that staff respond to resident request immediately. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident R82's clinical record indicated admission to the facility on 3/6/25, a BIMS of 10 . Review of a grievance filed by Resident R82, dated 11/3/25, revealed concerns documented for call light response. Resident reported workers will turn off call light and state they will be back soon, it takes up to thirty minutes, and this happens often. Review of Resident 14's clinical record indicated admission to the facility on 6/15/17, a BIMS of 15. Review of a grievance filed by Resident R14, dated 11/5/25, revealed concerns documented for call lights not being answered and the resident calls her daughter, who calls into the facility requesting the call light be answered. Review of Resident R123s clinical record indicated admission to the facility on [DATE], a BIMS of 14. Review of a grievance filed by Resident R123, dated 11/11/25, revealed concerns documented for call lights. Resident reported call bells wait time is too long and laying in feces. Review of Resident R62's clinical record indicated admission to the facility on 9/4/25, a BIMS of 14 . Review of a grievance filed by Resident 62, dated 12/1/25, revealed concerns documented for call lights. Resident noted aides take around 1-3 hours to answer his call light when he needs changed. Review of Resident R79's clinical record indicated admission to the facility on 3/6/25, a BIMS of 9. Review of a grievance filed by Resident R79, dated 2/18/26, revealed concerns documented for care. Resident reported he did not see a nurse aide after 8:50 p.m. on 2/17/26. Resident stated, feeling like he is one of the last people to be taken care of. Review of Resident R122's clinical record indicated admission to the facility on 4/19/25, a BIMS of 14. Review of Resident Council Minutes dated 12/1/25, revealed concerns from Resident R122 related to call light response. The meeting minutes included feels like he is waiting too long to get help to go to the bathroom. Review of Resident R15's clinical record indicated admission to the facility on [DATE], a BIMS of 15. During an interview on 3/23/26 at approximately 10:00 a.m., Resident R15, when asked about call light response time, resident stated you wait for help when you use your call light, thirty minutes is common, sometimes more than an hour, sometimes you sit in a soiled brief. Review of Resident R16's clinical record indicated admission to the facility on 1/18/22, a BIMS of 14. During an interview on 3/23/26 at approximately 10:15 a.m., Resident R16, when asked about call light response time, resident stated often you wait a long time for help when you use your call light, thirty minutes maybe longer than that some days. You can't do anything about it. Review of Resident R22's clinical record indicated admission to the facility on [DATE], a BIMS of 11. During an interview on 3/23/26 at approximately 10:30 a.m., Resident R22, when asked about call light response time, resident stated, it a wait, it's all the time or it seems that way. When you need help you need it now not in a half hour or hour. Review of Resident R82's clinical record indicated admission to the facility on 3/6/25, a BIMS of 10 . During an interview on 3/23/26 at approximately 10:45 a.m., Resident R82, when asked about call light response time, resident stated, you wait a long time for help when you use your call light, easily thirty minutes or more some of the time. It's the agency staff mostly, sometimes they come in turn off the light and leave. I have reported this before. During a resident group interview (Residents R500, R501, R502, R503, and R504), on 3/23/26 at approximately 1:30 p.m., when asked if they felt the staff answer call lights and respond immediately to the request (per facility policy), consensus from the group was no. Residents verbalized frustration with the response time when using the call light. Residents stated often it takes thirty minutes or more for a response. Sometimes they come into the room and turn off the light and leave without taking care of what you need. Residents stated, it seems like this occurs more often when it's its agency staff working. During an interview on 3/24/26 at 8:30 a.m. the Director of Nursing confirmed the facility failed to make certain call lights were answered timely. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to enforce its established policy regarding smoking, smoking areas, and smoking safety for one of five residents reviewed (Residents R39).Findings include: Review of the facility policy Smoking Policy and Guidelines for Residents reviewed on 1/6/26 with a previous review date of 1/6/25, indicated, it is the policy of the facility to provide reasonable accommodations to residents who smoke, while maintaining a safe environment for all residents, visitors, and staff. Smoking is only permitted in the designated area outside the facility. The designated area is the external courtyard by the courtyard cafe. Smoking in nursing homes across the country is the number one cause of fires. Most of the incidents were caused by residents who attempted to sneak smoke in their rooms or other unauthorized areas of the facility. All smoking paraphernalia shall be kept secure by facility. If, at any time, it becomes known by facility staff that a resident is in possession of smoking paraphernalia and/or has smoked in an unauthorized are, the resident will be asked to turn such paraphernalia over to facility staff as well as allow a search for his/her room to ensure that all materials are being maintained and stored in a proper manner. All smoking paraphernalia must be stored and kept in a designated secured area. Review of Resident R39's admission record indicated he was originally admitted on [DATE]. Review of Resident R39's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/10/26, indicated the diagnoses of diabetes mellitus (high blood sugar), hypertension (high blood pressure), and hyperlipidemia (elevated cholesterol in the blood). Review of clinical records revealed a form titled Smoking/Tobacco/Vaping Safety Assessment and Evaluation dated 12/26/25, indicated that Resident R39 had been assessed with the ability to safely smoke independently. The assessment indicated that Resident R39 understood and agreed that smoking items are not stored in their room for safety. Review of clinical records revealed a form titled Acknowledgement of Smoking Policy Review was signed by Resident R39 on 8/4/25. The form indicated I have read the facility smoking policy provided during the facility admission process. Should I request to smoke, I will make the request know to appropriate facility personnel. During an observation on 3/22/26 at approximately 10:30 a.m. Resident R39 was observed by the survey team smoking outside at the front entrance of the building. Resident R39 was again observed at approximately 1:00 p.m. on 3/22/26, smoking outside the front entrance of the building by the survey team. During an interview and observation on 3/23/26 at approximately 11:00 a.m. with Resident 39, he stated that he is an independent smoker and keeps his cigarettes and lighter in his room or on his person. The residents' cigarettes and lighter were observed by the surveyor in the resident's room. The resident stated he can smoke in three locations at the facility, outside the front entry, the courtyard or the back parking lot. Resident 39 stated he does not go out to the back parking lot. During rounds with the Director of Nursing (DON) on 3/23/26 at approximately 11:30 a.m., Resident R39 confirmed he keeps his cigarettes and lighter with him in his room and he is not giving them up to anyone. Resident R39 also confirmed that he goes outside to the front lobby or the courtyard to smoke. During an interview on 3/22/26, at 11:45 a.m. the Director of Nursing confirmed that the facility failed to enforce its established policy regarding smoking, smoking areas, and smoking safety. 28 Pa. Code 201.18 (b)(1)(3) Management. 28 Pa. Code 209.3 (a) Smoking. 28 Pa. Code 211.10 (d) Resident care policies.

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four residents observed (Resident R88).Findings include:Review of facility policy Safeguarding of Posted Protected Health Information reviewed 1/6/26, indicated the facility will protect the privacy of resident's protected health information (PHI) from intentional or unintentional view when posting information. Posted information may include information located at the bedside, on whiteboards, on walls, or other public spaces.Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE], with diagnoses that included diabetes, history of falling, and muscle weakness.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 3/10/26, reveal the diagnoses remain current.During an observation on 3/23/26, at 8:30 a.m. revealed two DOCTOR APPOINTMENT NOTICE sheets on the wall in Resident R88's room printed on bright green paper. One notice indicated Resident R88 had an appointment with a vascular(body's network of vessels, including arteries, veins, and capillaries) doctor on 3/6/26, at 12:30 p.m. and provided the address of the appointment. It was pinned on Resident R88's corkboard which was visible from the doorway to the resident's room. The second notice was taped to the wall beside Resident R88's bed. It indicated Resident R88 had an appointment with nephrology (kidney specialist) on 3/26/26, at 11:40 a.m. and provided the address of the appointment. Review of the physician orders dated 2/25/26 and 3/19/26, confirmed the appointment dates, times, and locations were correct.Review of the care plan initiated 7/9/25, failed to indicate Resident R88 provided permission for the signs to be posted in her room and visible to other residents, visitors, family, and non-medical staff.During an interview on 3/23/26, at 1:32 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the appointment notices were posted in view of other residents, visitors, family, and non-medical staff.During an interview on 3/23/26, at 2:30 p.m. the Director of Nursing confirmed the facility failed to maintain the confidentiality of residents' medical information for Resident R88.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on two of three locations, nursing units (skilled care and intermediate care unit). Findings include: The facility policy Grievance Policy dated 1/6/26, with a previous review date of 1/6/25, indicated Grievances may be filed anonymously by placing completed form in a grievance box. Methods for reporting concerns/grievances will be posted and accessible to residents and resident representatives. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertain to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During an observation and interview with on 3/24/26, at 11:00 a.m., Employee E3 and the surveyor measured the height of the grievance boxes in two resident locations (skilled care and intermediate care unit). The grievance box on the skilled care unit was 70 inches above the floor and in line of sight of the nurse's station, out of the reach of most ambulatory residents and all those using wheelchairs. The grievance box on the intermediate care unit was 49.5 inches above the floor, out of the reach of residents in wheelchairs. During an interview on 3/24/25, at 2:00 p.m. the Director of Nursing confirmed the facility failed to make accessible grievance boxes to all residents. 28 PA Code: 201.18(e)(1) Management. 28 PA Code: 201.29(a)(b) Resident rights.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of thirteen sampled residents (Residents R15, R22, R70, and R77).Findings include: Review of the facility policy Oxygen Concentrators reviewed on 1/6/26 with a previous review date of 1/6/25, indicated Change cannula weekly (11-7) and as needed. Review of Resident R15's admission record indicated she was originally admitted on [DATE]. Review of Resident R15's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/5/26, indicated the diagnoses of acute respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), hypertension (high blood pressure), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear and uneasiness). Review of Resident R15's current physician orders dated 9/15/25, indicated resident is on 2 liters per minute of oxygen. During an observation and interview on 3/22/26, at approximately 10:00 a.m. with Registered Nurse (RN) Employee E1, Resident R15 was observed in their room using oxygen. The oxygen tubing was not labeled. Review of Resident R15's clinical record revealed the resident did not have a care plan for oxygen use. Review of Resident R22's admission record indicated she was originally admitted on [DATE]. Review of Resident R22's MDS dated [DATE], indicated the diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), diabetes mellitus (high blood sugar), and hypertension (high blood pressure). Review of Resident R22's current physician orders dated 2/6/26, indicated resident is on 2 liters per minute of oxygen. During an observation and interview on 3/20/26, at approximately 10:15 a.m. with Registered Nurse (RN) Employee E1, Resident R22 was observed in their room using oxygen. The oxygen tubing date label was illegible. Review of Resident R22's clinical record revealed the resident did not have a care plan for oxygen use. Review of Resident R70's admission record indicated she was originally admitted on [DATE]. Review of Resident R70's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/10/26, indicated the diagnoses of acute respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), hypertension (high blood pressure), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear and uneasiness). Review of Resident R70's current physician orders dated 3/5/26, indicated resident is on 5-7 liters per minute of oxygen. During an observation and interview on 3/22/26, at approximately 10:30 a.m. with Registered Nurse (RN) Employee E1, Resident R70 was observed in their room using oxygen. The oxygen tubing date label was illegible. Review of Resident R77's admission record indicated he was originally admitted on [DATE]. Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/15/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD progressive lung disease limiting airflow to the lungs), diabetes mellitus (high blood sugar), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear and uneasiness). Review of Resident R77's current physician orders dated 3/5/26, indicated resident is on 3 liters per minute of oxygen. During an observation and interview on 3/22/26, at approximately 10:45 a.m. with Registered Nurse (RN) Employee E1, Resident R77 was observed in their room using oxygen. The oxygen tubing was dated 3-12-26. During an interview on 3/22/26, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of seven residents reviewed (Residents R16).Findings include: Review of the facility policy Hemodialysis, Home Hemodialysis Policy dated 1/6/26 with a previous review date of 1/6/25. The policy indicates each resident is provided with a dialysis communication binder, so the facility and dialysis center can communicate. The dialysis binder is part of the individual medical record. Review of the admission record indicated Resident R16 was originally admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated diagnoses off end stage renal disease (condition where kidneys lose the ability to remove waste and balance fluids), cerebrovascular accident (stroke, loss of blood flow to part of the brain), and dependence on renal dialysis (treatment to replace the function of the kidneys). Review of Resident R16's physician order dated 3/14/25, indicated dialysis: Tuesday, Thursday, and Saturday at [dialysis center]. Chair time scheduled at 8:00 a.m. Review of Resident R16's current care plan indicated dialysis three times a week, treatments as scheduled: Tuesday, Thursday, and Saturday at [dialysis center]. Resident original (discontinued) dialysis schedule is also listed on the care plan with a date of 2/22/22, Resident receives Dialysis M-W-F at [dialysis center], Review of Resident R16's dialysis communication forms from 1/1/26 through 3/22/26 indicated the communication forms were incomplete on the following dates:The dialysis nurse and nursing home nurse did not sign the forms on the following dates: 3/10, 3/17 and 3/21.The nursing home nurse did not sign the forms on the following dates: 2/14, 2/24, 2/28, 3/7.The dialysis nurse did not sign the form on the following dates: 1/3, 1/10, 1/13, 1/17, 1/20, 1/24, 1/27, 1/31, 2/5, 2/7, 2/10, 2/17, 3/3. During an interview on 3/23/26, at 2:15 p.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on a review of facility policies, documents and staff interviews, it was determined that the facility failed to implement a Covid-19 vaccination program in a timely manner for 30 of 105 residents (Resident R1. R2, R3, R4, R5, R7, R14, R15, R17, R18, R19, R20, R21. R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, and R38) on 9/29/25, five of 108 residents ( Resident R9, R10, R11, R12 and R13) on 9/30/25, 10 residents admitted to the facility during the time period of 12/22/25, through 1/7/26, (R39, R40, R41, R42, R43, R44, R45, R46, R47, and R48) and three residents that the consent form was undated (Resident R6, R8 and R16) which resulted in the facility failing to provide the covid 19 vaccine as consented by the resident or resident's responsible party as required.Findings include: Based on a review of the facility's Infection Control - Covid 19 Care and Management Policy, Section Vaccinations dated 1/6/26, revealed that the facility encourages resident to remain up to date with all recommended Covid 19 vaccine doses to protect against SARS-CoV-2 infection. Newly admitted resident's vaccination status is determined and the resident is offered a vaccine as recommended. A review of the facility's resident education and consent documents revealed that on 9/29/25, 9/30/25, and upon admission to the facility the facility educated residents and resident responsible parties regarding the administration of the Covid 19 vaccine. During the time period of 9/29/25, through 1/7/26, there were 48 resident consent forms completed for the administration of the vaccine. A review of resident electronic medication administration records revealed that the facility had failed to administer the Covid 19 vaccine at the time of the resident's consent form being completed. During an interview on 1/28/26, at 12:15 pm the Director of Nursing confirmed that as of 1/28/26, the facility failed to provide 48 residents the Covid 19 vaccine as consented by the resident or the resident's responsible party. 28 Pa Code: 201.18(b)(1) Management

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Transfer/Lift Policy, dated 1/6/25, indicated it is the facility's policy to provide safe care for each resident and staff when having to physically transfer/lift a resident and all resident care will be provided in accordance with the individual resident's care plan. Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/26/25, included diagnoses of anxiety, spinal stenosis(spaces inside the spine get too small), muscle weakness, and syncope (sudden temporary loss of consciousness) with collapse. Review of Section GG: Functional Abilities indicated that Resident R1 required substantial/maximal assistance for chair/bed-to-chair transfers. Review of a physician order dated 10/14/24, indicated Resident R1 transfer with a mechanical lift with the assist of two. This is the current order. Review of Resident R1's plan of care for ADLs (activities of daily living) Functional Status / Rehabilitation Potential, updated 10/14/24, indicated that the resident will transfer with a mechanical lift with the assist of two. Review of a progress note dated 8/9/25, at 12:33 p.m. indicated, Patient was being transferred from the bed to the wheelchair with assist x 1 when she struck her left shin on the wheelchair leg rest attachment causing a 5cm laceration to her anterior shin. Review of a progress note dated 8/9/25, at 2:22 p.m. indicated, Patient returned from hospital with 2 internal sutured and 12 external sutures that will need removed here in 10 days. Review of facility submitted information on 8/10/25, indicated On 8/9/25 at approximately 12:30 pm, resident was being transferred to her wheelchair by 1 CNA [certified nursing assistant] from the bed to the chair. Resident's transfer statues is an assist times two with a hoyer. During this transfer the resident obtained a 5 cm laceration to her left anterior shin. Resident was sent to the emergency department for repair of the laceration and returned to the facility. Review of an employee statement written by nursing assistant (NA), Employee E1, dated 8/10/25, indicated, I was transferring her from the bed to the wheelchair when her left shin hit the bottom of the wheelchair. I noticed it was bleeding and went to get help from the licensed practical nurse (LPN) and registered nurse (RN) Supervisor. I did it by myself because the resident said ‘one person can put her in the chair'. I was not aware that she was a hoyer lift. Review of the facility's plan of correction included:-Wound will be monitored for signs/symptoms of infection.-Nursing care plan updated to include any new orders.-Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs.-PT/OT (physical therapy / occupational therapy) consult ordered for transfers.-All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments.-All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries.-Education provided to NA, LPN, and RN regarding how to look up resident's transfer status, proper transfer protocol, and what to do if resident refuses assist of 2 with any type of lift. During an interview on 8/28/25, NA employees E2, E3, E4, E5, E6, and E7 were interviewed, and confirmed they were provided education on resident transfer status, proper transfer protocol, and what to do if a resident refuses assist of 2 with any type of lift. Review of education sign-in sheets on 8/28/25, confirmed in-service on transfer/lift protocol was completed on 8/11/25 During an interview on 8/28/25 at approximately 1:32 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R1) A review of the facility policy Change In Condition dated 1/6/25, indicated to evaluate any changes through direct observation and document findings. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE] with diagnoses that included locked in state (a condition where a person is aware but cannot move or communicate verbally due to complete paralysis of all voluntary muscles except for vertical eye movements and blinking). A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 5/12/25, indicated the diagnoses remained current. A review of an incident report dated 5/8/25, indicated Resident R1 was observed to have bruising on the right thumb and a complaint of pain. A review of Resident R1's nurse progress notes did not include documentation of an evaluation to the right thumb for bruising and pain. During an interview on 6/3/25, at 11:15 a.m. the Director of Nursing confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R1. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity of one of nine residents reviewed that receives medications (Resident R77). In addition, the facility failed to uphold the resident ' s rights to voice grievances without fear of retaliation for three of nine residents reviewed (Resident R301, R302, R303). Findings include: Review of the facility policy Resident Rights last reviewed 1/6/25, indicated residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to be treated with respect and dignity and care for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each Resident ' s individuality, thus protecting and promoting the right of the Resident. The Resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. A review of the facility policy Administration Procedure for All Medications:, last reviewed 1/6/25, indicated that privacy is provided for the resident during administration of medications and all 5 Rights should be followed during medication administration (Right Resident, Right Drug, Right Dose, Right Route of Administration and Right Time). Review of the clinical record revealed Resident R77 was admitted on [DATE], with diagnoses that included diabetes (body has troubling controlling blood sugar), high blood pressure, muscle weakness and history of falling. During an observation on 3/26/25, at 10:08 a.m. Resident R77 was administered medications, both pills and liquid, in the dining hall as she was awaiting the Resident Group meeting to start. During an interview on 3/26/25, at approximately 11:00 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R77 did not have an order or care plan to receive her medications anywhere but in her room in private. During an interview on 3/27/25, at 9:30 a.m. Registered Nurse Employee E3 confirmed that Resident R77 did not have an order or care plan to receive medications anywhere but in her room in private. During an interview on 3/26/25, between 10:00 a.m. and 11:00 a.m. Resident R301 stated they feel discriminated against because of some issues he had in the past and they feel that their needs are not being handled properly and he has fear of not being assisted or given the chance to find alternate transportation for an event he needs to attend. The resident requested to remain anonymous. During an interview on 3/26/25, between 10:00 a.m. and 11:00 a.m. Resident R303 did not want to be interviewed until they confirmed that their name was not going to be mentioned when the state surveyor discussed the issue with the facility. They stated they are afraid to speak up against the facility staff in fear of retaliation. They stated they did not want the staff to come back and not take care of them. Their concern was that their call bell would be ignored, resident care not given, or staff being mean to them. This resident requested to remain anonymous. During an interview on 3/27/25, at 12:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to uphold the privacy and dignity of one resident receiving medications not in private and failed to ensure resident ' s do not feel retaliated against when voicing complaints or grievances. 28 Pa Code: 201.29 (i) Resident rights.

Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. (Resident R50). Findings include: Review of the facility policy, Behavior Health Program dated 1/6/25, indicated; The physician will utilize giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition. Review of Resident R50's admission record indicated she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R50's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of quadriplegia (a condition that causes partial or total loss of sensation and movement in the torso and all four limbs), chronic respiratory failure (a condition where oxygen and carbon dioxide are unable to adequately exchange in the lungs), and tracheostomy(a surgical procedure where an incision is made in the trachea to relieve an obstruction to allow breathing and prevent buildup of secretions. Review of Resident R50's MDS, failed to include documentation of depression diagnosis. Review of Section N: Medications revealed Resident R50 received antipsychotic medications in the seven days prior to the assessment. Review of a physician order dated 8/8/23, indicated Resident R50 received Mirtazapine (an anti-depressant medication) 15 mg once per day at bedtime for depression. Review of a physician order dated 1/25/24, indicated Resident R50 received Trazodone (an anti-depressant medication) 100 mg once per day at bedtime for depression. Review of a physician order dated 3/5/25, indicated Resident R50 received Duloxetine (an anti-depressant medication) 60 mg once per day for depression. Review of Resident R50's care plan for the use of anti-depressant medication initiated 8/9/23, indicated Resident R50 received psychotropic medication related to depression. During an interview 3/27/25, at approximately 1:00 p.m. Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.2(a)(c) Physician services. 28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services. 28 Pa. Code: 211.12(c)(d)(5) Nursing services.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure a medication cart for one of three observed (Medication cart A). Findings include: Review of the facility policy Storage of Medications indicated medications and biologicals are stored safely, securely, and properly. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. During an observation on 3/3/25, at 8:57 a.m. A medication cart was observed unlocked, unattended, with the computer screen open to the electronic medication administration record for the resident ' s served from A cart. The following items were located on top of the medication cart: One pair of scissors. One bottle of Miralax (laxative) 13 bottles of over-the-counter medications Six bottles of liquid prescription medication One intravenous antibiotic solution bag Four medication blister packs with medication included During an interview on 3/3/25, at 9:02 a.m. Licensed Practical Nurse (LPN) Employee E1 stated but all of those bottles are over-the-counter medications. During an interview on 2/24/25, at 10:35 a.m. the Assistant Director of Nursing Employee E2 confirmed the medication carts should be secured when unattended, medications should be inside the medication cart, and the computer screen should be locked. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of ten residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property reviewed 1/2/24, defines abuse as the willful infliction of injury, and includes verbal, sexual, physical, and mental abuse. Willful is defined as the individual must have acted deliberately. Physical abuse includes hitting, slapping, pinching, kicking, etc. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment The admission record indicated that Resident R1 was readmitted to the facility on [DATE], with diagnoses that included dementia (dementia (group of symptoms affecting memory, thinking and social abilities), high blood pressure, and diabetes. A review of the admission Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 8/6/24 indicated the diagnoses remain current. Further review of the MDS Section C: Cognitive Patterns, Question C0500 BIMS Summary Score indicated Resident R1 scored 04 out of a possible 15 on the BIMS assessment indicating she had severe impairment. Review of facility provided information dated 8/22/24, at approximately 4:20 p.m. Nurse Aide (NA) Employee E2 witnessed NA Employee E1 strike Resident R1 in the face multiple times. NA Employee E1 was also witnessed restraining Resident R1 by holding her arms down. Resident R1 was able to get one of her arms free and attempted to strike NA Employee E1 unsuccessfully. NA Employee E1 then began to slap the resident in her face several times very hard then walked away. During an interview on 9/11/24, at 9:20 a.m. the Director of Nursing stated NA Employee E2 came to the front office upset and shaking, stating she just witnessed Resident R1 being physically abused by NA Employee E1. NA Employee E1 was immediately switched assignments and monitored by the Assistant Director of Nursing until the cops arrived. The police were immediately notified, and NA Employee E1 was arrested at the facility and taken to jail. Review of a progress note dated 8/23/24, at 2:44 p.m. revealed Resident R1 had a visible abrasion to the left nose measuring 1.5 centimeters (cm). An interview was attempted on 9/11/24, at 10:30 a.m. Resident R1 was unable to answer questions appropriately. Review of the care plan dated 1/14/20, indicated to allow Resident R1 to de-escalate when agitated, prior to further care. Further review of the care plan dated 3/2/20 indicated when resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress, staff to walk calmly away and approach later. On 1/9/24, indicated the following interventions should be attempted as non-pharm (no medication) approached when attempting to redirect combative behaviors: Staff leave room when resident gets agitated and attempt care at a later time. Review of the Behavior Symptoms charting dated 8/20/24 through 8/22/24, revealed Resident R1 did not have behavioral symptoms (yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, siting, threatening behavior, etc.) during that time. A telephone interview was attempted on 9/11/24, at 10:51 a.m. with NA Employee E2. A voicemail was left, no return telephone call was received. A telephone interview was attempted on 9/11/24, at 10:53 a.m. with NA Employee E1. A voicemail was unable to be left, Mailbox is full message received. Facility provided re-education was conducted on 8/23/24, on Abuse and Neglect for all facility staff. Review of NA Employee E1 ' s personal file revealed Abuse training was completed on 7/23/24. During an interview on 9/11/24, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain a resident was free from physical abuse for one resident (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eighteen of twenty residents reviewed (Resident R1, R10, R38, R39, R57, R68, R70, R76, R77, R78, R79, R87, R94, R95, R96, R206, R207, R208). Findings include: A review of the facility policy Advanced Directives reviewed 1/13/23 and 1/2/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), dysphagia (difficulty swallowing) and tracheostomy (a hole made in throat to place a tube into the person ' s trachea or windpipe). A review of the clinical record failed to reveal an advance directive or documentation that Resident R1 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R10 was readmitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD - constriction of the airways making it difficult to breath). A review of the clinical record failed to reveal an advance directive or documentation that Resident R10 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R38 was readmitted to the facility on [DATE], with diagnoses that include paralysis (no movement of lower body or legs), dysphagia, respiratory failure (disease or injury that causes interference with the lungs to deliver oxygen), and tracheostomy. Review of the clinical record failed to reveal an advance directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R39 was admitted to the facility on [DATE], with diagnoses that include tracheostomy, muscular dystrophy (genetic condition that causes progressive weakness and loss of muscle mass), diabetes and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R39 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R57 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, chronic pain, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R57 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R68 was readmitted to the facility on [DATE], with diagnoses of high blood pressure, respiratory failure, and tracheostomy. A review of the clinical record failed to reveal an advance directive or documentation that Resident R68 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R70 was readmitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and amputation below left knee. A review of the clinical record failed to reveal an advance directive or documentation that Resident R70 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R76 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, COPD, and muscle weakness. A review of the clinical record failed to reveal an advance directive or documentation that Resident R76 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R77 was admitted to the facility on [DATE], with diagnoses that include a stroke (an interruption of the blood flow within your brain that causes the death of brain cells), with paralysis on right side, high blood pressure, and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R77 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses that include stroke, high blood pressure and end-stage renal disease (ESRD - when the kidneys permanently fail to work). A review of the clinical record failed to reveal an advance directive or documentation that Resident R78 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R79 was readmitted to the facility on [DATE], with diagnoses that include amyotrophic lateral sclerosis (ALS - weakens all muscles and impacts physical function), tracheostomy, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R79 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R87 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, ALS, tracheostomy. A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R94 was admitted to the facility on [DATE], with diagnoses that includes respiratory failure, tracheostomy, and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R94 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R95 was readmitted to the facility on [DATE], with diagnoses that includes ALS, tracheostomy, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R95 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R96 was admitted to the facility on [DATE], with diagnoses that include diabetes, and muscle weakness. \ A review of the clinical record failed to reveal an advance directive or documentation that Resident R96 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R206 was admitted to the facility on [DATE], with diagnoses that include dementia (loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), diabetes, and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R206 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R207 was admitted to the facility on [DATE], with diagnoses that include Parkinson ' s disease (affects movement of muscles often seen with tremors, shaking), dysphagia, and abdominal hernia (weakening of abdominal muscle causing a bulge). A review of the clinical record failed to reveal an advance directive or documentation that Resident R207 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R208 was admitted to the facility on [DATE], with diagnoses that include diabetes, atrial fibrillation (abnormal heartbeat) and nicotine dependence. A review of the clinical record failed to reveal an advance directive or documentation that Resident R208 was given the opportunity to formulate an Advanced Directive. During an interview on 2/22/2024, at 1:44 p.m. the Social Services Assistant E2 stated she confused the POLST with Advance Directives, confirming Residents (Resident R1, R10, R38, R39, R57, R68, R70, R76, R77, R78, R79, R87, R94, R95, R96, R206, R207, R208), were not afforded the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility. During an interview on 2/22/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to afford the residents the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for six of nine residents reviewed (Residents R10, R14, R46, R54, R68, and R70). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility provided education Diabetic Management indicated if the blood sugar falls below 70, call physician for guidance. and if you have a sliding scale order with parameters that state to call the MD (doctor) at certain high or low levels you must call the MD and document their response. Review of the facility policy Hypoglycemia Management reviewed 1/13/23 and 1/2/24, indicated the healthcare provider may designate and individual parameter for hypoglycemia, if so use this number (along with clinical symptoms) to determine whether interventions are necessary. For asymptomatic and responsive residents with blood glucose reading less than 70 (or ordered parameters) give the resident an oral form of rapidly absorbed glucose (juice, soda), recheck blood glucose in 15 minutes. Review of the facility policy Change of Condition reviewed 1/13/23 and 1/2/24, indicated it is the policy of the facility to inform residents, physician/providers. and resident representative of a change in resident's condition. Evaluate any changes noted through direct observation. Obtain a complete set of vital signs. Obtain an other data necessary for a complete evaluation (blood glucose fingerstick, neurochecks, etc.). Follow up by the licensed staff of the change in condition should continue for a minimum of 72 hours following the onset of the change, or as ordered by the physician. Follow up is to include a minimum: full set of vital signs, and an assessment with updates regarding the change in condition and observations. Review of the facility policy Charting and Documentation Policy Statement reviewed 1/13/23 and 1/2/24, indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc. must be documented in the resident's clinical records. All incidents, accidents, or changes in the resident's condition must be recorded. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R10' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/9/24, indicated the diagnoses remain current. Review of a physician ' s order dated 6/21/23, glucose monitoring before meals and at bedtimes. Further review of a physician order dated 11/20/23, indicated to inject Determir (long-acting type of insulin that works slowly, over about 24 hours) 7 units one time a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 2/17/24, at 10:09 p.m. CBG was noted to be 402. On 2/18/24, at 4:57 p.m. CBG was noted to be 434. On 2/19/24, at 3:54 p.m. CBG was noted to be 447. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan revised 1/9/24, failed to indicate interventions for diabetes, hyperglycemia, or hypoglycemia. Review of a clinical record indicated Resident R14 was readmitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and obesity. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician ' s orders dated 3/17/23, indicated blood glucose monitor AC (before meals) and HS (at bedtime), notify Dr is BS (blood sugar) is less than 90 in the AM or greater than 400. Further review of physician's order dated 5/10/23 through 11/22/23, indicated to inject Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 4 units two times a day , and 8 units one time a day. Further review of a physician's order dated 11/22/23, indicated to inject Lispro (Humalog) insulin 6 units with meals. An order dated 1/23/24, indicated glargine (long-acting type of insulin that works slowly, over about 24 hours) inject 42 units one time a day. Review of Resident R14's eMAR revealed that the resident's CBG's were as follows: On 9/10/23, at 5:50 a.m. CBG was noted to be 58. On 9/11/23, at 5:34 a.m. CBG was noted to be 51. On 9/24/23, at 11:08 a.m. CBG was noted to be 403. On 12/15/23, at 8:22 a.m. CBG was noted to be 431. On 1/19/24, at 8:40 a.m. CBG was noted to be 471. On 1/22/24, at 5:46 a.m. CBG was noted to be 82. On 2/3/24, at 6:07 a.m. CBG was noted to be 81. On 2/5/24, at 6:08 a.m. CBG was noted to be 73. A review of Resident R14's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. Monitor/document/report as needed signs and symptoms of hypo-/hyperglycemia A review of Resident R14's care plan dated 10/12/13,diabetes medication as ordered by doctor. Monitor/document/report for side effects and effectiveness. Review of the clinical record indicated Resident R46 was readmitted to the facility on [DATE], with diagnoses that included diabetes, dementia, and difficulty swallowing. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 10/4/22, glucagon 1mg injection as needed for symptomatic hypoglycemia. Further review of a physician's order dated 1/24/23, indicated Levemir (Determir) inject 25 units one time a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 11/8/23, at 3:54 p.m CBG was noted to be 478. On 12/5/23, at 4:39 p.m. CBG was noted to be 66. On 2/9/24, at 5:00 p.m. CBG was noted to be 415. Review of Resident R46's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/ hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/22/20, indicated diabetes medications as ordered by doctor, monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. Monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included diabetes, difficulty swallowing, and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Review of the physician's orders revealed the following orders: On 8/15/23 through 10/17/23, Humalog insulin per sliding scale 120 or greater inject 12 units one time a day. On 10/17/23 through 11/2/23, Humalog insulin 10 units one time a day. On 11/2/23 through 11/14/23, Humalog insulin 15 units one time a day. On 11/14/23 through 1/31/24, Humalog insulin 20 units before meals. On 1/31/24, Humalog insulin 20 units before meals, hold is blood sugar is less than 120 or not eating. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 10/8/23, at 8:24 p.m. CBG was noted to be 411. On 10/11/23, at 8:11 p.m. CBG was noted to be 414. On 10/27/23, at 3:37 p.m. CBG was noted to be 525. On 10/29/23, at 4:35 p.m. CBG was noted to be 436. On 10/29/23, at 9:31 p.m. CBG was noted to be e 413. On 11/2/23, at 12:06 p.m. CBG was noted to be 401. On 12/7/23, at 9:29 p.m. CBG was noted to be 454. On 1/27/24, at 4:56 p.m. CBG was noted to be 415. On 2/4/24, at 9:14 p.m. CBG was noted to be 402. On 2/7/24, at 6:22 p.m. CBG was noted to be 467. On 2/7/24, at 9:54 p.m. CBG was noted to be 436. On 2/14/24, at 9:05 p.m. CBG was noted to be 436. On 2/18/24, at 4:24 p.m. CBG was noted to be 420. On 2/18/24, at 8:43 p.m. CBG was noted to be 406. Review of Resident 54's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 4/19/23, indicated to diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed for signs and symptoms of hyperglycemia. Review of the clinical record indicated Resident R68 was readmitted to the facility on [DATE], with diagnoses that included diabetes, and hyperglycemia. Review of Resident R68's MDS dated [DATE], indicated the diagnoses remain current. Review of a physician ' s order dated 11/3/23, indicated to inject Determir insulin 28 units one time a day (long-acting type of insulin that works slowly, over about 24 hours). Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 12/5/23, at 5:50 a.m. CBG was noted to be 58. On 12/6/23, at 11:09 p.m. CBG was noted to be 31. Blood glucose was not rechecked until 12/7/23, at 5:07 a.m Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/20/22, indicated to give diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed signs and symptoms of hypoglycemia. Anticipate and meet the resident's needs. Review of the clinical record indicated Resident R70 was readmitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. Review of Resident R70' s MDS dated [DATE], indicated the diagnoses remain current. Review of a physician ' s order dated 1/31/24, indicated Levemir (long-acting type of insulin that works slowly, over about 24 hours) 30 units two times a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 2/2/24, at 8:51 a.m. CBG was noted to be 402. On 2/3/24, at 8:01 a.m. CBG was noted to be 433. On 2/3/24, at 8:52 p.m. CBG was noted to be 404. On 2/4/24, at 9:44 p.m. CBG was noted to be 439. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan failed to indicate interventions for diabetes, hyperglycemia, or hypoglycemia prior to 2/8/24. During an interview on 2/23/24, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E3 stated its a judgement call on when they would notify the doctor. If the blood glucose was low they would give juice or snack, monitor, check on the resident every hour and double check the fingerstick if the resident is symptomatic. If the blood glucose was outside of the ordered parameters they would call the doctor, give the ordered amount of insulin, and if symptomatic they would call the doctor. During an interview on 2/23/24, at 9:05 a.m. LPN Employee E4 stated for blood sugars over 400, they would check the parameters, call the provider for orders, assess the resident, recheck the blood glucose in 15-20 minutes. If the blood sugar was less than 60 they would offer a snack, and call the doctor if snack was not successful. During an interview on 2/23/24, at 9:09 a.m. LPN Employee E5 stated she would check the resident's orders for parameters. If blood glucose was less than 60-70, she would give juice or snack, report the incident to the Registered Nurse (RN) supervisor, and recheck the blood glucose in 30 minutes. For blood sugars over 150, she would report it to the RN supervisor if it was beyond the sliding scale. She would give the ordered dose on insulin, recheck blood glucose in 30 minutes and if ot responding to the medication she would notify the doctor. During an interview on 2/23/24, at 9:15 a.m. LPN Employee 6 stated for blood sugars less than 70 they would give snack or glucose gel. For blood sugars over 400, they would notify the doctor, complete an assessment, document in the vital signs and progress notes During an interview on 2/23/24, at 12:00 p.m. LPN Employee E7 stated for blood glucose less than 60-70, they would give glucose gel, call the doctor, monitor vital signs, and recheck the blood glucose in 15-20 minutes. If blood glucose was over 400 they would call the doctor, administer insulin and monitor vital signs. During an interview on 2/23/24, at 1:30 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose, failed to follow the care plan interventions, and failed to recheck blood sugars for Residents R10, R14, R46, R54, R68, and R70. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to assess for the use of an assistive device for one of eight residents (Resident R54). Findings include: Review of Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/3/24 included the diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and physical debility. Section GG: Functional Abilities and Goals indicated that Resident R54 utilized a manual wheelchair. Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed a score of 12. During an interview on 2/20/24, at 1:18 p.m. Resident R54 stated that he was frustrated that the physical therapy department would not allow him to use his motorized wheelchair. Review of the clinical record on 2/20/24, at 1:40 p.m. failed to reveal an assessment for Resident R54's ability to use a motorized wheelchair. During an interview on 2/23/24, at 12:07 p.m. the Rehabilitation Director Employee E18 confirmed that Resident R54 was not assessed for the use of a power wheelchair. Rehabilitation Director Employee E18 stated that at the time of admission (approximately eight months previous) Resident R54, his family, and medical providers had decided that a motorized wheelchair was not appropriate. Rehabilitation Director Employee E18 confirmed that after admission Resident R54 has requested the use of his motorized wheelchair, but that no further assessment had been completed to reflect the change in Resident R54's wishes and his level of functioning. During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to assess for the use of an assistive device for one of eight residents. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of in one of two medication rooms (100-Unit medication room ). Findings include: Review of the facility policy Storage of Medications dated 1/2/24, indicated medications are and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. During an observation of the 100-Unit medication room on 2/21/24, at 12:58 p.m. the following was observed: (2) opened bottles of resident specific Dakins solution. (1) liter bag of NSS, with no overwrap. (9) vials of ceftriaxone, with an expiration date of 05/2023, stored in a drawer with luau party supplies. (1) urethral catheter, with an expiration date of 6/28/23. (4) intravenous fluid administration sets, with an expiration date of 10/13/23. (1) Sterile Foley Cath Insertion Kit, opened, with items removed. (1) Syringe with an expiration date of 10/11/23. (6) External catheters with an expiration date of 5/28/22. (6) External catheters with an expiration date of 9/28/22. During an interview on 2/21/24, at 1:15 p.m. LPN Employee E10 confirmed the above observation. During an interview on 2/23/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medical supplies were properly stored in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, facility specific documents, and staff interview, it was determined that the facility failed to provide adequate supervision and effective safety measures for one of twenty-one residents which resulted in actual harm during an elopement from the facility requiring emergency treatment and admission to hospital. Resident R18 eloped and was missing for approximately two hours and fifteen minutes before staff found her, which created actual harm requiring hospitalization . The immediate jeopardy was determined to constitute a past non-compliance immediate jeopardy situation for one of twenty-one residents reviewed for elopement (Resident R18). Findings include: The facility policy Elopement/Wandering Resident, last reviewed on 1/12/21, indicated 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. Wandering is defined as a confused individual who moves about the facility and grounds not knowing where he/she is and is in jeopardy of injury or becoming lost. Residents with a history of wandering will be identified on individual care plans, that are updated at each admission, discharge, and/or change in behavior reported by staff. The facility's Registered Nurse Unit Manager updated job description, indicated the primary purpose is to supervise and coordinate the activities of nursing personnel engaged in nursing services, and ensure that standards of nursing care are upheld and policies and procedures are followed. The facility's License Practical Nurse updated job description, indicated the Licensed Practical Nurse provides care and treatment in accordance with physician orders and works under the direction of physicians and Registered Nurses within the scope of practice. The job description further identified that the Licensed Practical Nurse is to monitor and follow-up on Certified Nursing Assistant (CNA) assignments to ensure quality resident care and services. The facility's Certified Nursing Assistant updated job description, indicated that the primary purpose is to perform direct resident care duties under the supervision of licensed nursing personnel. Review of Resident R18's clinical record indicated resident was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), [CONDITION(S)] (unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life), and unspecified dementia without behaviors disturbances (a group of symptoms that affects memory, thinking, and interferes with daily life). The Minimum Data Set (MDS-periodic assessment of resident care needs) for Resident R18 dated 11/05/21, indicted that diagnosis remained current. Review of the MDS for Resident R18 dated 11/5/21, Section C0500 BIMS (Brief Interview for Mental Status) indicated a Summary Score of 13 (intact cognitive response), G0110 Activities of Daily Living (ADL) Assistance, Sub Section 1 (ADL Self-Performance) indicated B. Transfers with supervision (oversight, encouragement or cueing), C. Walks in room with supervision, D. Walks in corridor with supervision, E. Locomotion on unit with supervision, F. Locomotion off unit with supervision. Section G0600 Mobility Devices indicated walker and wheelchair normally used. Review of care plan initiated 7/30/21, indicated that Resident R18 has limited physical mobility, uses a wheeled walker for walking, and on 8/2/21, care plan was revised to include that resident requires assist of 1 with staff for use of wheeled walker for mobility. The care plan failed to indicate areas of focus related to wandering or elopement. Review of clinical documentation identified as Physical Therapy Discharge Summary, dated 11/2/21, identified that Resident R18 short-term goals #1 to complete transfers with no cueing in order to prepare for gait activities requires supervision and additional goal #2 will safely ambulate on level surfaces 100 feet with rolling walker with no cues to reduce risk for falls and to increase independence within facility, resident was able to complete 240 feet with wheeled walker with supervision. Review of Resident R18's clinical record revealed that Resident R18 eloped from the facility 1/3/22, and incurred injury resulting in transfer to the emergency room and subsequent hospital stay. Review of the progress note by Registered Nurse (RN) Employee E12 dated 1/3/22, at 4:30 a.m., indicated resident R18 stated I was trying to warn that man up the street. Review of incident investigation documentation dated 1/3/22, indicated the resident was last seen at midnight by RN for daily census count. Video camera utilized on front door of property, identified that resident left through the front entrance doors at 12:32 a.m. dressed in nightgown, long-sleeved sweater, and slipper shoes. Resident was found at 2:43 a.m. by Nursing Assistant (NA) Employee E10 at front entrance on ground with wheeled walker. Resident was brought back into the facility by 3 staff members, assessed for injuries, and vitals obtained. Physician was notified and resident was sent to the emergency room . Progress note dated 1/3/22, at 10:04 a.m., indicated Resident R18 was admitted with elevated troponin (a measure of proteins in the blood indicative of identifying cardiac changes) and hypothermia. Review of hospital discharge report dated 1/5/22, at 2:11 p.m., identifies diagnoses of hypothermia and accidental fall. Facility Progress note dated 1/6/22, at 10:53 a.m., indicated Resident R18 was readmitted last evening with diagnosis of hypothermia. Review of facility's investigation documentation, a written statement by NA Employee E10, dated 1/3/22, stated that NA E10 went outside to car, heard noise, looked right, saw a walker, and heard someone calling for help. Resident R18 was found lying on the storm drain. NA Employee E10 proceeded to seek help from inside the building from NA Employee E11, LPN Employee E4, and RN Employee E3, who together got Resident R18 into a wheelchair. Review of facility's investigation documentation, a written statement by NA Employee E11, dated 1/3/22, stated that she was made aware by NA Employee E10 that a resident had fallen outside. With RN Employee E3 and LPN Employee E4, NA Employee E11 found resident lying at the side of the curb. A wheelchair was obtained for the resident, and Resident R18 was taken back inside. Review of facility's investigation documentation, a written statement by Employee LPN Employee E4, dated 1/3/22, stated that NA Employee E10 came and got me and the RN Employee R3, that she saw a resident outside on the ground, by the main entrance. LPN Employee E4, with RN Employee E3 and NA Employee E10, went outside, saw R18 on the ground screaming for help. When asked why she was outside, Resident R18 stated that I had to help that man. Review of facility's Incident report, dated 1/3/22, at 4:31 a.m., by RN Employee E3 stated that NA Employee E10 notified RN Employee E3 resident was lying on the ground outside of the facility. RN Employee E3, LPN Employee E4, and NA Employee E10 helped bring her inside to her room. RN Employee E3 assessed resident for injury. Her right hand was swollen and black and blue. She also had a laceration on her right hand. Her buttocks are black and blue and several abrasions on her buttocks noted. RN notified MD and ordered for resident to be sent to the hospital for further evaluation. Resident's son was notified. Further documentation on this report identified resident was ambulatory without assistance, using walker. Review of facility provided document identified that this event, was submitted on 1/6/22, by Nursing Home Administrator (NHA), stated that this morning an aide had walked to her car and noted Resident R18 to be on the ground by the curb at the main entrance. Resident R18 was assessed by RN Employee E3 and was noted to be on her right side. Resident R18's right hand was swollen with bruising and a small laceration also noted. Resident R18 had some bruising and abrasions to her buttock. Resident R18 was alert and verbal and stated that I was going to go help that man. Another statement during interview from resident I was trying to warn that man up the street. No man was noted to be outside. She was assisted into the facility. Family and physician were notified. Her vitals were 96.3, P 84, R 22, and BP 147/80. Physician notified with order to send to the emergency room . Resident R18 was in the emergency room with an elevated troponin and slight hypothermia. An investigation and timeline were initiated on this event. It was noted that R18 was visualized by RN Employee R3 on duty at midnight during the midnight census head count. Review of video footage shows her walking out of the front door dressed in an evening gown with a long sweater and slipper shoes at approximately 12:33 a.m., on 1/3/22. It was 2:30 a.m. when the aides were making rounds and another aide went to her car and noted Resident R18 outside. Review of facility procedure related to Front Entrance access, during an interview on 4/28/22, at 10:00 a.m, with the NHA, the protocol for locking the front entrance, which is completed daily by the evening receptionist, usually at the end of that shift, around 8:00 p.m., revealed that no entry/reentry or way to alert staff from the front entrance, was available at the time of the elopement incident 1/3/22. Around 12:30 a.m.; the front door entrance would have been locked for entry/reentry into facility. This was confirmed by the NHA. Based on the facility action plan initiated 1/5/22, battery operated doorbell for the front entrance was to be installed, and monitored regularly for proper operation. Installation of battery operated doorbell for the front entrance was confirmed by the NHA at the time of interview. During an interview on 4/28/22, at 11:50 a.m., LPN Employee E4 recalled the events of Resident R18's elopement. LPN Employee E4 stated that she and other staff members were by the ambulance entrance in the middle of the facility, when a NA came in and said somebody is outside in the sewer grate. LPN Employee E4 continued to state that we all went outside together because we did not know that it was a resident. LPN Employee E4, NA Employee E11, and RN Employee E3 found Resident R18 on her back, and Resident R18 said that she was trying to warn or help a man. LPN E4 stated that she was not shivering but was cold to touch and had on a nightgown, and a zip jacket. LPN Employee E4 stated that RN Employee E3 does walking rounds (a systematic process for identifying resident care or service needs) for the midnight census, and when asked how she would know that a resident was not missing, LPN Employee E4 stated that Resident R18 is continent through the night and independent, but the aides round at 1:00 a.m., 3:00 a.m., and 5:00 a.m. During an interview on 4/28/22, at 4:14 p.m., RN Employee E3 recalled the events of Resident R18's elopement. RN Employee E3 stated NA Employee E10 walked out to her car, and she heard someone yelling. NA Employee E10 went over and saw Resident R18, and she came back inside and let us know. We went out together, RN Employee E3, LPN Employee E4 , and 2 NA's Employee E10 and Employee E11, and found Resident R18 lying on a grate in the road. RN Employee E3, LPN Employee E4, and 2 NA's Employee E10 and Employee E11, tried to get Resident R18 up and Resident R18 couldn't stand up alone, so NA Employee E11 went and got a wheelchair. RN Employee E3 stated that Resident R18 was shivering and complained of being cold. RN Employee E3 continue to state that walking rounds are done every night to see if patients are in their rooms, and that it was completed around 10:00 p.m. or 11:00 p.m. and that Resident R18 was present. RN Employee E3 further stated that when asking LPN Employee E4 and NA Employee E10 when the last time Resident R18 was checked or seen, they said around 12:00 a.m. (1/3/22). RN Employee E3 identified that NA Employee E10 should have rounded at 01:00 a.m. RN Employee E3 stated that she no longer works for this facility. During an interview on 4/29/22, at 9:40 a.m., NA Employee E10 stated that she and LPN Employee E4 saw resident in hallway by nursing station around 12:30 a.m., just before rounds. Resident R18 engaged in conversation with them, and stated was going to bed. NA Employee E10 stated that Resident R18 was usually up at night was out in the hallway or at the nurse station. When asked about 1:00 a.m. rounds, identified as standard practice by LPN Employee E4 and RN Employee E3, NA Employee E10 stated that Resident R18 was just seen about half-an-hour earlier on her way to her room to go to bed. Further discussion with NA Employee E10, revealed that only 2 NAs were assigned to that unit, when 3 NAs were normally assigned to this hallway, causing 1:00 a.m. rounds to be extended due to additional care provided. NA Employee E10 recalled going out to car to get a drink, leaving from the ambulance entrance, looked to the right and saw a walker, proceeded to return inside the facility, and identified the situation to LPN Employee E4 and RN Employee E3. Upon bringing resident back inside via wheelchair, and placing her into bed, NA Employee E10 stated that resident was not blue, but Resident R18 stated feeling cold. NA Employee E10 could not recall specific temperature of resident taken, however did verify that a temperature did register on thermometer. During an interview on 4/28/22, at 2:15 p.m., Corporate RN Consultant Employee E13 and the NHA confirmed that the facility failed to provide necessary supervision to ensure safety which resulted in actual harm, due to an elopement by Resident R18 causing resident to be locked out of the facility for over two hours in below 30 degree Fahrenheit temperature during which location of resident was unknown, fell , became hypothermic, and had to be transported to the hospital placing the facility in a past non-compliance immediate jeopardy situation. Review of the facility action plan indicated that on 1/5/22, immediate actions were taken to include installation of a Stop Sign alarm on the main entrance front lobby door, Exit Stopper Multifunction Door Alarm, on 1/12/22, provided Resident R18 with a wander guard (electronic system device, typically a wrist or ankle band, worn to prevent individuals from moving outside of specified area without authorization) per physician order to be monitored for placement and function every day. Staff education was provided on alarms and doorbell protocols, and installation of battery operated doorbell for front entrance. All facility doors where checked to identify doors that are not alarmed, and completed thirty day monitoring audit for proper operation of door monitors and patient wandering system. Staff education started 1/13/22 and completed 1/15/22. The facility Quality Assessment and Assurance Committee met to review and resolve the failure of the facility to provide adequate supervision to prevent the elopement of Resident R18 and prevent further elopements. On 4/28/22, at 2:15 p.m., an Immediate Jeopardy Template was provided to the Corporate RN Consultant and NHA. The past non-compliance Immediate Jeopardy situation was in effect until 4/28/22, 4:37 p.m. The facility submitted the corrective action plan which included immediate actions taken post elopement defined as transferring Resident R18 to the emergency room for evaluation, Resident R18's care plan was reviewed and revised, purchasing a Stop Sign Alarm, and checked all other like residents that were able to ambulate/self-propel independently for needed care plan revisions. Post elopement, the facility initiated a Performance Improvement Plan with the following actions, purchase and installation of Stop Sign Alarm on the inside set of main entrance doors on 1/11/22, education provided to nursing and administrative staffs on the new alarm system protocol on 1/13/22, 1/14/22, and 1/15/22, audit on 1/4/22, by Maintenance to check and validate that the front entrance is the only door not alarmed, ninety day audits by Maintenance to check all door alarms are functioning properly, Elopement Policy was updated to include addition of door alarm, and discussion and review of Performance Improvement Plan associated with event in the monthly QAPI (Quality Assurance/Process Improvement) meetings. During interviews on 4/28/22, at 10:38 a.m., at 10:39 a.m., at 10:40 a.m., at 10:45 a.m., and 10:48 a.m., NA Employee E5, NA Employee E6, LPN Employee E7, Housekeeping Employee E8, and Unit Clerk Employee E1 confirmed comprehension of education on alarms and doorbell protocols. During an interview on 4/29/22, at 9:40 a.m., NA Employee E10 also confirmed comprehension of education on alarms and doorbell protocols. Review of facility documentation and staff interviews indicated that the corrective action plan had been fully implemented and completed on 4/28/22, at 4:37 p.m., and the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/22/22, 11/6/20 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/22/22, 11/6/20 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 11/6/20 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 4/22/22, 11/6/20 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/6/20