Every finding on record at Twin Lakes Rehabilitation and Healthcare Center

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after an injury occurred for one of four residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated April 23, 2026, revealed that the resident was always understood and always understood others, cognitively intact, and independent in eating. The resident's care plan, dated September 24, 2025 revealed that the resident required a one-handled cup with a straw lid for beverages. A nurse's note, dated May 7, 2026 revealed that the nurse was asked to assess a new skin area on Resident 1. The nurse stated that the wound was a burn related to a coffee spill on May 6, 2026. An interview with Nurse Aide 1 on May 14, 2026 at 11:16 a.m. revealed that on May 6, 2026 she made a cup of coffee for Resident 1 and his roommate. She poured their coffee into large Styrofoam cups and served the coffee to the residents. She stated that she helped Resident 1 put sugar and cream into his coffee and then went to help his roommate with his. While opening sugar and cream for the roommate she heard Resident 1 say oh sh*t and when she turned around she noticed that he had spilled his coffee all over the front of his legs and that he did not have pants on, only a brief. She stated that she told her nurse that the spill occurred. There was no documented evidence in Resident 1 was assessed for burns related to the coffee spill. An interview with Director of Nursing on May 14, 2026 revealed that a Registered Nurse should have assessed Resident 1 for burns when he spilled his coffee on himself. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for wound care were followed for one of four residents reviewed (Resident 1). Findings include: The facility's wound care policy, dated April 8, 2026, indicated that staff should follow physician's orders for wound care. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated April 23, 2026, revealed that the resident was always understood and always understood others, cognitively intact, and had several wounds. The resident's care plan, dated March 16, 2026 revealed that the resident's treatment's should be applied per the physician's orders. Physician's orders for Resident 1, dated May 6, 2026, included an order for the left leg wound to be cleansed with wound cleanser, pat dry, apply triamcinolone 0.1% followed by Hydrofera blue, then secured with dry dressing. Observations of wound care for Resident 1 on May 14, 2026 at 10:25 a.m. revealed that Registered Nurse 2 washed her hands, donned gloves, removed the old dressing, cleansed the wound with wound cleanser, applied Hydrofera blue, then covered the wound with secured gauze. She did not apply the triamcinolone cream. Interview with Registered Nurse 2 on May 14, 2026 at 10:32 a.m. revealed that she did not apply the triamcinolone cream as ordered. Interview with the Director of Nursing on May 14, 2026 at 12:10 p.m. revealed that Registered Nurse 2 should have applied the triamcinolone cream as ordered. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of four residents reviewed (Resident 1). This deficiency is being cited as past non-compliance. Findings include: A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated April 23, 2026, revealed that the resident was always understood and always understood others, cognitively intact, and independent in eating. The resident's care plan, dated September 24, 2025 revealed that the resident required a one-handled cup with a straw lid for beverages. An investigation into a coffee spill for Resident 1, dated May 7, 2026, revealed that the resident spilled a cup of coffee on himself after being served a cup of coffee in a large Styrofoam cup. An interview with Nurse Aide 1 on May 14, 2026 at 11:16 a.m. revealed that on May 6, 2026 she made a cup of coffee for Resident 1 and his roommate. She poured their coffee into large Styrofoam cups and served the coffee to the residents. She stated that she helped Resident 1 put sugar and cream into his coffee and then went to help his roommate with his. While opening sugar and cream for the roommate she heard Resident 1 say oh sh*t and when she turned around she noticed that he had spilled his coffee all over the front of his legs and that he did not have pants on, only a brief. She stated that she told her nurse that the spill occurred. She also stated that she was not aware that the resident required a one handled cup with a straw lid for beverages. An interview with Director of Nursing on May 14, 2026 revealed that Resident 1 should have been served hot liquids in the adaptive equipment as he required in order to avoid any accidental spills or burns. Following the incident on May 6, 2026, the facility's corrective actions included:1. On May 7, 2026 the resident was assessed for any burns related to the coffee spill. The nurse aide that served the coffee in the Styrofoam cup was educated on the importance of serving hot liquids in the appropriate cups for residents based on their care plan needs.2. Residents were assessed to determine if they had the appropriate assistive devices necessary.3. Education records, dated May 8 and 9, 2026 revealed that all of the facility's nursing staff received education regarding the resident's needs for adaptive equipment.4. The Director of Nursing or designee will audit resident's adaptive equipment needs to ensure that their care plans are followed five days a week for one week, and then three days a week for one week and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on May 8, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to drink in accordance with the resident's care plan for one of four residents reviewed (Resident 1). This deficiency is being cited as past non-compliance. Findings include: A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated April 23, 2026, revealed that the resident was always understood and always understood others, cognitively intact, and independent in eating. The resident's care plan, dated September 24, 2025 revealed that the resident required a one-handled cup with a straw lid for beverages. An investigation into a coffee spill for Resident 1, dated May 7, 2026, revealed that the resident spilled a cup of coffee on himself after being served a cup of coffee in a large Styrofoam cup. An interview with Nurse Aide 1 on May 14, 2026 at 11:16 a.m. revealed that on May 6, 2026 she made a cup of coffee for Resident 1 and his roommate. She poured their coffee into large Styrofoam cups and served the coffee to the residents. She stated that she helped Resident 1 put sugar and cream into his coffee and then went to help his roommate with his. While opening sugar and cream for the roommate she heard Resident 1 say oh sh*t and when she turned around she noticed that he had spilled his coffee all over the front of his legs and that he did not have pants on, only a brief. She stated that she told her nurse that the spill occurred. She also stated that she was not aware that the resident required a one handled cup with a straw lid for beverages. An interview with Director of Nursing on May 14, 2026 revealed that Resident 1 should have been served hot liquids in the adaptive equipment as he required. Following the incident on May 6, 2026, the facility's corrective actions included:1. On May 7, 2026 the resident was assessed for any burns related to the coffee spill. The nurse aide that served the coffee in the Styrofoam cup was educated on the importance of serving hot liquids in the appropriate cups for residents based on their care plan needs.2. Residents were assessed to determine if they had the appropriate assistive devices necessary.3. Education records, dated May 8 and 9, 2026 revealed that all of the facility's nursing staff received education regarding the resident's needs for adaptive equipment.4. The Director of Nursing or designee will audit resident's adaptive equipment needs to ensure that their care plans are followed five days a week for one week, and then three days a week for one week and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F810 on May 8, 2026. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during wound care for one of four residents reviewed (Resident 1).Findings include: The facility's policy for wound care, dated April 8, 2026, indicated that after removing an old wound dressing staff should remove their gloves, perform hand sanitization, and don new gloves. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated April 23, 2026, revealed that the resident was always understood and always understood others, cognitively intact, and had several wounds. The resident's care plan, dated March 16, 2026 revealed that the resident's treatment's should be applied per the physician's orders. Physician's orders for Resident 1, dated May 6, 2026, included an order for the left leg wound to be cleansed with wound cleanser, pat dry, apply triamcinolone 0.1% followed by Hydrofera blue, then secured with dry dressing. Observations of wound care for Resident 1 on May 14, 2026 at 10:25 a.m. revealed that Registered Nurse 2 washed her hands, donned gloves, removed the old dressing, cleansed the wound with wound cleanser, applied Hydrofera blue, then covered the wound with secured gauze. She did not apply the triamcinolone cream. Interview with Registered Nurse 2 on May 14, 2026 at 10:32 a.m. revealed that she did not change her gloves or perform hand sanitization after removing the dirty dressing and before applying the new wound dressing and that she should have. Interview with the Director of Nursing on May 14, 2026 at 12:10 p.m. revealed that Registered Nurse 2 should have changed her gloves and performed hand sanitization between removing the dirty dressing and applying the new dressing. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records and grievances, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance for one of 7 residents reviewed (Resident 2).Findings include:The facility's policy regarding grievances/complaints, filing, dated April 8, 2026, revealed that residents and family members may file a grievance and that the grievance will be resolved within five working days.A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 17, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, and had a full set of dentures. A review of Resident 1's inventory sheet, dated December 11, 2025 revealed that the resident had a full set of dentures with him when he was admitted .A grievance for Resident 2, dated December 29, 2025 revealed that the resident's dentures had been missing since that morning. The findings of the grievance revealed that the facility would reimburse the family for the missing dentures.Social Services note for Resident 2, dated January 9, 2026 revealed that the resident's son was inquiring as to the status of the resident's missing dentures and that he provided the name and phone number for the dentist. An interview with the Nursing Home Administrator on April 17, 2026 at 3:22 p.m. revealed that the main office was emailed the invoice which included the amount and address to make the payment to replace the dentures on February 20, 2026. As of April 17, 2026 at 10:30 a.m. the invoice had not been paid and the grievance had not been resolved.28 Pa. Code 201.29(i) Resident rights.28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the stove/oven was maintained in working condition in the kitchen.Findings include:Observations of the kitchen on April 17, 2026 at 12:09 p.m. revealed that the main stove/oven was not working and that the lunch being prepared consisted of a cold ham and cheese sandwich. An interview with the cook at that time revealed that the stove/oven had not worked for over 2 months. She stated that the facility ordered a new one, it arrived, but would not connect because the electric hook up was not correct. She stated that the resident's menu has been altered for over a month due to stove/oven not working and that the residents are unhappy about it.An interview with the Dietary Manager on April 17, 2026 at 12:14 p.m. revealed that the stove/oven had been down for over a month. She stated that the company ordered a new stove, but when it arrived it was a gas hookup and the facility is not set up for that. That stove/oven was returned and another one arrived, however, the electric hook up was not the correct wattage, therefore an electrician is scheduled to come to the facility to install the proper hook up.An interview with the Nursing Home Administrator on April 17, 2026 at 3:22 p.m. confirmed that the stove/oven was not working and had not been working for over a month.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for two of four residents reviewed (Resident 3, 4). Findings include: An admission change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 30, 2026, revealed that the resident was cognitively intact, stage 4 pressure ulcer(full thickness skin and tissue loss exposing muscle, tendon or bone) on admission, required assistance from staff for daily care needs, and had medical diagnosis that included stroke. Physician's orders for Resident 3, dated January 6, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip and cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration Record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 12, 2026, and January 18, 2026. Physician's orders for Resident 3, dated January 19, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip, apply zinc oxide paste to peri-wound, cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 24, 2026, and January 25, 2026. An interview with the Director of Nursing on February 4, 2026, at 12:12 p.m. confirmed that there was no documented evidence that Resident 3's wound treatments were completed as ordered on the dates listed above. A quarterly MDS assessment for Resident 4, dated December 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had pressure ulcer, and had medical diagnosis that included dementia.Review of skin and wound notes for Resident 4 dated December 22, 2025, January 2, 2026, and January 9, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with a dry dressing, and change daily, and as needed . However, review of the Treatment Administration Record (TAR) for Resident 4 dated January 2026, revealed that on January 1 through the 12, 2026, the treatment to the right and left buttocks pressure ulcers was documented as being left open to air, with no dry dressing. A skin and wound note dated January 26, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with bordered gauze, and change daily, and as needed. However, review of the TAR dated January 2026 revealed that the treatment to the right and left buttocks pressure ulcers was documented as being completed three times a day on January 26, 2026, through February 3, 2026. Interview with the Assistant Director of Nursing on February 4, 2026, at 2:11 p.m. confirmed that there was no documented evidence that the wound care consultant's recommendations for the treatments to Resident 4's pressure ulcers were being completed as ordered. 28 Pa. Code 211.12(d)(5) Nursing services. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for two of four residents reviewed (Resident 3, 4). Findings include: An admission change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated December 30, 2026, revealed that the resident was cognitively intact, stage 4 pressure ulcer(full thickness skin and tissue loss exposing muscle, tendon or bone) on admission, required assistance from staff for daily care needs, and had medical diagnosis that included stroke. Physician's orders for Resident 3, dated January 6, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip and cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration Record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 12, 2026, and January 18, 2026. Physician's orders for Resident 3, dated January 19, 2026, included an order for the resident to have his left buttock cleansed with wound cleanser, pat dry, pack with iodoform packing strip, apply zinc oxide paste to peri-wound, cover with silicone border every dayshift. A review of Resident 3's January 2026 Treatment Administration record was reviewed and there is no documented evidence his treatment was completed per physician orders on January 24, 2026, and January 25, 2026. An interview with the Director of Nursing on February 4, 2026, at 12:12 p.m. confirmed that there was no documented evidence that Resident 3's wound treatments were completed as ordered on the dates listed above. A quarterly MDS assessment for Resident 4, dated December 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had pressure ulcer, and had medical diagnosis that included dementia. Review of skin and wound notes for Resident 4 dated December 22, 2025, January 2, 2026, and January 9, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with a dry dressing, and change daily, and as needed . However, review of the Treatment Administration Record (TAR) for Resident 4 dated January 2026, revealed that on January 1 through the 12, 2026, the treatment to the right and left buttocks pressure ulcers was documented as being left open to air, with no dry dressing. A skin and wound note dated January 26, 2026, included that the wound treatment recommendations to the right and left buttocks pressure ulcers were to cleanse with wound cleanser or normal saline (salt water), apply Zinc Oxide Paste to base of the wound, secure with bordered gauze, and change daily, and as needed. However, review of the TAR dated January 2026 revealed that the treatment to the right and left buttocks pressure ulcers was documented as being completed three times a day on January 26, 2026, through February 3, 2026. Interview with the Assistant Director of Nursing on February 4, 2026, at 2:11 p.m. confirmed that there was no documented evidence that the wound care consultant's recommendations for the treatments to Resident 4's pressure ulcers were being completed as ordered. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure a safe route of egress through emergency exit doors for residents on two of three units ([NAME] and [NAME] units), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: The facility's policy regarding exits or means of egress, dated July 28, 2025, indicated that the facility had designated exits for each area of the building to allow for rapid evacuation. Exit doors would remain unlocked at all times and residents were never denied access to unlocked exits. Exit doors were to never be blocked, even briefly.The maintenance logbook for December 2025 and January 2026 revealed that the doors, locks, gates and alarms on the [NAME] and [NAME] short and long hall doors, had their operation tested daily on December 29, 30, and 31, 2025. They were marked as Pass on the logbook for these dates and there was no mention of zip ties or rolled gauze being in place. There was no documented evidence that the doors on the [NAME] and [NAME] short and long halls were checked for operation on January 1, 2026, due to the Maintenance Director being scheduled off. The instructions for checking the doors and hardware for proper operation and condition, undated, indicated that the door closures were to be checked for any obstructions and any discrepancies were to be noted.Observations on January 2, 2026, at 9:19 a.m. revealed that the two emergency doors on the short hall of the [NAME] unit had the handles to the two doors secured shut with a zip tie (self-locking plastic device), preventing egress to the outside.Interview with Licensed Practical Nurse 1 on January 2, 2026, at 9:22 a.m. revealed that she was the medication nurse on the short hall of the [NAME] unit and she was not aware that there were zip ties on the emergency exit doors preventing egress.Interview with Nurse Aide 2 on January 2, 2026, at 9:26 a.m. revealed that she was not aware that there were zip ties securing shut the emergency exit doors on the [NAME] short hall. She indicated that the wind would blow on the doors and cause the alarm to sound.Interview with the Registered Nurse Supervisor 3 on January 2, 2026, at 10:36 a.m. revealed that the wind would cause the emergency exit doors on the short hall of the [NAME] unit to alarm, but she was unaware of any exit doors being secured shut with zip ties.Observations on January 2, 2026, at 9:20 a.m. revealed that the two emergency doors on the short hall of the [NAME] unit had the handles to the two doors secured shut with a zip tie and had rolled gauze wrapped tightly around the door handles and stretched to attach to the railing adjacent to the doors preventing egress to the outside.Interview with Nurse Aide 4 on January 2, 2026, at 9:22 a.m. revealed that the emergency exit doors on the short hall of the [NAME] unit would alarm frequently due to the high winds but was not aware that the exit doors were secured shut with zip ties. Interview with the Registered Nurse 5 on January 2, 2026, at 9:26 a.m. confirmed that the emergency exit doors of the [NAME] unit were zip tied shut and had rolled gauze wrapped around the handles. She indicated that they were probably placed on the doors to prevent the alarm from going off due to the high winds that would set off the alarm. She stated that she was not usually on that unit and was unsure how long the zip ties and gauze were on the doors.Interview with Maintenance Worker 6 on January 2, 2026, at 9:42 a.m. revealed that he was not aware of any exit doors being secured with zip ties or rolled gauze.Interview with the Nursing Home Administrator on January 2, 2026, at 9:45 a.m. revealed that the wind would rattle the emergency exit doors causing the door alarm to frequently trigger, which required staff to go to the doors and re-set the alarm. He stated that he was not aware that the exit doors on the short halls of the [NAME] and [NAME] units were secured shut with zip ties and rolled gauze. He confirmed that the doors should not have been secured shut with zip ties or rolled gauze and he was unaware who applied the zip ties and rolled gauze.Interview with the Director of Nursing on January 2, 2026, at 12:36 p.m. confirmed that she was not aware that there were emergency exit doors secured shut with zip ties and gauze on the [NAME] and [NAME] units.On January 2, 2026, at 12:41 p.m. the Nursing Home Administrator was informed that the health and safety of the residents was placed in Immediate Jeopardy due to the emergency exit doors on the short halls of the [NAME] and [NAME] units being secured shut with zip ties and rolled gauze which would have prevented resident egress from the facility during and emergency. The Immediate Jeopardy template was also provided to the Nursing Home Administrator.The facility submitted and implemented an immediate action plan that included removing the zip ties and rolled gauze that secured the emergency exit doors shut, inspected all doors to ensure proper functioning, educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed, and maintenance would check all exit doors for proper functioning on a daily basis.The Immediate Jeopardy was lifted on January 2, 2026, at 4:46 p.m. when it was confirmed that the facility had removed the zip ties from the emergency exit doors, ensured that all exit doors were accessible, staff were educated, and all emergency exit doors were inspected/repaired by a door company.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well being of residents in the facility by failing to ensure that emergency exit doors were accessible to residents, allowing egress to the outside during an emergency situation, placing the residents at risk for serious harm which created an Immediate Jeopardy situation.Findings included:The job description for the Nursing Home Administrator, undated, revealed that the administrator's essential job functions included the planning, developing, organizing, implementing and directing of programs and activities; assuring that the facility was properly maintained, and clean and safe for resident comfort and conveniences; and implement an effective accident prevention program. The facility failed to ensure these responsibilities were carried out, as evidenced by the emergency exit doors being secured shut with zip ties and rolled gauze, ensuring that all emergency exits were accessible to residents, allowing egress during an emergency situation. This demonstrated a lack of effective oversight to address the safety of residents during an emergency situation.The job Description for the Director of Nursing, dated June 25, 2025, indicated that the Director of Nursing was responsible for the planning, developing, organizing, and directing the overall operation of the Nursing Service Department in accordance with current Federal, State, and local standards, guidelines and regulations that governed the facility; develop, maintain and periodically update written policies and procedures that govern the day to day functions of the nursing services department; monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies; and ensure that all resident care rooms, treatment areas, etc. are maintained in a clean, safe and sanitary manner. The DON failed to ensure that all emergency exit doors were accessible to residents, allowing egress to the outside during an emergency situation.Based on the findings the facility's inability to ensure that all emergency exits were accessible to residents and allowed egress during an emergency situation resulted in Immediate Jeopardy to the health and safety of residents on the [NAME] and [NAME] units. This demonstrates a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents.The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, revealed the facility's administration did not fulfill essential job duties to ensure resident safety and regulatory compliance. This included a failure to ensure that emergency exits on the [NAME] and [NAME] units were accessible to residents and allowed egress to the outside during an emergency situation.Refer F689 28 Pa. Code: 201.14 (a) Responsibility of licensee28 Pa. Code: 201.18 (b)(1)(3)(e)(1) Management28 Pa. Code 211.12 (c)(d)(1)(3)(5)Nursing services

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 46 residents reviewed (Resident 67).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated September 30, 2025, revealed that the resident was cognitively intact, was scheduled routine pain medications, had complaints of difficulty or pain when swallowing, had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable or has difficulty eating or drinking by mouth) and received tube feedings, was on a mechanically altered diet, received opioid medications (a controlled pain medication), had a tracheostomy (surgical incision in the neck that creates an opening into the windpipe), and had diagnoses including chronic respiratory failure (blood does not have enough oxygen and causes difficulty breathing), malignant neoplasm of the oropharynx (throat cancer), acquired absence of the larynx (connects the throat to the windpipe and plays a role in swallowing, breathing and speech). Physician's orders for Resident 67, dated October 1, 2025, included an order to give 100 milligrams (mg) of Trazadone (an antidepressant medication used to treat depression or aide with sleep) by mouth at bedtime.Physician's orders for Resident 67, dated October 6, 2025, included an order for the resident to receive 5 mg of Oxycodone (a controlled pain medication) by mouth every 24 hours as needed for breakthrough pain.Physician's orders for Resident 67, dated October 13, 2025, included an order to give 600 mg of Gabapentin (medication used to treat pain) by mouth three times a day for pain scheduled to be given at 9:00 a.m., 2:00 p.m. and 8:00 p.m.Physician's orders for Resident 67, dated November 19, 2025, included an order to give 500 mg of Cephalexin (an antibiotic) by mouth two times a day for five days.Observations of Resident 67 on November 18, 2025, at 9:40 a.m. revealed the resident sitting at the edge of his bed. Licensed Practical Nurse 2 came into the resident's room and administered his 9:00 a.m. medications through his feeding tube.There was no documented evidence in Resident 67's clinical record to indicate that the facility attempted to clarify the physician's orders for the medications listed above to indicate if the medications should be given through his feeding tube or by mouth.Interview with the Director of Nursing on November 20, 2025, at 8:38 a.m. revealed that Resident 67 takes some of his medications by mouth and some by way of his feeding tube per his preference.Interview with Resident 67 on November 20, 2025, at 10:13 a.m. revealed that he does not take any of his medications by mouth. He indicated that all of his medications are crushed and administered by way of his feeding tube because he cannot swallow.Interview with Licensed Practical Nurse 3 on November 20, 2025, at 10:14 a.m. confirmed that Resident 67 does not take any medications by mouth. She indicated that all of his medications were crushed and given by way of his feeding tube. She indicated that his Gabapentin had been recently changed to the 600 mg tablet that could be crushed.Interview with the Director of Nursing on November 20, 2025, at 10:37 a.m. confirmed that the physician's orders for Resident 67's medications listed above, should have been clarified to indicate if the medications should have been given through his feeding tube or by mouth, and they were not.28 Pa. Code 211.12(d)(1) Nursing Services.

Based on observations and resident and staff interviews, it was determined that the facility failed to serve food that was palatable to residents.Findings include:Interview with Resident 1 on November 17, 2025, at 1:33 p.m. revealed that he did not like the food because the meat and potatoes were always over cooked and tough to chew.Interview with Resident 94 on November 17, 2025, at 1:19 p.m. revealed that the meat was very tough, and at times she could not eat what was served. She said that the meat was usually dry and too tough to cut or chew. Observations in the kitchen on November 20, 2025, at 12:23 p.m. revealed that the lunch meal consisted of Salisbury steak, scalloped potatoes, mixed vegetables, and gelatin. These items were placed on a test tray at 12:30 p.m. and tasted for palatability. The Salisbury steak was covered with gravy, hard and crispy around the edges and tough to cut. Interview with the Dietary Manager on November 20, 2025, at 12:33 p.m. confirmed that the Salisbury steak was harder and crispy on the edges. She indicated that the oven does not heat evenly, and one side is hotter than the other. She believed that is why the edges get hard and indicated that the edges of the food often get done before the middle.28 Pa. Code 211.6(b) Dietary Services

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include:The facility's policy related to sanitation, dated July 28, 2025, revealed that all equipment, food contact surfaces and utensils would be washed to remove or completely loosen soils by using manual or mechanical means necessary, and sanitized using hot water and/or chemical sanitizing solutions. Manual washing and sanitizing would employ a three-step process for washing, rinsing and sanitizing: scrape food particles and wash using hot water and detergent; rinse with hot water to remove soap residue; and sanitize with hot water or chemical sanitizing solution.Observations in the kitchen on November 17, 2025, at 9:08 a.m. revealed that the three-compartment sink was being used and there were utensils and pans drying on the counter; however, the sanitizer log, dated November 2025, revealed that there was no documented evidence that temperature/chemical checks were being done for each meal from November 11, 2025 through breakfast on November 17, 2025.Interview with the Dietary Manager on November 17, 2025, at the time of the observation, confirmed that there was no documented evidence that temperature/chemical checks were being done for each meal from November 11, 2025, through breakfast on November 17, 2025.28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bell was within reach for one of 46 residents reviewed (Resident 85).Findings include: Review of the facility's call bell policy, dated July 28, 2025, indicated that the call light was to be accessible to the resident when in bed.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 85, dated October 31, 2025, revealed that the resident could make herself understood and understand others, required assistance from staff for care needs, was incontinent of bowel and bladder, and had diagnoses that included seizures and stroke. A care plan for Resident 85, dated October 26, 2025, indicated that the resident was at risk for falls due to impaired mobility, and the call bell was to be in reach.Observations of Resident 85 on November 17, 2025, at 11:10 a.m. revealed that the resident was laying on her bed requesting pain medication. Her call bell was positioned on the top of the bed, above her and out of reach. When she was asked where her call bell was, she indicated that she did not know.Interview with Registered Nurse Supervisor 1 on November 17, 2025, at 11:16 a.m., confirmed that the tap call bell should have been over her lap so that she could reach it.Interview with the Director of Nursing on November 18, 2025, at 10:12 a.m. confirmed that Resident 85's call bell should have been within reach.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 46 residents reviewed (Resident 67). Findings include:The facility's policy regarding controlled substance disposal, dated July 28, 2025, indicated that when a fentanyl patch was removed from a resident, the patch was to be folded in half with the adhesive attaching to the adhesive, and the patch was placed in inert material, such as cat litter, to render the mixture unusable in the presence of two licensed personnel. The disposal was to be documented per the facility policy.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated September 30, 2025, revealed that the resident was cognitively intact, was scheduled routine pain medications, had complaints of difficulty or pain when swallowing, had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable or has difficulty eating or drinking by mouth) and received tube feedings, was on a mechanically altered diet, received opioid medications (a controlled pain medication), had a tracheostomy (surgical incision in the neck that creates an opening into the windpipe), and had diagnoses including chronic respiratory failure (blood does not have enough oxygen and causes difficulty breathing), malignant neoplasm of the oropharynx (throat cancer), acquired absence of the larynx (connects the throat to the windpipe and plays a role in swallowing, breathing and speech). Physician's orders for Resident 67, dated October 3, 7, and 8, 2025, included orders for the resident to receive 25 micrograms (mcg) of Fentanyl transdermal patch (a narcotic pain medication administered through the skin) to be applied every 72 hours for pain and removed per schedule.Physician's orders for Resident 67, dated October 8, and 22, 2025, and November 6 and 12, 2025, included an order for the resident to receive 50 mcg of Fentanyl transdermal patch to be applied every 72 hours for pain and remove per schedule.Observations of Resident 67 on November 18, 2025, at 9:40 a.m. revealed Licensed Practical Nurse 2 came into the resident's room to administer his a.m. medications. She removed the fentanyl patch from the right side of his chest area, rolled the patch up in her glove and discarded it in the resident's waste basket. She then applied the new patch to his left chest area and left the room. The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 67, dated October and November 2025, revealed that a Fentanyl patch was applied to the resident on October 3, 7, 9, 12, 15, 19, 22, 25, 28, and 31, 2025; and on November 3, 6, 9, 12, 15 and 18, 2025. There was no documented evidence that two staff members witnessed and signed that the old patch was destroyed after removal on these dates.Interview with Licensed Practical Nurse 2 on November 18, 2025, at 10:17 a.m. confirmed that she should not have discarded Resident 67's fentanyl patch in his waste basket. She indicated that she should have discarded it in the sharps container.Interview with the Registered Nurse Supervisor 1 on November 18, 2025, at 1:25 p.m. indicated that narcotics were to be disposed of in the drug buster. Fentanyl patches would be initialed and dated when applied, would have two nurses initial for disposal of the patch, and it would be placed in the drug buster as well.Interviews with the Director of Nursing on November 18, 2025, at 3:25 p.m. and November 20, 2025, at 10:39 a.m. confirmed that the Fentanyl patch for Resident 67 should not have been discarded in the resident's waste basket and should have been disposed of in the drug buster and witnessed by two nurses, and also confirmed that there was no documented evidence that two staff members witnessed and signed that Resident 67's old patches were destroyed after removal on the above-mentioned dates.28 Pa. Code 211.9(a)(h) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from accidents that resulted in injury for one of 46 residents reviewed (Resident 46). This deficiency is being cited as past non-compliance.Findings include:The facility's Assistive Devices and Equipment policy, dated July 28, 2025, indicated that residents who did not self-propel, should have leg rests on their wheelchair when being transported. admission paperwork for Resident 46, dated October 14, 2025, revealed that the resident was admitted to the facility on [DATE], from the hospital with a diagnosis of Covid pneumonia, stasis dermatitis of bilateral lower extremities, and also had a history of trans ischemic attack (mini-stroke). Resident on two liters of oxygen via nasal cannula. She was alert and oriented and required assistance from two staff members for care. Resident 46 utilized a walker or a wheelchair for mobility.An incident note for Resident 46, dated November 10, 2025, revealed that the resident was being transported back to the resident's room in her wheelchair by an activity aide. She then dropped her feet onto the floor with the wheelchair in motion and fell forward out of the wheelchair onto floor. She had bleeding from her nose and upper lip. Interview with Resident 46 on November 17, 2025, at 1 p.m. stated that the footrests were not in place on her wheelchair at the time of the fall. A written statement by the activity aide, dated November 10, 2025, revealed that Resident 46 was in the dining room for Bingo and stated that she needed to go to the bathroom. She pushed the resident back to her room; she put feet on the floor and fell out of the wheelchair. An interview with the Director of Nursing on November 19, 2025, at 10:10 a.m. confirmed that Resident 46 did not have her leg rests on her wheelchair during transport, and that she should have been transported with her leg rests on the wheelchair.Following the incident on November 10, 2025, the facility's corrective actions included:1. On November 10, 2025, the resident was immediately assessed, and x-ray and neurological checks were initiated per facility protocol. Care was provided to the resident for a minor nasal abrasion. The Activity Aide was immediately suspended pending the investigation and was re-educated on proper wheelchair transport procedures prior to her return to duties.2. On November 10, 2025, facility wide audit conducted of all wheelchairs to ensure that each had properly attached and functional leg rests and footrests. Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting held on November 11, 2025, to review the incident, identify root causes, and develop corrective and preventative measures.3. Education records, dated November 12, 2025, revealed that all of the facility's nursing, Activities, Therapy, and Support department staff received re-education regarding proper wheelchair use and transport safety. Ensuring leg rests and footrests are in place before transport and responding safely to residents' toileting requests. Safe transport procedures have been incorporated into the new employee orientation. The Falls Performance Improvement Project (PIP) would continue to track all fall-related incidents, including those involving wheelchair transport, for trend analysis. Any future incidents involving equipment misuse or unsafe transport would be reviewed through the QAPI process for systemic improvement.4. The Director of Rehabilitation or designee will conduct daily audits for one week and weekly audits for three weeks to observe at least three random resident transports per unit weekly, ensuring compliance with wheelchair safety and transport. Ongoing compliance will be verified through the facility's monthly Quality Assurance Performance Improvement (QAPI) committee.Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on November 12, 2025.This deficiency was being cited as past non-compliance.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 46 residents reviewed (Resident 6). Findings include: The facility's policy regarding podiatry services (specialized foot care), dated July 28, 2025, indicated that the residents were to receive the appropriate care and treatment in order to maintain mobility and foot health. Overall foot care included the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes, peripheral vascular disease, immobility, etc.). An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 18, 2025, indicated that the resident was alert and oriented, dependent on staff for daily care needs, and had a diagnosis of diabetes (disease that interferes with blood sugar control). A podiatry note, dated May 16, 2025, revealed that Resident 6 was seen for routine podiatry care and his chief complaint was onychomycosis (a fungal infection of the nail causing them to become discolored, thick and brittle). A recommendation was made for Resident 6 to have routine podiatry care again in 12 weeks and he was placed on the podiatry list to be seen on September 12, 2025. Observations on November 17, 2025, at 10:45 a.m. revealed that all of Resident 6's toenails were mycotic and approximately one-quarter inch over the ends of his toes, and both great toes were wrapped with a dry dressing. There was no documented evidence that Resident 6 received podiatry care on September 12, 2025. Interview with the Director of Nursing on November 19, 2025, at 12:06 p.m. confirmed that Resident 6 should have received podiatry care when the podiatrist visited the facility on September 12, 2025, and he did not. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 46 residents reviewed (Resident 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 31, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs and had diagnoses that included anxiety, dementia and psychosis (a mental state involving a loss with reality with symptoms of delusions and hallucinations). Physician's orders, dated April 25, 2025, included an order to discontinue Resident 7's quetiapine (an antipsychotic medication). A care plan for Resident 7, dated June 12, 2025, indicated that the resident was at risk for adverse effects related to the use of antipsychotic medication. Interview with the Director of Nursing on November 19, 2025, at 1:25 p.m. confirmed that Resident 7's care plan should have been revised when her quetiapine was discontinued, and it was not. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for dental needs for one of 46 residents reviewed (Resident 89). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated September 16, 2025, indicated that the resident was alert and oriented, and required assistance for daily care, including oral care.A physician's order for Resident 89, dated November 2025, revealed that the resident was scheduled for dental extractions in January 2026 and that she required pre-testing for extractions in December 2025.There was no documented evidence that a care plan was developed to address Resident 89's care needs related to her dental problems.An interview with Resident 89 on November 17, 2025, at 11:38 a.m. revealed that the resident had multiple teeth missing, had obvious dental carries, as well as misaligned front teeth. She indicated that she was in need of dental care to pull several teeth.An interview with the Director of Nursing on November 19, 2025, at 11:12 a.m. revealed that there was no care plan in place regarding Resident 89's dental needs and that there should have been.28 Pa. Code 211.10 (a)(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for five of 48 residents reviewed (Residents 46, 68, 71, 83, 122). Findings include: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 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 46 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 14 days after admission.An admission MDS assessment for Resident 68 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 22 days after admission.An admission MDS assessment for Resident 71 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 14 days after admission.An admission MDS assessment for Resident 83 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 14 days after admission.An admission MDS assessment for Resident 122 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 15 days after admission.Interview with the Director of Nursing on November 20, 2025, at 1:48 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on a review of facility policies, clinical records, and information submitted by the facility, as well as resident and staff interviews, it was determined that the facility failed to promptly take measures necessary to protect residents from verbal and physical abuse after abuse was identified for two of 47 residents reviewed (Residents 71, 73). This failure placed the residents in immediate jeopardy due to the actual verbal and physical abuse that already occurred, as well as the potential for further verbal and physical abuse to occur. Findings include: Review of the facility's abuse policy, dated February 17, 2022, revealed that residents have the right to be free from abuse and neglect. Nursing notes, dated April 7, 2022, revealed that Resident 71 and Resident 73 arrived at the facility around the same time and were placed in the same room together. Resident 71 is the mother of Resident 73. Interview with Family Member 1 on December 6, 2022, at 1:45 p.m. revealed that Resident 73 had no power of attorney or legal guardian. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 71, dated November 12, 2022, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had behaviors such as physical and verbal aggression towards others, and had diagnoses that included dementia. Resident 71's care plan for verbal and aggressive behaviors towards Resident 73, dated May 24, 2022, indicated that staff would monitor her aggressive behaviors towards him. A quarterly MDS assessment for Resident 73, dated August 11, 2022, indicated that the resident was cognitively intact, required extensive assistance from staff for care, had a feeding tube (a tube surgically placed into the stomach for nutrition), had behaviors such as verbal aggression, and had diagnoses that included cerebral palsy (injury at birth that causes difficulty with movement, muscle tone and posture), dementia with behavioral disturbance (memory loss), and dysphagia (swallowing difficulties). An interview with Family Member 1 on December 6, 2022, at 1:45 p.m. revealed that he did not want his mother and brother separated and he felt that they should remain in the same room. He stated that his mother would never hurt his brother. He said that he knew that his mother had dementia, but he did not think that her having dementia would alter her thought process or her ability to deal with stressful situations. He stated that Resident 73 was independent, enjoyed going for walks, was social in his neighborhood, and enjoyed going out to eat at restaurants. In December 2021 Resident 73 got COVID and became very ill. He was intubated and ended up with a feeding tube as well. He said that Resident 73 deteriorated significantly but because of his intellectual disabilities, Resident 73 does not understand what has happened to him or that he is not able to go home or go out to eat or just walk around anymore. A nursing note for Resident 73, dated April 18, 2022, revealed that he had displayed verbal behaviors such as yelling out. A nursing note, dated April 21, 2022, revealed that Resident 73 was yelling out and threatening staff saying that he did not like anyone there and would get them all in serious trouble by saying they did sexual things to him. Staff were unable to calm him as he yelled, and he began to call the staff names. A nursing note for Resident 71, dated April 19, 2022, revealed that she did not want to be moved to another room away from Resident 73 (her son), despite the yelling and arguing between them. A nursing note for Resident 73, dated April 25, 2022, revealed that he was evaluated by speech therapy and determined that he was not safe to eat foods and that he would continue to require the feeding tube. His sister stated that she understood but still wanted him to have food. A nursing note for Resident 73, dated May 1, 2022, revealed that his family requested he be served food regardless of his risk of aspiration (choking on the food). A nursing note, dated May 6, 2022, revealed that Resident 73 was yelling out and Resident 71 began yelling at him, which increased his behaviors. A nursing note for Resident 71, dated May 6, 2022, revealed that she was antagonizing Resident 73 when he was quiet and was heard saying piss your pants, that will get them in trouble. She was very argumentative with caretakers. A nursing note for Resident 73, dated May 6, 2022, revealed that he was yelling out and the nurse heard Resident 71 yell shut up you retard at him. A nursing note for Resident 73, dated May 7, 2022, revealed that he screamed continuously the entire shift and redirection and medication were ineffective. A nursing note for Resident 73, dated May 8, 2022, at 3:58 a.m. revealed that he yelled out the entire shift and was not able to be redirected. Other residents were upset and mad that they could not sleep. A nursing note for Resident 73, dated May 8, 2022, at 10:01 a.m. revealed that he was medicated to calm him, and that Resident 71 was found giving him drinks of water, despite his inability to swallow safely and the physician's order to not give him anything by mouth. A nursing note, dated May 12, 2022, revealed that Resident 73 and Resident 71 were yelling at each other and that despite the nurse's efforts she could not calm Resident 73. Resident 71 was very agitated and was telling Resident 73 to shut up, shut the hell up, these people hate you and don't want to come in because of you. When asked what she needed, Resident 71 stated him to shut the hell up. She then yelled at Resident 73 I hate you, you're just a waste of time, shut the hell up you idiot. A social service note for Resident 73, dated May 13, 2022, revealed that she phoned his sister to request a family meeting to discuss his behaviors. A social service note for Resident 73, dated May 17, 2022, revealed that a family meeting was held with his siblings. An individual caregiver was recommended to the family, and they were to investigate that suggestion. The family was to update the social worker regarding a one-on-one care intervention. A nursing note for Resident 73, dated May 18, 2022, revealed that the nurse practitioner recommended medication changes and discussed this with his sister. However, on May 19, 2022, his sister decided she did not want any medication changes and wanted the medication discontinued. A nursing note for Resident 73, dated May 21, 2022, revealed that he was very agitated and continually screamed out all shift and was not able to be redirected. He continued to yell out all shift and began to make comments that his mother masturbated him and that he would say staff touched him sexually to get everyone in trouble. He could not be redirected. A nursing note for Resident 73, dated May 24, 2022, revealed that he continuously yelled throughout the shift and that he was not able to be consoled. He yelled at staff and called them names and yelled at Resident 71 as well. A nursing note for Resident 73, dated June 1, 2022, revealed that he continuously yelled out and had attention seeking behaviors. Resident 71 was overheard yelling shut up you retard to Resident 73, which aggravated him more. When the nurse attempted to educate Resident 71 that she should not call him a retard, she replied, I call them like I see them. A nursing note for Resident 71, dated June 16, 2022, revealed that she was having an increase in behaviors and was trying to pull Resident 73 out of bed. She was confused and not easily redirected. Staff phoned her daughter to try to redirect and that was unsuccessful. A nursing note for Resident 73, dated June 23, 2022, revealed that he had increased yelling outbursts at staff and that numerous attempts to calm him were unsuccessful. At 8:15 p.m. the nurse charted that the resident could not be consoled and was continuing to yell and scream so much that he was sweating profusely. He was given one-on-one attention and care and he continued to scream. The family refused medication for behaviors. A nursing note for Resident 71, dated July 4, 2022, revealed that she was complaining of hand and wrist pain and was found to have slight bruising and swelling to the left hand and wrist. The licensed practical nurse stated that she observed Resident 71 slap Resident 73 across the face. A nursing note for Resident 71, dated July 5, 2022, revealed that the licensed practical nurse now stated she did not see her slap Resident 73, but she heard a slap sound and heard the resident say ouch. A nursing note for Resident 73, dated July 17, 2022, revealed that his family was feeding him food that was not pureed, which was his ordered consistency. A nursing note for Resident 71, dated July 26, 2022, revealed that she was cursing and yelling at staff and yelling at Resident 73 to shut up and called him stupid. A nursing note for Resident 73, dated July 31, 2022, revealed that he was demanding care from staff stating he was wet or soiled; however, when care was provided, he would be dry, and he would yell at the staff and call them swear words. He also continued to yell at his mother. A nursing note for Resident 73, dated August 8, 2022, revealed that he was yelling obscenities and upsetting other residents, unable to be calmed. A nursing note for Resident 73, dated August 11, 2022, revealed that he was found to have cookies that were not pureed and when staff removed them for his safety he yelled and swore loudly and continuously. The speech therapist sat with him and fed him the cookie to try to calm him; however, he continued to yell and scream. A social service's note for Resident 73, dated August 14, 2022, revealed that he was yelling out and Resident 71 called him crazy and told him to shut up. A nursing note for Resident 73, dated August 16, 2022, revealed that he was having behaviors and could not be redirected. Staff phoned his family for assistance, and they stated they would try to come in. A nursing note for Resident 73, dated August 19, 2022, revealed that his sister told nursing staff that she and her siblings had been bringing him regular consistency food in, not pureed, and she would like his diet changed to regular. His sister was educated that he is at risk of aspiration and the family should not bring him in regular foods. A nursing note for Resident 73, dated August 22, 2022, revealed that the nursing staff phoned his sister to inform her that he had medication changes to help with his anxiety and behaviors. A nursing note for Resident 73, dated August 25, 2022, revealed that his sister phoned and again requested his diet be changed to regular because she has been feeding him regular foods. She was informed he would need a test to determine if he was safe on regular foods and she agreed. She was educated that he required pureed foods and nectar thick liquids at that time. A nursing note for Resident 73, dated August 28, 2022, revealed that he returned from a doctor appointment with two cans of regular soda. The soda was placed in the refrigerator for later use. Later that evening the resident fell while screaming they took my pop. A nursing note for Resident 73, dated September 6, 2022, revealed that his sister was observed feeding him a regular can of soda and that she was aware he was not supposed to have it. A nursing note for Resident 73, dated September 15, 2022, revealed that his sister was in to visit and left him with regular pop in his room. A nursing note for Resident 73, dated October 15, 2022, revealed that he continuously yelled and demanded soda. Staff explained he could not have regular soda and he was angry and stated that his sisters gave him regular soda and so should they. A nursing note for Resident 73, dated October 9, 2022, revealed that he returned from the hospital and was yelling out. His brother phoned the nurses and requested that Resident 73 be medicated with calming medication due to his yelling out and having behaviors. A nursing note for Resident 73, dated October 10, 2022, revealed that his sister did not want him to have calming medications. A nursing note for Resident 73, dated October 17, 2022, revealed that his sister was upset because she believed the facility was over-medicating the resident and that he was sedated. She expressed anger regarding her brother making decisions regarding Resident 73's care. A nursing note for Resident 73, dated October 19, 2022, revealed that he was ordered an anti-emetic (vomiting) medication for calming, to be administered once every eight hours if needed. A nursing note for Resident 73, dated October 26, 2022, revealed that he called staff derogatory names and threatened to put a gun to their head and blow their brains out. A nursing note for Resident 73, dated November 10, 2022, revealed that he was yelling at Resident 71 when she placed her hands on his face and said, Shut up or I will claw your f*cking eyes out. She then pushed his face away. A nursing note for Resident 73, dated November 11, 2022, revealed that his brother did not want Resident 73 moved out of his current room that he shared with Resident 71. He stated that he would talk to his family about having a one-on-one come into the building. Resident 73's sister then phoned and stated she did not want a room move or to have Resident 73 separated from Resident 71. A nursing note for Resident 73, dated November 16, 2022, revealed that his siblings all agreed that Resident 73 could be medicated for his behaviors and that they did not want him separated from Resident 71. A nursing note for Resident 73, dated December 2, 2022, revealed that he had an increase in behaviors and that he and his mother continued to yell at each other, and they could not be redirected. Resident 73's sister was present, and they continued to yell. Despite the ongoing verbal abuse between Resident 73 and Resident 71, as well as nursing notes indicating that they observed physical contact between Resident 71 and Resident 73 when Resident 71 was agitated and frustrated with him, the facility allowed the residents to remain in the same room with each other. A care plan for Resident 71's verbal and aggressive behaviors towards Resident 73, dated May 24, 2022, indicated that staff would monitor her aggressive behaviors towards him; however, there was no documented evidence that her behaviors were monitored. According to the nursing notes above, staff were unable to redirect Resident 71 or calm her when Resident 73 was yelling out. There was no documented evidence that a care plan addressing Resident 73's behaviors towards his mother was developed until November 6, 2022, seven months after his behaviors began, and it had not been revised to reflect any new interventions since that time. There was no documented evidence that Resident 73's behaviors were being monitored. According to the nursing notes above, staff were never able to redirect him or calm him. During the interview with Family Member 1 on December 6, 2022, at 1:45 p.m., he also stated that he believes Resident 73 yells and screams all the time because he can no longer go home or out to eat or for a walk. He further said that he believes Resident 71 gets upset with Resident 73 because she must listen to him scream all day and all night. Family Member 1 stated that Resident 73 had no power of attorney or legal guardian. Family Member 1 stated that he was the power of attorney for Resident 71, and he thought that gave him the ability to make decisions for Resident 73 as well; however, his siblings were also making decisions for Resident 73, and they would often contradict one another. Family Member 1 stated he thought about getting guardianship for Resident 73, but he was unsure how to go about it and the facility never mentioned that that was an option or that it was important so that one person was making decisions while another family member changed the plan. The facility's failure to act upon the potential signs of physical and verbal abuse placed the residents in immediate jeopardy. The facility indicated that they had interventions in place and that Resident 71's and Resident 73's care plans were updated with interventions to prevent further abuse by either resident; however, a review of the care plans provided revealed that neither resident had any changes regarding their behaviors towards one another. Interview with Nurse Aide 4 on December 5, 2022, at 3:48 p.m. revealed that Residents 71 and 73 often yell at each other and that she tries to separate them; however, they do not like to leave their room. She said that there are family members that visit, but they are not able to get them to stop yelling at each other either. She said the family instigates the residents by bringing food and drink items in for Resident 73 that he cannot have because he is on pureed diet with thickened liquids, then Resident 73 gets angry when staff have to take the items. Then Resident 71 yells at them all. Interview with Nurse Aide 5 on December 5, 2022, at 3:52 p.m. revealed that Resident 71 and Resident 73 constantly yell at each other, and the staff are not able to redirect them. She stated that Resident 73 gets angry that Resident 71 yells at him and then he yells more. She said Resident 71 yells at Resident 73 and calls him names. Interview with Registered Nurse 6 on December 5, 2022, at 4:17 p.m. revealed that Resident 73 yells a lot and that Resident 71 yells and swears at him to shut up and calls him names. She said that recently a nurse aide came to get her because the nurse aide witnessed Resident 71 with her hands on Resident 73's neck telling him to shut up and calling him names. She said she wanted to separate the residents since they room together and constantly yell at one another, but administration told her she is not permitted to move either of them. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 6, 2022, at 12:20 p.m. related to the facility's failure to ensure that immediate and adequate safeguards were taken to protect Resident 73 from potential physical and verbal abuse perpetrated by his mother. Nursing staff observed multiple occasions of verbal abuse by both Resident 71 and 73, as well as Resident 71 getting frustrated and grabbing at or slapping at Resident 73 to get his attention and to tell him to shut up. The corrective action plan included the following interventions: The facility provided one-on-one supervision to monitor Residents 71 and 73 when together until an alternate plan was identified. The facility ordered immediate psychological and psychiatric evaluations for Residents 71 and 73. The facility provided immediate verbal education for staff on implementing abuse prohibition procedures to include: the definition of abuse, identifying abuse, immediate investigation of alleged abuse, reporting of abuse, signs and symptoms of sexual abuse, and protection of residents to prevent the potential for further abuse. Staff will be provided with verbal education on abuse on the beginning of their shift prior to having any contact with residents until all staff have been re-educated. Administrative staff conducted a facility-wide audit 30 days retroactively to identify other residents that were at risk of physical, verbal abuse, and/or psychosocial harm. Administrative staff will perform audits five times a week once a week for two weeks and monthly for two months of any reported/identified altercations between residents indicative of or may lead to abuse of any form. Staff were provided with immediate education on abuse. Following verification of the completion of this corrective action plan the immediate jeopardy was lifted at 3:00 p.m. on December 7, 2022. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on clinical record reviews as well as interviews with staff, it was determined that the facility failed to adequately monitor, assess, and provide the necessary and timely behavioral health care and services for residents exhibiting psychological and/or physical distress for two of 47 residents reviewed (Residents 71 and 73). Findings include: Nursing notes, dated April 7, 2022, revealed that Resident 71 and Resident 73 arrived at the facility around the same time and were placed in the same room together. Resident 71 is the mother of Resident 73. Interview with Family Member 1 on December 6, 2022, at 1:45 p.m. revealed that Resident 73 had no power of attorney or legal guardian. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 71, dated November 12, 2022, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had behaviors such as physical and verbal aggression towards others, and had diagnoses that included dementia. Resident 71's care plan for verbal and aggressive behaviors towards Resident 73, dated May 24, 2022, indicated that staff would monitor her aggressive behaviors towards him. A quarterly MDS assessment for Resident 73, dated August 11, 2022, indicated that the resident was cognitively intact, required extensive assistance from staff for care, had a feeding tube (a tube surgically placed into the stomach for nutrition), had behaviors such as verbal aggression, and had diagnoses that included cerebral palsy (injury at birth that causes difficulty with movement, muscle tone and posture), dementia with behavioral disturbance (memory loss), and dysphagia (swallowing difficulties). An interview with Family Member 1 on December 6, 2022, at 1:45 p.m. revealed that he did not want his mother and brother separated and he felt that they should remain in the same room. He stated that his mother would never hurt his brother. He said that he knew that his mother had dementia, but he did not think that her having dementia would alter her thought process or her ability to deal with stressful situations. He stated that Resident 73 was independent, enjoyed going for walks, was social in his neighborhood, and enjoyed going out to eat at restaurants. In December 2021 Resident 73 got COVID and became very ill. He was intubated and ended up with a feeding tube as well. He said that Resident 73 deteriorated significantly but because of his intellectual disabilities, Resident 73 does not understand what has happened to him or that he is not able to go home or go out to eat or just walk around anymore. A nursing note for Resident 73, dated April 18, 2022, revealed that he had displayed verbal behaviors such as yelling out. A nursing note dated April 21, 2022, revealed that Resident 73 was yelling out and threatening staff saying that he did not like anyone there and would get them all in serious trouble by saying they did sexual things to him. Staff were unable to calm him as he yelled, and he began to call the staff names. A nursing note for Resident 71, dated April 19, 2022, revealed that she did not want to be moved to another room away from Resident 73 (her son), despite the yelling and arguing between them. A nursing note for Resident 73, dated April 25, 2022, revealed that he was evaluated by speech therapy and determined that he was not safe to eat foods and that he would continue to require the feeding tube. His sister stated that she understood but still wanted him to have food. A nursing note for Resident 73, dated May 1, 2022, revealed that his family requested he be served food regardless of his risk of aspiration (choking on the food). A nursing note, dated May 6, 2022, revealed that Resident 73 was yelling out and Resident 71 began yelling at him, which increased his behaviors. A nursing note for Resident 71, dated May 6, 2022, revealed that she was antagonizing Resident 73 when he was quiet and was heard saying piss your pants, that will get them in trouble. She was very argumentative with caretakers. A nursing note for Resident 73, dated May 6, 2022, revealed that he was yelling out and the nurse heard Resident 71 yell shut up you retard at him. A nursing note for Resident 73, dated May 7, 2022, revealed that he screamed continuously the entire shift and redirection and medication were ineffective. A nursing note for Resident 73, dated May 8, 2022, at 3:58 a.m. revealed that he yelled out the entire shift and was not able to be redirected. Other residents were upset and mad that they could not sleep. A nursing note for Resident 73, dated May 8, 2022, at 10:01 a.m. revealed that he was medicated to calm him, and that Resident 71 was found giving him drinks of water, despite his inability to swallow safely, and the physician's order to not give him anything by mouth. A nursing note, dated May 12, 2022, revealed that Resident 73 and Resident 71 were yelling at each other and that despite the nurse's efforts she could not calm Resident 73. Resident 71 was very agitated and was telling Resident 73 to shut up, shut the hell up, these people hate you and don't want to come in because of you. When asked what she needed, Resident 71 stated him to shut the hell up. She then yelled at Resident 73 I hate you, you're just a waste of time, shut the hell up you idiot. A social service note for Resident 73, dated May 13, 2022, revealed that she phoned his sister to request a family meeting to discuss his behaviors. A social service note for Resident 73, dated May 17, 2022, revealed that a family meeting was held with his siblings. An individual caregiver was recommended to the family, and they were to investigate that suggestion. The family was to update the social worker regarding a one-on-one care intervention. A nursing note for Resident 73, dated May 18, 2022, revealed that the nurse practitioner recommended medication changes and discussed this with his sister. However, on May 19, 2022, his sister decided she did not want any medication changes and wanted the medication discontinued. A nursing note for Resident 73, dated May 21, 2022, revealed that he was very agitated and continually screamed out all shift and was not able to be redirected. He continued to yell out all shift and began to make comments that his mother masturbated him and that he would say staff touched him sexually to get everyone in trouble. He could not be redirected. A nursing note for Resident 73, dated May 24, 2022, revealed that he continuously yelled throughout the shift and that he was not able to be consoled. He yelled at staff and called them names and yelled at Resident 71 as well. A nursing note for Resident 73, dated June 1, 2022, revealed that he continuously yelled out and had attention-seeking behaviors. Resident 71 was overheard yelling shut up you retard to Resident 73, which aggravated him more. When the nurse attempted to educate Resident 71 that she should not call him a retard, she replied, I call them like I see them. A nursing note for Resident 71, dated June 16, 2022, revealed that she was having an increase in behaviors and was trying to pull Resident 73 out of bed. She was confused and not easily redirected. Staff phoned her daughter to try to redirect and that was unsuccessful. A nursing note for Resident 73, dated June 23, 2022, revealed that he had increased yelling outbursts at staff and that numerous attempts to calm him were unsuccessful. At 8:15 p.m. the nurse charted that the resident could not be consoled and was continuing to yell and scream so much that he was sweating profusely. He was given one-on-one attention and care and he continued to scream. The family refused medication for behaviors. A nursing note for Resident 71, dated July 4, 2022, revealed that she was complaining of hand and wrist pain and was found to have slight bruising and swelling to the left hand and wrist. The licensed practical nurse stated that she observed Resident 71 slap Resident 73 across the face. A nursing note for Resident 71, dated July 5, 2022, revealed that the licensed practical nurse now stated she did not see her slap Resident 73, but she heard a slap sound and heard the resident say ouch. A nursing note for Resident 73, dated July 17, 2022, revealed that his family was feeding him food that was not pureed, which was his ordered consistency. A nursing note for Resident 71, dated July 26, 2022, revealed that she was cursing and yelling at staff and yelling at Resident 73 to shut up and called him stupid. A nursing note for Resident 73, dated July 31, 2022, revealed that he was demanding care from staff, stating he was wet or soiled; however, when care was provided, he would be dry, and he would yell at the staff and call them swear words. He also continued to yell at his mother. A nursing note for Resident 73, dated August 8, 2022, revealed that he was yelling obscenities and upsetting other residents, unable to be calmed. A nursing note for Resident 73, dated August 11, 2022, revealed that he was found to have cookies that were not pureed and when staff removed them for his safety he yelled and swore loudly and continuously. The speech therapist sat with him and fed him the cookie to try to calm him; however, he continued to yell and scream. A social service's note for Resident 73, dated August 14, 2022, revealed that he was yelling out and Resident 71 called him crazy and told him to shut up. A nursing note for Resident 73, dated August 16, 2022, revealed that he was having behaviors and could not be redirected. Staff phoned his family for assistance, and they stated they would try to come in. A nursing note for Resident 73, dated August 19, 2022, revealed that his sister told nursing staff that she and her siblings had been bringing him regular consistency food in, not pureed, and she would like his diet changed to regular. His sister was educated that he is at risk of aspiration and the family should not bring him in regular foods. A nursing note for Resident 73, dated August 22, 2022, revealed that the nursing staff phoned his sister to inform her that he had medication changes to help with his anxiety and behaviors. A nursing note for Resident 73, dated August 25, 2022, revealed that his sister phoned and again requested his diet be changed to regular because she has been feeding him regular foods. She was informed he would need a test to determine if he was safe on regular foods and she agreed. She was educated that he required pureed foods and nectar thick liquids at that time. A nursing note for Resident 73, dated August 28, 2022, revealed that he returned from a doctor appointment with two cans of regular soda. The soda was placed in the refrigerator for later use. Later in that evening the resident fell while screaming they took my pop. A nursing note for Resident 73, dated September 6, 2022, revealed that his sister was observed feeding him a regular can of soda and that she was aware he was not supposed to have it. A nursing note for Resident 73, dated September 15, 2022, revealed that his sister was in to visit and left him with regular pop in his room. A nursing note for Resident 73, dated October 9, 2022, revealed that he returned from the hospital and was yelling out. His brother phoned the nurses and requested that Resident 73 be medicated with calming medication due to his yelling out and having behaviors. A nursing note for Resident 73, dated October 10, 2022, revealed that his sister did not want him to have calming medications. A nursing note for Resident 73, dated October 15, 2022, revealed that he continuously yelled and demanded soda. Staff explained he could not have regular soda and he was angry and stated that his sisters gave him regular soda and so should they. A nursing note for Resident 73, dated October 17, 2022, revealed that his sister was upset because she believed the facility was over-medicating the resident and that he was sedated. She expressed anger regarding her brother making decisions regarding Resident 73's care. A nursing note for Resident 73, dated October 19, 2022, revealed that he was ordered an anti-emetic (vomiting) medication for calming, to be administered once every eight hours if needed. A nursing note for Resident 73, dated October 26, 2022, revealed that he called staff derogatory names and threatened to put a gun to their head and blow their brains out. A nursing note for Resident 73, dated November 10, 2022, revealed that he was yelling at Resident 71 when she placed her hands on his face and said, shut up or I will claw your f*cking eyes out. She then pushed his face away. A nursing note for Resident 73, dated November 11, 2022, revealed that his brother did not want Resident 73 moved out of his current room that he shared with Resident 71. He stated that he would talk to his family about having a one-on-one come into the building. Resident 73's sister then phoned and stated she did not want a room move or to have Resident 73 separated from Resident 71. A nursing note for Resident 73, dated November 16, 2022, revealed that his siblings all agreed that Resident 73 could be medicated for his behaviors and that they did not want him separated from Resident 71. A nursing note for Resident 73, dated December 2, 2022, revealed that he had an increase in behaviors and that he and his mother continued to yell at each other, and they could not be redirected. Resident 73's sister was present, and they continued to yell. Despite the ongoing verbal abuse between Resident 73 and Resident 71, as well as nursing notes indicating that they observed physical contact between Resident 71 and Resident 73 when Resident 71 was agitated and frustrated with him, the facility allowed the residents to remain in the same room with each other. A care plan for Resident 71's verbal and aggressive behaviors towards Resident 73, dated May 24, 2022, indicated that staff would monitor her aggressive behaviors towards him; however, there was no documented evidence that her behaviors were monitored. According to the nursing notes above, staff were unable to redirect Resident 71 or calm her when Resident 73 was yelling out. There was no documented evidence that a care plan addressing Resident 73's behavior was developed until November 6, 2022, seven months after his behaviors began and it had not been revised to reflect any new interventions since that time. There was no documented evidence that Resident 73's behaviors were being monitored. According to the nursing notes above, staff were never able to redirect him or calm him. During the interview with Family Member 1 on December 6, 2022, at 1:45 p.m. he also stated that he believes Resident 73 yells and screams all the time because he can no longer go home or out to eat or for a walk. He further said that he believes Resident 71 gets upset with Resident 73 because she must listen to him scream all day and all night. Family Member 1 stated that Resident 73 had no power of attorney or legal guardian. Family Member 1 stated that he was the power of attorney for Resident 71, and he thought that gave him the ability to make decisions for Resident 73 as well; however, his siblings were also making decisions for Resident 73, and they would often contradict one another. Family Member 1 stated he thought about getting guardianship for Resident 73, but he was unsure how to go about it and the facility never mentioned that that was an option or that it was important so that one person was making decisions while another family member changed the plan. The facility indicated that they had interventions in place and that Resident 71's and Resident 73's care plans were updated with interventions to prevent further behaviors by either resident; however, a review of the care plans provided revealed that neither resident had any changes regarding their behaviors towards one another. Interview with Nurse Aide 4 on December 5, 2022, at 3:48 p.m. revealed that Residents 71 and 73 often yell at each other and that she tries to separate them; however, they do not like to leave their room. She said that there are family members that visit, but they are not able to get them to stop yelling at each other either. She said the family instigates the residents by bringing food and drink items in for Resident 73 that he cannot have because he is on pureed diet with thickened liquids, then Resident 73 gets angry when staff have to take the items. Then Resident 71 yells at them all. Interview with Nurse Aide 5 on December 5, 2022, at 3:52 p.m. revealed that Resident 71 and Resident 73 constantly yell at each other, and the staff are not able to redirect them. She stated that Resident 73 gets angry that Resident 71 yells at him and then he yells more. She said Resident 71 yells at Resident 73 and calls him names. Interview with Registered Nurse 6 on December 5, 2022, at 4:17 p.m. revealed that Resident 73 yells a lot and that Resident 71 yells and swears at him to shut up and calls him names. She said that recently a nurse aide came to get her because the nurse aide witnessed Resident 71 with her hands on Resident 73's neck telling him to shut up and calling him names. She said she wanted to separate the residents since they room together and constantly yell at one another, but administration told her she is not permitted to move either of them. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, by failing to adequately monitor residents' bowel function and to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A quarterly MDS assessment for Resident 41, dated November 24, 2021, revealed that the resident was cognitively impaired, required staff assistance for toileting, and was always incontinent of bowel. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 41's bowel records for December 2021 revealed that she did not have a bowel movement from December 11-19, 2021, (9 days) and December 21-24 (4 days), and the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Milk of Magnesia was administered on December 14 with an E for effective; however, there was no documented bowel movement in the resident's clinical record. There was no Milk of Magnesia administered between December 21-31, 2021; however, a suppository was administered on December 27 and was I ineffective and an enema was administered on December 27 and was I ineffective. A nursing note for Resident 41, dated December 27, 2021, indicated that her abdomen was very distended and that the registered nurse was made aware. A nursing note, dated December 28, 2021, indicated that she had complaints of abdominal pain, abdomen was distended and there were no bowel sounds present, and the registered nurse was notified. A nursing note, dated December 28, 2021, indicated that the resident had an x-ray of her abdomen and that there was some dilation of the large and small bowel loops (stretching) and possible fecal obstruction in the rectum. A nursing note, dated December 29, 2021, indicated that the resident continued to have a distended abdomen, medication administered was ineffective, and that staff will continue to monitor. A nursing note, dated December 29, 2021, indicated that the resident had another abdominal x-ray and that she had an ileus (blocked intestine and bowel movement is not able to move through this area) and that a nasogastric tube (NG tube - a tube inserted through the nose and into the stomach so that stomach and intestine contents can be pulled out because they will not pass through the intestines due to a block) was inserted. The resident was transferred to the hospital at that time and admitted with fecal impaction. emergency room records for Resident 41, dated December 29, 2021, indicated that the resident had grossly impacted rectal and distal sigmoid colonic fecal matter. Hospital records, dated December 30, 2021, indicated that Resident 41 had an NG tube placed and that she had air-filled dilated colonic and small bowel loops, distal colonic stool retention was significant. Hospital records for Resident 41, dated January 3, 2022, indicated that the resident had over two liters of bilious fluid (bile) taken out through the NG tube in 24 hours and that the physician performed manual disimpaction of stool at bedside with a large amount of solid stool coming out. She continued to receive enemas and had several more large bowel movements. Hospital records for Resident 41, dated January 4, 2022, indicated that she was diagnosed with chronic constipation and stercoral proctitis (stercoral proctitis is a rare life-threatening [CONDITION(S)] process involving the rectal wall secondary to chronic constipation and fecal impaction). Interview with the Director of Nursing on January 12, 2022, confirmed that Resident 41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 31's Medication Administration Records (MAR) and Treatment Administration Records (TARs), as well as the resident's clinical record revealed that there was no documented evidence that the resident's temperature was obtained as ordered during the daylight and/or evening shifts on January 9 and 10, 2022, and during the evening shifts on January 8, and 11, 2022. Interview with Registered Nurse 4 on January 12, 2022, at 12:00 p.m. confirmed that there was no documented evidence that Resident 31's temperatures were taken as ordered on the above listed dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to provide pain management for one of 49 residents reviewed (Resident 33), resulting in intolerable pain during care. Findings include: The facility's policy regarding pain management, dated (MONTH) 14, 2019, indicated that staff would implement the pain management program including evaluation/re-evaluation for residents experiencing either acute or chronic pain. The policy also indicated that pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. Staff were to obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated (MONTH) 8, 2019, revealed that the resident was cognitively intact, required limited assistance from staff for his care, and had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. six hours as needed for mild pain. physician's orders [REDACTED]. Resident 33's care plan for pain, dated (MONTH) 12, (YEAR), revealed that he had chronic pain related to his back and general discomfort, and that the physician was to be notified if his pain medication was ineffective. A care plan related to a risk of altered skin integrity revealed a goal for the resident not to develop new areas. A nursing note for Resident 33, dated (MONTH) 26, 2019, at 11:00 p.m. revealed that pain-relieving gel was applied to the second toe on the right foot. A nursing note dated (MONTH) 29, 2019, at 11:01 a.m. revealed that the resident had concerns regarding a scab to the second toe on his right foot, and the wound nurse was informed that the resident would like to see her. A wound nurse note for Resident 33, dated (MONTH) 1, 2019, at 2:34 p.m. revealed that the resident's right second toe was assessed due to a report that there was a scab. The area was 1.5 x 1.0 cm and was scabbed with some light serous exudate (a clear, thin, watery drainage). physician's orders [REDACTED]. Interview with Resident 33 on (MONTH) 6, 2019, at 9:36 a.m., in the presence of the Wound Care Coordinator and immediately prior to wound care being provided, revealed that he did not sleep well the night before because of the severe pain he had been experiencing in his toe. The resident stated, It kept me up most of the night. Observation of wound care to Resident 33's right second toe by the Wound Care Coordinator on (MONTH) 6, 2019, at 9:39 a.m. revealed that the toe was very red and swollen from the base of the toenail to the bottom of the toe. A brownish, partially opened, partially scabbed area (approximately dime sized) was noted in the middle of the toe. The wound nurse cleansed the resident's toe using a gauze pad that had been soaked with normal saline. While cleaning the wound, Resident 33 was throwing his head back and pounding his fists on the mattress, then grabbing his head and squeezing while rocking back and forth. The resident continued these actions while the wound nurse continued the wound care. She painted the wound with a [MEDICATION NAME] soaked swab, applying it onto the open/scabbed area using a repeated circular motion. A dry gauze pad was then placed on top of the toe. At no time during Resident 33's wound care did the Wound Care Coordinator offer to stop and check for pain medication. Interview with the Wound Care Coordinator on (MONTH) 6, 2019, at 9:50 a.m. confirmed that Resident 33 was experiencing severe pain and she should have stopped the treatment and offered to see about additional pain medication, but she knew that he already received his routine pain medication that morning. She confirmed that the wound on the right second toe had deteriorated since she examined it a week ago, and she would now need to notify the wound doctor. When asked if Resident 33's primary care doctor or the wound doctor were notified when she first assessed the wound on (MONTH) 1, 2019, she confirmed that neither were notified at that time, that the physician's orders [REDACTED]. Interview with Licensed Practical Nurse 18 on (MONTH) 6, 2019, at 10:03 a.m. revealed that she could administer 650 mg of Tylenol to Resident 33 because he had a routine dose of [MEDICATION NAME] that morning and it was too early for another dose, and he received [MEDICATION NAME] and a Salonpas patch that morning. A follow-up interview with Resident 33 on (MONTH) 6, 2019, at 12:00 p.m. revealed that he has had [MEDICAL CONDITION] pain (a result of damage to the peripheral nerves, often causing weakness, numbness and pain, usually in the feet) for a while now. The resident stated, This pain in my toe is worse than that, it's horrible. It's keeping me up at night, and I've asked to have the doctor look at it, but I don't think he was ever told. I get [MEDICATION NAME] regularly but it doesn't touch this pain. It felt like a knife being shoved in there when she was doing whatever she was doing this morning. I don't know how much more of this I can take. An interview with the Director of Nursing on (MONTH) 6, 2019, at 12:47 p.m. confirmed that if Resident 33's pain was worse than usual, then the physician should have been notified about it. She also confirmed that she spoke with the Wound Care Coordinator, who told her that Resident 33 had really bad pain during the treatment. Interview with Resident 33 on (MONTH) 7, 2019, at 9:54 a.m. revealed that he started having the pain again a short while ago and that the doctor still has not seen him. He once again confirmed that the pain he had yesterday was unbearable and that he's afraid he may lose his toe. The resident stated that the pain is so bad that he is not able to complete his therapy and that they seem to be pushing him when he is not able. He stated, If the pain wasn't so bad, I might be able to get through a therapy session. Interview with Certified Occupational Therapy Assistant (COTA) 16 on (MONTH) 7, 2019, at 11:42 a.m. confirmed that Resident 33 has not been able to complete some of his therapy treatments due to the pain in his right second toe, and there have been days recently when he refused to get out of bed because of the pain. As a result, therapy was not able to see him. She also stated that the area on his toe was noticed approximately two weeks ago as a scabbed area, and then it got angry looking and wound treatments were started. She confirmed that it is preventing him from progressing in his treatment. An occupational therapy note for Resident 33, dated (MONTH) 19, 2019, indicated that the resident was progressing well with therapy, was motivated to participate, and his maximum functional potential had yet to be achieved. An occupational therapy note dated (MONTH) 5, 2019, indicated that over the course of the last couple of treatment sessions the resident has been declining the use of the sit-to-stand lift due to developing a sore area to the second toe on the right foot. An occupational therapy note dated (MONTH) 6, 2019, indicated that discharge planning was completed consisting of a discussion of the appropriateness of using a sit-to-stand lift with staff now that the resident had a wound to the anterior side of the second toe. The therapist offered discharge now and to revisit continuing the use of the sit-to-stand lift when the wound was healed, or if he felt he would be able to continue treatment and begin using a sit-to-stand lift with staff primarily. Interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 6, 2019, at 1:45 p.m. revealed that they were not aware that the pain was affecting Resident 33's therapy treatment. The Director of Nursing indicated that Resident 33 was not a drug seeker and would not put on an act to obtain more pain medication. There was no documented evidence in Resident 33's clinical record to indicate that as of (MONTH) 8, 2019, at 3:00 p.m. a physician was notified about the wound on the right second toe (first noted on (MONTH) 26, 2019) or the change in condition with deterioration and increased pain. Interview with the Director of Nursing on (MONTH) 8, 2019, at 3:00 p.m. confirmed that she was not aware of any progress notes from Resident 33's primary care physician or wound physician to indicate that the resident was seen by either of them related to his toe. 42 CFR 483.25(k) Pain Management. Previously cited 8/17/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/17/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 5/11/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/17/19, 3/29/19, 2/13/19, 10/10/18, 10/1/18, 8/17/18, 7/19/18, 5/11/18.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified about potential side effects of anticoagulant therapy, resulting in a delay in treatment for [REDACTED]. Findings include: A [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 8, (YEAR), indicated that she was at risk for bleeding due to anticoagulant therapy (providing medication to thin the blood), and she was to have blood tests and medications as ordered by the physician and was to be observed for any bruising or bleeding. physician's orders [REDACTED]. The resident was also ordered to have blood drawn for a [MEDICATION NAME] time and international normalized ratio (PT/INR - blood tests that determine how long it takes the blood to clot) to monitor the therapeutic levels (appropriate range) of [MEDICATION NAME]. A laboratory report for Resident 2, dated (MONTH) 27, (YEAR), revealed that the resident's PT was 30.6 seconds (normal range is 9.4 to 12.5 seconds) and her INR was 2.8 (the therapeutic range for a person on [MEDICATION NAME] is 2.0-3.0). physician's orders [REDACTED]. However, there was no documented evidence that the PT/INR was completed on (MONTH) 30, (YEAR). A nursing note for Resident 2, dated (MONTH) 19, (YEAR), at 11:20 a.m. revealed that the resident had bruising to her right arm that measured 10.0 x 5.0 centimeters (cm) and the physician was notified. A physician's progress note dated (MONTH) 20, (YEAR), indicated that the resident's condition was to be observed. A nursing note for Resident 2, dated (MONTH) 21, (YEAR), at 7:55 a.m. indicated that the resident's family member was notified about a bruise on her left hip and right knee. There was no documented evidence that the resident was assessed by a registered nurse or that the physician was notified about these new bruises. A nursing note for Resident 2, dated (MONTH) 22, (YEAR), indicated that the resident had a moderate amount of bloody drainage from her PEG tube site. There was no documented evidence that the physician was notified about this change in the resident's condition. A nursing note for Resident 2, dated (MONTH) 24, (YEAR), at 10:35 a.m. indicated that the resident had a large, black-colored stool, her color was pale, she was diaphoretic (an unusual degree of sweating), and she was placed on oxygen at 5 liters per minute due to a low oxygen saturation level of 78 percent. A physician's orders [REDACTED]. A hospital physician's note for Resident 2, dated (MONTH) 24, (YEAR), indicated that upon arrival to the hospital it was noted that her INR was supratherapeutic (above a safe range) at 13.3, she was provided with fresh frozen plasma (a blood product used to treat conditions with low blood clotting factors) and vitamin K to reverse the bleeding time, and that her blood count (red blood cells) was low, which required a transfusion of two units of whole blood. A hospital physician's discharge summary for Resident 2, dated (MONTH) 1, (YEAR), indicated that the resident had a gastrointestinal (abdominal) bleed secondary to a 4 millimeter ulcer underneath her PEG tube site, [MEDICATION NAME] coagulopathy (a clotting defect caused by [MEDICATION NAME] that results in serious and/or life-threatening bleeding), acute blood loss resulting in [MEDICAL CONDITION] (low level of red blood cells), and acute kidney injury due to blood volume loss. Interview with Registered Nurse 2 on (MONTH) 10, (YEAR), at 8:20 p.m. revealed that the licensed practical nurse should have notified the registered nurse about Resident 2's new bruises on the hip and knee, and then the physician should have been notified. She also confirmed that the PT/INR tests ordered by the physician for (MONTH) 30, (YEAR), were missed and were never obtained, and the physician was not notified because this was not recognized until after Resident 2's admission to the hospital. Interview with Registered Nurse 1 on (MONTH) 10, (YEAR), at 8:15 p.m. confirmed that the physician should have been notified about Resident 2's new bruises and bleeding at the PEG tube site and there was no documented evidence that this was done. 42 CFR 483.10(g)(14)(i)-(iv)(15) Notify of Changes. Previously cited 12/26/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/11/18, 7/28/17, 6/8/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/17/18, 7/19/18, 5/11/18, 11/30/17, 7/28/17, 6/8/17. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 5/11/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/1/18, 8/17/18, 7/19/18, 5/11/18, 11/30/17, 7/28/17, 6/8/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/1/18, 8/17/18, 5/11/18, 7/28/17, 6/8/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/1/18, 8/17/18, 7/19/18, 5/11/18, 12/26/17, 11/30/17, 7/28/17, 6/8/17.

Based on clinical record reviews, facility accident/incident reports, manufacture's directions for use, and information submitted to the Department of Health, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer equipment and techniques were used for one of 27 residents reviewed (Resident 1) who required the use of a mechanical lift for transfers, resulting in a fall with a fracture. Findings include: An undated manufacturer's user instruction manual for the Joern's Hoyer Presence electric portable patient lift indicated that the intended use of the lifting device was for the safe lifting and transfer of an individual from one resting surface to another (such as bed to a wheelchair). Joern's Healthcare recommended that the transfer of a patient be fully risk assessed and conducted safely over a short distance only. The Hoyer Presence lift incorporated a 6-point cradle (metal frame that has hooks for a sling to attach to) as a standard and was designed to be used in conjunction with the Hoyer range of slings (the resident is placed in the sling, which is attached to the lift). Within the manual, a WARNING indicated important safety information for a hazard that might cause serious injury. A WARNING within the operative information section of the manual indicated DO NOT use a sling unless it is recommended for use with the lift, ALWAYS check that the sling is suitable for the particular patient and is the correct size and capacity, NEVER use a sling that is frayed or damaged, and ALWAYS fit the sling according to the instructions provided. Operating instructions for the use of the slings included a WARNING that Joern's Healthcare recommended that slings be checked regularly and particularly before use for signs of fraying or damage, DO NOT use slings that are worn or damaged, and that HOYER RECOMMENDS THE USE OF [MEDICATION NAME] HOYER PARTS. Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. The Hoyer Presence training video revealed that as the resident was being raised, staff were to confirm the secure attachment of the sling to the cradle. Manufacturer's direction for use regarding Invacare patient slings, dated 2013, indicated that only Invacare slings and accessories should be used on Invacare lifts. A quaterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 1, (YEAR), revealed that the resident was confused and was dependent with transfers. A current physician's orders [REDACTED]. A nursing note for Resident 1, dated (MONTH) 17, (YEAR), at 6:10 p.m. revealed that the resident fell during a transfer to bed from the shower chair. She had a small laceration to the hairline on the right forehead, above her eyebrow, and a laceration to the upper right shin and left outer ankle. A nursing note, dated (MONTH) 18, (YEAR), at 2:57 a.m. revealed that Resident 1's left knee was swollen and tender with manipulation, the physician would be notified in the morning, and staff would continue to observe for any other changes. A nursing note, dated (MONTH) 18, (YEAR), at 2:53 p.m revealed that the resident complained of pain and an X-ray was ordered. An X-ray report, dated (MONTH) 18, (YEAR), revealed that the resident had an acute (recent) distal femoral (area of the large leg bone closest to the knee) fracture. A facility investigation report, dated (MONTH) 17, (YEAR), at 5:55 p.m. revealed that Resident 1 was being transferred from a shower chair to bed with a mechanical lift, when the lift sling let go and the resident slowly fell to the floor. Information submitted by the facility on (MONTH) 17, (YEAR), revealed that Nurse Aide 6 stated that the bottom right strap must not have been secured properly. Interview with Nurse Aide 6 on (MONTH) 11, (YEAR), at 12:49 p.m. revealed that Resident 1 was lifted out of bed, put on the shower chair, and showered by a hospice aide. She was brought back after the shower, and while she was in the shower chair, he attached the sling to the lift bar (cradle) of the mechanical lift. He could not say that as the resident was being raised that he stopped and checked the sling on the lift bar for proper attachment. As the resident was being lifted up from the shower chair, he was not sure how far up, she began to slide and fell to the floor. Interview with Hospice Aide 7 on (MONTH) 11, (YEAR), at 12:15 p.m. revealed that she showered Resident 1 while she was in the shower chair and then returned her to her room. When she returned to the room Nurse Aide 6 attached the sling to the mechanical lift and started lifting the resident in the air. She stated that neither one of them re-checked the sling attachments as the resident was being raised. As she was being raised with the lift, the resident began to slide out. Interviews with the Nursing Home Administrator and observations on (MONTH) 10, (YEAR), at 10:06 a.m. and 12:48 p.m. revealed that he thought that Resident 1 fell from a Hoyer Quickfit sling and when he provided a sling for examination, observations of the sling at that time revealed that it was an Invacare lift sling, not a Hoyer lift sling. The Nursing Home Administrator thought that Invacare lift slings could be used with the Hoyer lifts. He confirmed that the facility only purchased Invacare lift slings and did not purchase any Joern's Hoyer lift slings. Interview with a representative of Joern's Technical Support on (MONTH) 11, (YEAR), at 11:40 a.m. revealed that it was recommended that Joern's products be used with other Joern's products, and they could not guarantee a product unless it was one of their own. Interview with the Director of Nursing on (MONTH) 11, (YEAR), at 1:26 p.m. confirmed that the lift sling should be rechecked for proper attachment as the resident was being raised in the lift. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 7/28/17, 6/8/17, 6/30/16, 5/27/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/28/17, 6/8/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/28/17, 6/8/17, 6/30/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/30/17, 7/28/17, 6/8/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/26/17, 11/30/17, 7/28/17, 6/8/17, 1/17/17, 11/7/16, 6/30/16, 5/27/16.

Based on review of policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of 27 residents reviewed (Resident 86) was free from non-consensual sexual contact perpetrated by other residents (Resident 65). Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 6, (YEAR), revealed that the facility's leadership prohibited mental, physical, and/or verbal abuse, and ensured that alleged violations involving abuse were reported immediately. All new and current employees, including volunteers, were to receive continuous education, training, and reinforcement that identify all aspects of abuse prohibition, including the prompt reporting of allegations without fear of reprisal. All alleged violations of abuse were to be reported verbally immediately to the facility abuse coordinator, the administrator, and to other officals in accordance with state law, including the State Survey Agency (Department of Health). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated (MONTH) 7, (YEAR), indicated that the resident was understood, could understand others, required limited assistance from staff for mobility throughout the facility, and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 30, (YEAR), indicated that the resident was at risk for wandering and the staff were to assist in reorientating the resident to her room and facility with verbal cues, encourage group activities and attempt to keep her occupied, and to monitor the resident's location with visual checks, at least every two hours. A nursing note for Resident 65, dated (MONTH) 4, (YEAR), at 6:40 a.m. revealed that the nurse witnessed the resident walking into three other residents' rooms, and she was re-directed each time. When asked what she was doing, the resident stated, Touching the patients. The nurse told the resident that she cannot go into other residents' rooms, and the resident stated, I know and walked away. The note indicated that the registered nurse supervisor was aware of this behavior. A nursing note for Resident 65, dated (MONTH) 4, (YEAR), at 4:07 p.m. revealed that the resident was observed walking into other residents' rooms, and she was re-directed each time. When the resident was asked what she was doing, she stated, Looking. The nurse told the resident that she cannot go into other residents' rooms and the resident stated, I know and walked away. The note indicated that the registered nurse supervisor was aware of this behavior, and the resident's behavior increased at this time. A nursing note for Resident 65, dated (MONTH) 6, (YEAR), at 3:41 a.m. revealed that the resident was witnessed at her roommate's bed with her hand inside the roommate's brief. Resident 65 was wearing a glove and the nurse aide told her to leave her roommate alone. An Investigation Worksheet for Resident 86, dated (MONTH) 6, (YEAR), indicated that the roommate (Resident 65) was observed by the nurse aide to have a gloved hand inserted in Resident 86's vagina. A nursing note for Resident 65, dated (MONTH) 7, (YEAR), at 8:49 a.m. written as a late note for (MONTH) 4, (YEAR), at 6:40 a.m. revealed that the resident stated that she was touching the patients, but the nurse did not witness the resident touching any other residents. There was no documented evidence that the registered nurse supervisor immediately reported her knowledge of the potential physical abuse by Resident 65 on (MONTH) 4, (YEAR). There was no documented evidence that an investigation of the potential abuse was initiated until (MONTH) 6, (YEAR), and no documented evidence that interventions were initiated to prevent Resident 65 from touching other residents until (MONTH) 6, (YEAR), when there was a witnessed incident that occurred involving the resident. An admission MDS assessment for Resident 86, dated (MONTH) 29, (YEAR), revealed that the resident was cognitively impaired and required extensive assistance with care. There was no documented evidence regarding how Resident 86 reacted to the incident of (MONTH) 6, (YEAR). However, based on the reasonable person concept, which accounts for how most people would react to a situation, a determination of actual harm to the resident was made, due to the reasonable person feeling humiliated by non-consensual sexual contact. Information provided by the facility in the form of a typed document that was undated and not signed, indicated that a psychiatric consultation was ordered for Resident 65, she was placed on every 15-minute observations during nights and mornings, and then she was placed on one-on-one supervision with staff and continues with one-on-one supervision. Re-education on the abuse policy was initiated for the licensed nursing staff, direct caregivers, and ancillary staff, with added education regarding documentation, behaviors, care plans and reporting behaviors. Interviews with the Nursing Home Administrator and Director of Nursing on (MONTH) 11, (YEAR), at 1:50 p.m. revealed that they were not made aware of any incidents with Resident 65 on (MONTH) 4, (YEAR), and were not aware of any issues with the resident until (MONTH) 6, (YEAR), when the witnessed incident occurred and they started an investigation at that time. Interview with the Director of Nursing on (MONTH) 11, (YEAR), at 3:00 p.m. confirmed that if they had been made aware of the incident with Resident 65 on (MONTH) 4, (YEAR), they would have started an investigation at that time. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/28/17, 6/8/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/28/17, 6/8/17, 6/30/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/30/17, 7/28/17, 6/8/17. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/30/17, 7/28/17, 6/8/17, 1/17/17, 5/27/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/26/17, 11/30/17, 7/28/17, 6/8/17, 1/17/17, 11/7/16, 6/30/16, 5/27/16.

Based on review of manufacturer's instructions, clinical records, and written safety information, as well as observations and staff interviews, it was determined that the facility failed to ensure that transfers using mechanical lifts were completed with lifts that were in a safe working condition for one of 23 residents reviewed (Resident R23), placing the safety of this resident, as well as 17 additional residents who used the mechanical lifts, in Immediate Jeopardy. Findings include: The manufacturer's instructions for the use of the Hoyer Presence mechanical lift (a device that uses hydraulic power to lift and transfer residents between surfaces), dated 2014, indicated in Section 4, Safety Precautions, to never operate the lift with loose or missing parts, or missing fasteners. Observations on June 5, 2017, at 12:15 p.m. revealed that a Hoyer Presence mechanical lift on the short hall of the Mellon Wing did not have a hanger bar sling retainer (a spring-loaded, disc-like device that is depressed to allow a sling loop to be attached to the lift, and when released it returns to a position of contact with the hanger bar hook and prevents the sling loop from coming off the hook), on one of two spreader bar arms (where the lift sling loop connects to the hanger bar hook). Observations on June 5, 2017, at 12:27 p.m. revealed that a second Hoyer Presence mechanical lift on the short hall of the Mellon Wing did not have a hanger bar sling retainer on one of the spreader bar arms, and the other spreader bar arm's spring loaded portion of the sling retainer was broken and would not allow the spring-loaded disc to return to its position of contact with the hanger bar hook. Interview with Nurse Aide 1 on June 5, 2017, at 12:32 p.m. confirmed that the two Hoyer Presence mechanical lifts located on the short hall of the Mellon Wing were used for 15 residents on the hall. Observations on June 5, 2017, at 1:41 p.m. revealed that a Hoyer Presence mechanical lift on the long hall of the Palmer Wing had a hanger bar sling retainer that would not allow the spring-loaded disc to return to its position of contact with the hanger bar hook (the spring loaded portion was not functioning). An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R23, dated April 7, 2017, revealed that the resident required total assistance with transfers. Interview with Nurse Aide 2 on June 5, 2017, at 1:43 p.m. revealed that the Hoyer Presence mechanical lift located on long hall of the Palmer Wing was used for three residents living on that hall, including Resident R23. She also indicated that the Hoyer Presence mechanical lift may also be used for other residents when performing monthly weights. Interview with Technical Support Representative 5, a representative of the mechanical lift's manufacturer, on June 5, 2017, at 1:50 p.m. revealed that not having the hanger bar sling retainer on the hooks of the Hoyer Presence mechanical lift was a safety issue because the sling retainer ensured that the lift sling loops were secured on the lift hooks and prevented the sling loops from coming off the hooks. He stated that the lift should not be used if any portion of the disc or the spring were broken or missing. Observations on June 5, 2017, at 2:06 p.m. revealed that Nurse Aides 2 and 8 transferred Resident R23 from her bed to her wheelchair using a Hoyer Presence full body mechanical lifts that had a broken hanger bar sling retainer, which would not allow the spring-loaded disc to return to its position of contact with the hanger bar hook. Interview with the Maintenance Director on June 5, 2017, at 2:30 p.m. revealed that he performed a monthly preventative maintenance check on each mechanical lift, which consists of movement, balance, wheels, electricity and wires. He stated he does not look at the sling retainer springs or O-rings (discs) during his monthly checks because he was unaware of this mechanism. Interview with the Director of Nursing on June 8, 2017, at 8:48 a.m. revealed that he and the Quality Assurance Committee were not aware that the Hoyer Presence mechanical lifts had broken or missing hanger bar sling retainers, or that the manufacturer's directions for use instructed that the Hoyer Presence mechanical lifts were not to be used with loose or missing parts, or missing fasteners. On June 5, 2017, at 2:05 p.m. the Nursing Home Administrator was informed that the health and safety of residents who used the Hoyer Presence mechanical lifts with missing and/or broken sling retainers was in Immediate Jeopardy, due to the mechanical lifts not being properly equipped with the required hanger bar sling retainers. The facility submitted and implemented a plan to ensure residents' safety by removing the three Hoyer Presence mechanical lifts from use, and using another type of mechanical lift that did not require the use the sling retainer instead. The plan also included educating the nursing staff to inspect the mechanical lifts prior to use and to not use mechanical lifts with missing or broken parts. On June 6, 2017, at 1:35 p.m. the facility completed education with approximately eighty percent of the nursing staff, and the remaining twenty percent were not to report to the nursing units for duty until after they received education. Based on approval of the facility's plan, the Immediate Jeopardy was removed at that time. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/30/16, 5/27/16, 4/28/15. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/7/17, 4/27/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/30/16, 4/27/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/27/16, 4/16/15. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/17/17, 11/7/16, 6/30/17, 5/27/16, 9/11/15, 8/26/15, 6/11/15, 4/28/15, 4/16/15.

Based on a review of clinical records, Department of Health files, and an abuse investigation report, as well as observations and staff interviews, it was determined that the facility failed to protect all 117 residents, residing in the facility during an investigation into a sexual abuse allegation, by keeping an exit door unlocked 24 hours a day, seven days a week constituting Immediate Jeopardy. Findings include: The Comprehensive Resident assessment dated [DATE], for Resident CR1, revealed that the resident could sometimes make herself understood, required extensive assistance for toileting and hygiene, required total assistance with bathing, was frequently incontinent of bowel and bladder, and had [DIAGNOSES REDACTED]. A nursing note dated 5/2/11 at 10:40 p.m., revealed that the resident was very pale, diaphoretic (excessive sweating caused by a medical emergency), short of breath, had rhonchi scattered (coarse rattling sound in the lungs, somewhat like snoring, usually caused by secretion in bronchial airways) in each lung, pulse was weak, and oxygen saturation was 81 to 83 percent (normal is greater than 95%) on room air. A physician's orders [REDACTED]. Hospital records dated 5/2/11 at 10:57 p.m., revealed that the resident arrived at the hospital with complaints of shortness of breath, pain to her groin area, and when the hospital staff attempted to place an indwelling urinary catheter, they identified bruising and bleeding of the vaginal area. A sexual assault report indicated that the resident had bruising and swelling on her labia majora (outside area of the female external genitalia), bruising and abrasions to the inner right vaginal wall, and a laceration/tear with bleeding to the posterior fourchette (the bandlike fold of skin, about one inch from the anus, forming the posterior margin of the external genitals of a female). A report submitted to the Department of Health from the facility dated 5/3/11, revealed that on 5/2/11 at 10:40 p.m., Resident CR1 was sent to the hospital due to respiratory and cardiac distress, and at 3:00 a.m., the Pennsylvania State Police arrived at the facility, at the request of the coroner, for a suspicious death and possible evidence of recent genital trauma. The facility's investigation report, submitted to the Department of Health on 5/11/11, did not indicate that any of the doors in the facility were checked to ensure that they were secure and did not allow any unauthorized person entry into the building. Observations on 5/9/11 at 9:30 a.m., 5/10/11 at 2:30 p.m., and on 5/11/11 at 10:45 a.m., revealed that an exit door, from the main dining room to an outside courtyard, was not locked and did not have an alarm that sounded when entering or exiting the door. The courtyard fence was approximately three feet high and had two unlocked, gated doors that manually opened to a service road, that surrounded the outside of the courtyard fence. There was a wooded hillside on the other side of the road. Anyone entering through the door from the outside courtyard had access into the unsupervised dining room and into an unsupervised hallway that ran between the nursing units, Rodgers Hall and Palmer Hall to the right and Mellon Hall to the left, as well as the main lobby, therapy, kitchen, and administrative areas. Interview on 5/9/11 at 9:30 a.m., with Nurse Aide 1 and the Maintenance Director, revealed that the exit door, from the main dining room to the outside courtyard in the back of the building, was kept unlocked at all times. They confirmed that the two gates on the courtyard fence were unlocked, could be opened by manually lifting up on the latch, and allowed anyone access to the building from outside. Interview on 5/11/11 at 11:00 a.m., with Registered Nurse 3, revealed that residents and families used the dining room door to go in and out, at any time throughout the day or night. Interview on 5/12/11 at 3:10 p.m., with Registered Nurse 4, revealed that she was aware that the dining room door was open at all hours of the day or night. She indicated that one day she went out another door and was locked outside; therefore, she just walked around the building and entered through the unlocked door from the outside courtyard, into the main dining room. Interview on 5/11/11 at 11:10 a.m., with the Administrator, revealed that the door from the main dining room to the outside courtyard was kept unlocked, 24 hours a day, seven days a week. She indicated that she did not look at this as a potential problem since it had been unlocked for years. The Administrator was informed on 5/12/11 at 4:15 p.m., that the health and safety of the residents were in immediate jeopardy due to the facility, upon receiving a sexual abuse allegation, not identifying that a door from the outside courtyard into the main dining room and hallway, was unlocked 24 hours a day, giving anyone access to the building and residents. The immediate jeopardy remained in place, with the state agency oversight on 5/12/11 and 5/13/11, until it was lifted on 5/13/11 at 2:56 p.m. 28 Pa. Code 201.14 (a) Responsibility of the licensee. 28 Pa. Code 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(3) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 5/2/11, 3/11/11.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified in a timely manner of a change in condition, for two of 44 residents reviewed (Residents CR1, CR2). Findings include: The comprehensive resident assessment, dated [DATE] for Resident CR1 indicated that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note and physician orders [REDACTED]. Review of vital sign (assessment of body functions) records from [DATE] through [DATE], revealed that the resident's temperature usually ranged from 96.2 to 98.8 degrees Fahrenheit, her pulse usually ranged from 64 to 96 beats per minute, her respirations usually ranged from 16 to 20 breaths per minute, and her blood pressure usually ranged from ,[DATE] to ,[DATE]. Interview on [DATE] at 2:45 p.m., with Nurse Aide 2, revealed that when she worked the 11:00 p.m. to 7:00 a.m. shift on [DATE], she started rounds at approximately 5:00 a.m., and found that the resident's forehead was pale and clammy (damp, moist), her temperature was 95.7 degrees Fahrenheit, her pulse was 115 beats per minute, her respirations were 16 beats per minute, and her blood pressure was ,[DATE], which she recorded on a vitals board (a clipboard kept at the nursing station where staff record the vital signs of all residents on the unit on one page) at the nursing station for the daylight shift and reported it to a licensed practical nurse. There was no documented evidence that the vital signs were recorded in the resident's clinical record. There was no documented evidence that the staff notified the physician of this change in condition or that they continued to monitor the resident's condition except for a nursing note on [DATE] at 10:30 a.m., that recorded a temperature of 95.4 degrees Fahrenheit. A late entry note dated [DATE] (four days later), for [DATE] for 5:00 p.m. and 8:00 p.m., completed by a licensed practical nurse, indicated that at 8:00 p.m., the resident had labored breathing (increased difficulty with breathing), skin was cool to touch, temperature was 94.7 degrees Fahrenheit, and following the resident's nebulizer treatment (a breathing treatment containing vaporized medication) at 8:00 p.m., the resident still had upper airway congestion. Interview on [DATE] at 3:20 p.m., with Nurse Aide 7, revealed that at the beginning of her shift on [DATE], between 3:00 and 3:15 p.m., the resident sounded "croupish" (loud, noisy respirations) and when the licensed practical nurse gave the resident her scheduled nebulizer treatment, the resident was unable to hold the nebulizer (the mouthpiece) up to her mouth, so they had to use a nebulizer mask instead. The resident refused dinner. Nurse Aide 7 indicated that she took it upon herself to report the resident's condition to the registered nurse supervisor at approximately 8:30 p.m. or 9:00 p.m., and asked her to come over to her unit to evaluate the resident. There was no documented evidence that the physician was notified of this change in condition or that the resident was assessed by a registered nurse on [DATE], at approximately 5:00 a.m., when the resident's vital signs were first identified to be abnormal, until 10:40 p.m., a period of 17 hours and 40 minutes, at which time the registered nurse found the resident to be very pale, diaphoretic (increased sweating), with shortness of breath and rhonchi in both lungs, weak, barely palpable (diminished) pulses, and decreased oxygen saturation (oxygen carried in the blood) of 81 to 83 percent. There was no documented evidence that the resident's lung sounds and respiratory status were assessed by a registered nurse, after the physician ordered treatment for [REDACTED]. Interview on [DATE] at 5:15 p.m., with Registered Nurse 6, confirmed that she did not assess the resident until approximately 10:00 p.m., when she found the resident with increased respiratory distress and had to transfer her to the hospital. Hospital emergency department records dated [DATE], indicated that the resident arrived at 10:57 p.m., with severe shortness of breath and an onset time of five hours ago, her pulse was 114, her blood pressure was ,[DATE], her breath sounds were diminished, and there was rhonchi present in both lungs. The records indicated that the resident had a critically high international normalized ratio (INR, a test that provides for interpretation of therapeutic blood clotting times) of 7.3 (normal range 0.8 to 1.1), a high [MEDICATION NAME] time (test that measures the time it takes for blood to clot) of 73.6 (normal range 9 to 12 seconds), a low hemoglobin (component of red blood cells that carries oxygen from the lungs to the tissues) of 8.6 mg/dl (measurement in milligrams per deciliter of blood with a normal range 11.6 to 15.9), a low hematocrit (percentage of total volume of red blood cells) of 26.8 mg/dl (normal range 34 to 48 mg/dl), a low red blood cell count of 2.88 mg/dl (normal range 3.84 to 5.24), and a high white blood cell count of 32.5 mg/dl (normal range 3.8 to 10.8 mg/dl). The records indicated that at 11:53 p.m., the resident's heart rate decreased and her blood pressure was unable to be obtained, and the resident expired at 11:55 p.m. A nursing data collection tool and [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Nursing notes dated [DATE] at 8:10 a.m., revealed that a facsimile was sent to the physician with a message that the resident had increased fatigue, was "not himself" per the family, had reddish-brown mucous with nose-blowing, and had continued diarrhea. At 10:00 a.m., the physician's office was called, and the above information was given to the office nurse to relay to the physician. At 12:15 p.m., Resident CR2's daughter was at the facility and requested that the resident be sent to the hospital. There was no documented evidence that the physician was notified of the resident's change in condition until the facsimile was received back at 12:30 p.m., four hours and twenty minutes after the change in condition was first identified, at which time an order was received from the physician to transfer the resident to the hospital. Hospital records dated [DATE], revealed that the resident had complaints of shortness of breath, was lethargic and unresponsive, appeared very unkempt (untidy, disheveled appearance), had [MEDICAL CONDITION] (swelling) of the lower extremities, had blood on the oral mucosa (lining) in his mouth. Laboratory test results revealed that his [MEDICATION NAME] time (a test that measures the time it takes for blood to clot) was 150 (normal range 9 to 12 seconds), and his international normalized ratio (INR, a test that provides for interpretation of therapeutic blood clotting times) was 15 (normal range 0.8 to 1.1). Interview on [DATE] at 10:40 a.m., with Registered Nurse 3 confirmed that she should have notified the physician of this change of condition sooner. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited [DATE]. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited [DATE], [DATE].