Every finding on record at Wecare at Monroeville Rehabilitation and NSG CTR

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for four of twelve residents (Residents R4, R5, R6, and R7).Findings include: Review of the Facility Assessment dated 3/17/26, indicated the facility will provide medication management. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/21/26, included diagnoses of sarcoidosis (inflammatory disease where the immune system forms swollen lumps of cells in various organs), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and asthma (condition where the airways narrow and swell). Review of a physician's order dated 6/17/26, at 4:31 p.m., indicated Resident R4 was to receive methocarbamol (muscle relaxant that works by calming overactive nerves in the body)500 mg (milligrams), two tablets (1000 mg) four times a day related to pain. The medication was scheduled to be received at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Review of a physician's order dated 6/17/26, at 4:16 p.m., indicated Resident R4 was to receive celecoxib 100 mg, twice daily for arthritis. The medication was scheduled to be received at 8:00 a.m. and 8:00 p.m. Review of a physician's order dated 6/17/26, at 4:25 p.m., indicated Resident R4 was to receive gabapentin (medication that can be used to treat nerve pain) 300 mg, one tablet at bedtime related to pain. Review of a physician's order dated 6/17/26, at 4:29 p.m., indicated Resident R4 was to receive Humalog insulin (injectable medication to treat high blood sugar) four units with meals and sliding scale coverage, before meals. The medication was scheduled to be received at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Review of a late entry progress note written by Registered Nurse (RN) Employee E3, dated 6/17/26, at 3:40 p.m. (created on 6/21/26, at 3:43 p.m.) indicated Resident's meds were not delivered until after 3-11 p.m. shift on June 17, 2026. Resident, DON (Director of Nursing) and family were notified. Review of Resident R4's Medication Admin Audit Report for 6/17/26, indicated RN Employee E3 administered the following:-5:00 p.m. Humalog documented as administered at 10:17 p.m.-5:00 p.m. methocarbamol documented as administered on 6/21/26, at 8:00 a.m.-8:00 p.m. celecoxib documented as administered on 6/21/26, at 8:00 a.m.-9:00 p.m. gabapentin documented as administered on 6/21/26, at 8:00 a.m.-9:00 p.m. methocarbamol documented as administered on 6/21/26, at 8:00 a.m. Review of Resident R4's progress notes did not include a reason for the omissions. Review of the facility provided inventory for the automated medication dispensing machine included Humalog, methocarbamol, celecoxib, and gabapentin. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (CAD, damage or disease in the heart's major blood vessels), diabetes, and high blood pressure. Review of a physician's order dated 6/4/26, at 3:54 p.m., indicated Resident R5 was to receive levofloxacin (antibiotic used for serious bacterial infections) for pneumonia (infection that inflames the air sacs in one or both lungs) 750 mg, to be given STAT. Review of a physician's order dated 6/4/26, at 3:55 p.m., indicated Resident R5 was to receive levofloxacin 750 mg for pneumonia, once per day, for six days, starting on 6/5/26. The medication was scheduled to be received at 9:00 a.m. Review of a progress note dated 6/4/26, at 4:30 p.m. indicated Resident R5 was sent to the hospital for evaluation respiratory distress (use of accessory muscles during respiration, intermittent cough), warm to touch, and weakness. Review of a progress note dated 6/5/26, at 2:25 a.m. indicated Resident R5 returned from the hospital. Review of Resident R5's Medication Administration Record (MAR) for June 2026 failed to include documentation that Resident R5 received her ordered levofloxacin on 6/5/26, at 9:00 a.m. The MAR did not include a reason for the omission. Review of Resident R5's progress notes did not include a reason for the omission. Review of the facility provided inventory for the automated medication dispensing machine included levofloxacin. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain), diabetes, and anxiety disorder. Review of a physician's order dated 6/24/26, indicated Resident R6 was to receive clonazepam (a medication to treat anxiety) three times per day. The medication was scheduled to be received at 9:00 a.m., 2:00 p.m., and 9:00 p.m. Review of a physician's order dated 6/25/26, indicated Resident R6 was to receive Humalog insulin on sliding scale coverage, before meals. The medication was scheduled to be received at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Review of Resident R6's MAR for July 2026 failed to include documentation that Resident R6 received his ordered Humalog on 7/1/26, at 7:30 a.m. and 11:30 a.m. and failed to include documentation that Resident R6 received his ordered clonazepam on 7/1/26, at 9:00 a.m. and 2:00 p.m. The MAR did not include a reason for the omission. Review of Resident R6's progress notes did not include a reason for the omissions. Review of the facility provided inventory for the automated medication dispensing machine included Humalog and clonazepam. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), epilepsy (disorder of the brain characterized by repeated seizures), and diverticulitis (condition when small pouches in the colon become inflamed or infected). Review of a physician's order dated 7/1/26, at 2:55 p.m. indicated Resident R7 was to receive doxycycline 100 mg (a medication to treat bacterial infections) twice per day. The medication was scheduled to be received at 8:00 a.m. and 8:00 p.m. Review of Resident R7's MAR for July 2026 failed to include documentation that Resident R7 received his ordered doxycycline on 7/1/26, at 8:00 a.m. The MAR did not include a reason for the omission. Review of Resident R7's progress notes did not include a reason for the omissions. Review of the facility provided inventory for the automated medication dispensing machine included doxycycline. During a follow-up communication on 7/5/26, at 3:15 p.m. the Nursing Home Administrator confirmed that the facility failed to implement procedures to ensure availability of prescribed medications for four of twelve residents. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 211.9(a)(1) Pharmacy Services28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care and personal hygiene care for two of four residents (Resident R1 and R2).Findings include: Review of the facility policy Wound Care dated 6/11/25, indicated wash and dry hands thoroughly. Put on clean gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Review of the facility policy Handwashing/Hand Hygiene dated 6/11/25, indicated use alcohol-based hand rub containing at least 62% alcohol and/or soap and water before handling clean or soiled dressings, gauze pads, etc.; After handling used dressings, contaminated equipment, etc.; The use of gloves does not replace hand washing/hand hygiene. Review of facility policy Enhanced Barrier Precautions dated 4/1/26, indicated enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO) to residents. EBPs are indicated for residents with wounds and/or indwelling medical devices (instruments or implants placed inside the body to remain for extended time to support, monitor, or treat medical conditions). Personal protective equipment (PPE) of gown and gloves are used during high-contact resident care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, or wound care. Observation of signage posted on Resident R1 and R2 room door indicated the need for enhanced barrier precautions. No signage was present related to contact precautions. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/28/26, included diagnoses of a hip fracture and aftercare needed after orthopedic surgery. Review of Section M: Skin Conditions indicated Resident R1 has surgical wounds. Review of Resident R1's baseline care plan initiated 6/24/26, failed to reveal a plan of care developed for enhanced barrier precautions. Review of Resident R1's comprehensive care plan in process on 7/5/26, failed to reveal a plan of care developed for enhanced barrier precautions. Review of a physician's order dated 6/25/26, indicated leave dressing in place for 5-7 days and then remove / may be changed as need for drainage, soilage, or saturation. One time a day for wounds. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and resistance to multiple antibiotics. Review of Section M: Skin Conditions indicated Resident R2 has diabetic foot ulcers. Review of Resident R2's baseline care plan initiated 6/22/26, failed to reveal a plan of care developed for enhanced barrier precautions. Review of Resident R2's comprehensive care plan in process on 7/5/26, revealed that Resident R2 required contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus, a type of staph bacterium that has developed resistance to many common antibiotics, including methicillin, penicillin, and amoxicillin) of a wound. Review of a physician's order dated 6/24/26, indicated Resident placed on contact precautions related to (mrsa) wound. Review of a physician's order dated 6/22/26, indicated Location (right foot) Clean wound with NSS (normal saline solution), pat dry, apply calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers), cover with 4x4 gauze, wrap with Kerlix (absorbent rolled bandage) and then ace wrap. During an observation of a wound dressing change on 7/5/26, at approximately 2:50 p.m. the following was observed:-Registered Nurses (RN) Employees E1 provided wound care without wearing a gown.-RN Employee E1 completed Resident R1's dressing change on his left upper thigh surgical wounds while Resident R1 was on a bedpan.-No clean field was present on the bed.-RN Employee E1 removed Resident R1's soiled dressings then reapplied clean dressings without changing gloves or performing hand hygiene. During an observation on 7/5/26, at approximately 2:55 Nurse Aide (NA) Employee E2 removed the bed pan and cleaned the remaining stool from Resident R1 without wearing a gown. During an observation of a wound dressing change on 7/5/26, at approximately 2:55 p.m. the following was observed:-RN Employees E1 provided wound care without wearing a gown.-No clean field was present on the bed, under Resident R2's foot.-RN Employee E1 removed Resident R2's dressing. Dressing was visibly soiled with drainage.-RN Employee E1 placed the soiled dressings on Resident R1's dresser, on an empty dressing wrapper.-RN Employee E1 cleaned Resident R2's wound with wound cleanser (order was for NSS), without changing gloves or performing hand hygiene.-RN Employee E1 looked through the clean dressing supplies items on the dresser top.-RN Employee E1 removed her right glove, and exited the room. RN Employee E1 was observed to be looking through the drawers of the treatment care just outside Resident R2's room door.-RN Employee E1 returned to the room, and placed the clean supplies on the dresser top next to the soiled dressing. Closer observation at this time revealed the clean supplies to be touching the soiled dressing.-RN Employee E1 donned a clean glove on her right hand, without performing hand hygiene.-RN Employee E1 reapplied a clean dressing. During an interview on 7/5/26, at approximately 3:15 p.m. the Nursing Home Administrator confirmed the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care and personal hygiene care for two of four residents.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.20(c) Staff development.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of eight residents (Resident R1 and R3).Findings include: Review of the facility policy Resident Rights dated 4/1/26, indicated that federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence be treated with respect, kindness and dignity, be free from abuse, neglect, access to people and services both inside and outside the facility. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/28/26, included diagnoses of a hip fracture and aftercare needed after orthopedic surgery. Review of Section C: Cognitive Patterns indicated that Resident R1 is cognitively intact. Review of Section H: Bladder and Bowel indicated Resident R1 is always continent of bladder and bowel. During an interview on 7/5/26, at approximately 11:00 a.m. Resident R1 stated that he is able to control his bowels, but has to wait a very long time when he requests to be put on the bed pan, and a very long time when he needs to be removed from it. Resident R1 stated that staff often put a brief on him for their convenience. He stated that he has had bowel movements in the brief, not due to uncontrolled bowel movements, but due to staff not responding when he needs to be put on the bed pan. Review of Resident R1's nurse aide documentation revealed that Nurse Aide (NA) Employee E2 documented on 7/5/26, at 12:26 p.m. Resident R1 was incontinent. During a second interview on 7/5/26, at 1:30 p.m. Resident R1 was asked if he had an episode of incontinence about an hour prior. Resident R1 stated that he had had a bowel movement, but it was in a bedpan. During an interview on 7/5/26, at 1:30 p.m. NA Employee E2 was asked if Resident R1 had an uncontrolled bowel movement or had used a bed pan. NA Employee E2 confirmed that Resident R1 had used a bed pan. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], included diagnoses of Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty), cirrhosis (chronic damage leading to scarring and failure) of the liver, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated that Resident R1 had moderate cognitive impairment. Review of Section H: Bladder and Bowel indicated Resident R1 is occasionally incontinent of bladder and frequently incontinent of bowel. During an observation on 7/5/26, at approximately 2:30 p.m. Resident R3 was observed in the dining room. Resident R3 was wearing a shirt with a large amount of food spillage on it. Fecal matter was visible on the back of Resident R3's pants and on the bottom portion of Resident R3's shirt. Resident R3 had greasy, unclean appearing hair and was extremely malodorous. During an observation on 7/5/26, at approximately 2:50 p.m. Resident R1 was observed to receive wound care and assistance with the bedpan with the room door open and the bed curtain only partially closed. Resident R3 was exposed from the waist down. During an interview on 7/5/26, at 3:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of eight residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility documents, clinical record review, observations, and resident interviews, it was determined that the facility failed to ensure a resident with limited mobility received assistance to maintain or improve mobility for one of three residents (Resident R1).Findings include: Review of the Facility Assessment documented 3/17/26, indicated the facility will provide care for residents with fractures and specialized rehabilitation services such as physical therapy. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/28/26, included diagnoses of a hip fracture and aftercare needed after orthopedic surgery. Review of Section C: Cognitive Patterns indicated that Resident R1 is cognitively intact. Review of Section GG: Functional Abilities indicated for Functional Range of Motion Resident R1 had impairment of both lower extremities. Review of Resident R1's baseline care plan initiated 6/24/26, indicated Resident R1 would receive physical therapy services. Review of an orthopedic surgery consultation report dated 7/1/26, indicated, Continue TDWB (can rest the foot on the floor for balance, but not put bodyweight on that leg), aggressive knee ROM (range of motion). During an interview on 7/5/26, at approximately 11:00 a.m. Resident R1 stated the doctor told him he needs to get out of bed every day to do his leg exercises. Resident R1 stated that he went out to the doctor on Wednesday (7/1/26) he has only been assisted out of bed for physical therapy, on Thursday and Friday (7/2/26, and 7/3/26). Resident R1 stated that he was not assisted out of bed on Saturday (7/4/26), and had not been assisted out of bed yet today. Resident R1 stated that when he told the nurse aides that he needed to get out of bed to do his range of motion exercises, he was told by staff that they did not know how to do that. Resident R1 confirmed that staff have not assisted him with range of motion exercises. During an interview on observation on 7/5/26, at 2:50 p.m. Resident R1 was in bed, and confirmed that he had not received assistance with range of motion exercises or assisted into his wheelchair to be able to complete any range of motion exercises on his own. During an interview on 7/5/26, at 3:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure a resident with limited mobility received assistance to maintain or improve mobility for one of three residents. 28 Pa. Code: 211.10(a)(c)(d) Resident Care Policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services

Based on observations, resident interviews, staff interviews, review of facility policies and Safety Data Sheets (standardized document that provides detailed information about the hazards, safe handling, storage, and emergency measures for chemical substances or mixtures), and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to have working laundry equipment to ensure clean and sanitized linens/laundry. This failure resulted in an Immediate Jeopardy for 67 of 67 residents in the facility.Findings include:Review of facility policy Departmental (Environmental Services) - Laundry and Linen dated 4/1/26, indicated this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General guidelines include:-consider all soiled linen to be potentially infectious and handle with standard precautions.-place any linen saturated with blood or body fluids into a leak-resistant bag before placed into a hamper.-handle soiled linen as little as possible to prevent agitation-prewash briefs, under pads, and any item soiled with feces, using the maximum setting of bleach/germicidal, then process through regular cycle.-clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.-Reprocess any linen that is not visibly clean upon competition of the cycle or any linen that falls on the floor.Review of facility policy Laundry and Bedding, Soiled dated 4/1/26, indicated soiled laundry/bedding shall be handled, transported, and processed to the best practices for infection prevention and control. All soiled laundry is handled as potentially contaminated using standard precautions (e.g. gloves and gowns when sorting). Washable pillows and pillow covers are laundered in hot water when soiled with bodily substances and before exchange between residents.Review of facility policy Enhanced Barrier Precautions dated 4/1/26, indicated enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO) to residents. EBPs are indicated for residents with wounds and/or indwelling medical devices (instruments or implants placed inside the body to remain for extended time to support, monitor, or treat medical conditions). Personal protective equipment (PPE) of gown and gloves are used during high-contact resident care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, or wound care.Review of Centers for Disease Control and Prevention recommendations for laundry and bedding (2024, May 1). G. Laundry and Bedding. Infection Control. https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html, indicated a temperature of at least 160 F (71 C) for a minimum of 25 minutes is commonly recommended for hot-water washing. Chlorine bleach becomes activated at water temperatures of 135 F-145 F (57.2 C-62.7 C).Review of the facility infection control information revealed the following infections were active in the facility for the months of April and May 2026: HIV (Human Immunodeficiency Syndrome), multiple Viral Hepatitis (infection that causes liver inflammation and damage), and various bacterial infections.During an Interview on 5/7/26, at 9:30 a.m. Confidential Employee E3 stated the facility did not have enough linen for the staff to complete resident care, and laundry takes the soiled linens once a day to wash them due to the washing machines not working.During an observation and interview on 5/7/26, at 9:36 a.m. Confidential Employee E2 was observed pushing a small metal laundry cart, uncovered, to the 200 Unit side linen cart. Confidential Employee E2 stated they have been using the two washing machines reserved for residents' use so staff have some linen available. They were unable to give a date the washers broke.During an observation on 5/7/26, at 9:40 a.m. Resident R9 was lying on a bare mattress while watching television. They did not have a pillow available, and no bed linens observed in the room.During an observation on 5/7/26, at 9:40 a.m. the laundry room was observed to have two washing machines not in use. The laundry area was noted to have a musty odor. The laundry chemicals were on the floor between the washers in the manufacturer's containers. During an interview on 5/7/26, at 9:40 a.m. Confidential Employee E1 stated the facility's two washing machines have not worked for three to four weeks. The two dryers were functioning properly. They stated staff have been using the two personal laundry machines and the Environmental Services (EVS) Director Employee E5 had taken some linens to the laundromat. When asked what laundry detergent was being used, they stated the staff use an empty 36-ounce plastic juice container to mix the facility's laundry detergent and de-stainer together, they eyeball the amount of detergent and de-stainer they add to the container and the amount that is used in each load of laundry. They were unable to give a date the washers broke. They confirmed the laundry is not covered between the laundry room and the personal laundry room, or when delivered to the nursing units.During an interview on 5/7/26, at 10:30 a.m. EVS Director Employee E5 stated he tried to help the facility out by taking soiled linen to the laundromat using his personal vehicle. He stated he put the soiled linens in a trash bag and would transport them in his personal vehicle; after washing, he transported the laundry back to the facility to use the facility's dryers. He stated he used the biggest washing machines at the laundromat and used the facility's laundry detergent and de-stainer that he transferred into empty laundry containers from home. He stated that he used approximately three cups of detergent and three cups of de-stainer for each load washed. When asked if the linens appeared clean after washing, he stated sometimes but some linens were stained and moldy from sitting so long. During an interview on 5/7/26, at 10:45 a.m. the Nursing Home Administrator (NHA) stated she was aware the facility washers were broken and rented a ten-foot U-Haul box truck to transport the soiled laundry to a sister-facility that had a washer they could use after hours.During observations on a subsequent visit on 5/19/26, at 9:00 a.m. through 11:00 a.m. the following was observed:-at 9:05 a.m. the resident laundry room door was noted to have a chair in the doorway preventing the door from closing, there was a soiled laundry smell noticed from the hallway. One washing machine had the lid open, full of assorted linens. The second washer was in process of washing bed pads and more linens. The personal laundry room smelled of soiled laundry that was noticeable in the hall.-at 9:15 a.m. the soiled linen door was not properly secured, upon opening the door a rancid aroma of musty clothing, soiled with bodily fluids and feces, was noted. The room contained multiple plastic bags of resident clothing.-at 9:17 a.m. Resident R9 was observed lying on the bare mattress watching television. No pillow was observed in the resident's room.-at 9:20 a.m. the 100 Back Hall was observed to have red bins outside of resident doors for soiled PPE (personal protective equipment - gowns, gloves, face mask, etc.). The red bins did not contain red bags to dispose of PPE to prevent cross-contamination (the transfer of disease-causing agents from one point to another) to other residents, staff, and visitors.-at 9:25 a.m. the soiled utility room was observed to have two red trash bins with black trash bags inside with hazardous waste red bags visible in the black bags.During an interview on 5/19/26, at 9:25 a.m. the Interim Director of Nursing (DON) confirmed the red bins for EBPs did not contain red bags, and confirmed the facility was throwing hazardous waste in the dumpster with regular trash.During a telephone interview on 5/19/26, at 9:30 a.m. Confidential Employee E14 stated when they got a clean gown for a resident there was dried feces smeared on it and some of dried feces fell on the floor off the gown.During an observation on 5/19/26, at 10:30 a.m. Maintenance Director Employee E8, EVS Director Employee E5, and Floor Tech Employee E9 were placing the residents' bagged laundry from the soiled linen room into garbage bags, stating they were going to take them to the laundromat. During an interview during the same time, EVS Director Employee E5 stated since the clothing was the residents' personal laundry, he thought it would be ok to take them to the laundromat.During an observation on 5/19/26, at 10:32 a.m. Resident R9 had a sheet on her mattress that had a large reddish-brown stain and did not appear to be laundered.During an interview on 5/19/26, at 10:45 a.m. Maintenance Director Employee E8 stated the water for the washing machines were set at 120 degrees Fahrenheit.During an interview and observation on 5/19/26, at 10:50 a.m. EVS Director Employee E5 stated the staff have been using an unmarked resident water pitcher to mix the laundry chemicals, half of the pitcher was used per laundry load.During an observation on 5/19/26, at 12:30 p.m. three small hazardous waste boxes were stored in a shed, ready to be picked up. Also stored in the same shed were 15 full oxygen tanks ready for resident use. The shed was unlabeled for oxygen storage or hazardous waste storage. The empty oxygen tanks were stored separately in a marked container.On 5/19/26, at 1:06 p.m., the Nursing Home Administrator was notified that the failure to implement proper infection control procedures regarding the potential for cross-contamination, hazardous waste disposal, and proper infection tracking. Immediate Jeopardy situation at F0880 L and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.This Immediate Jeopardy began on 4/17/26.On 5/19/26, at 2:30 p.m., the Interim Director of Nursing (IDON) was notified that the review of the Infection Control Tracking and Trending and Line Listing were reviewed and were not complete, with resident's being marked other with no known key as to what other meant. The IDON was unable to provide an answer and had to go back to the resident's clinical record to correctly identify what infections those residents marked with other had. This information was subsequently never provided to the survey agency.During an interview on 5/19/26, at 3:00 p.m. Laundry Employee E11 and Laundry Employee E12 stated they have been following what day shift was doing by using the personal washers and how much detergent and de-stainer was being used.During an observation on 5/19/26, at 3:05 p.m. a repair man was working on one washer and stated it would be fixed that day.The facility presented an acceptable action plan on 5/19/26, at 6:12 p.m.The facility's Plan of Correction contained the following:1. Linen has been transported via rented U-Haul to a sister facility with commercial washer and dryer as of 5/7/26, no linen or personal laundry has been taken to laundromat since 5/7/26, and staff are being re-educated not to use the personal laundry machines and on the correct laundering process. When asked if personal laundry could be taken to laundromat this morning NHA re-educated EVS and Maintenance not to use laundromat or personal washing machines. Red bins were placed outside infection precaution rooms as of 5/7/26. Red bags were replaced the morning of 5/19/26, the part came in and the vendor came out same day to fix washer. All residents will be supplied with appropriate and cleaned bedding and personal laundry. All laundry provided will be washed according to appropriate guidelines for contamination prior to being put back into use.2. EVS Director was educated on red bag process and infection prevention by Regional Infection Preventionist/Interim NHA on 5/9/26, at 11:50 a.m. All staff were sent hazardous waste and PPE education at 11:47 a.m. and is ongoing. Laundry staff are being educated on the proper chemicals, temperature, and process of washing linen, and to cease use of personal laundry equipment. EVS and Maintenance Director were educated on proper storage of hazardous materials. Education will be completed by noon on 5/20/26 and staff will be educated prior to next shift worked.3. Facility Interim DON was IP (infection preventionist) until 5/18/26. Facility tracker for infections is up to date as of 5/19/26. While new Interim ADON (Assistant Director of Nursing) is trained on IP the new Regional IP will perform IP duties.4. Red hazardous waste process audits will be conducted by the DON or designee every shift for one week, then weekly for four weeks. Facility laundering process will be audited by NHA or designee daily for five days, then weekly for four weeks. All residents will be assessed for potential for infections by DON or designee by 5/19/26. Infection tracking will be audited daily for five days then weekly for four weeks by Regional IP5. Results of audits will be reported at facility QAPI committee for review and recommendation. During interviews on 5/20/26, between 9:00 a.m. and 12:00 p.m. the following employees confirmed receiving education on infection control, proper PPE, hazardous waste in red bags for disposal, handwashing, and proper sanitation to prevent the cross-contamination of infectious materials, prior to beginning their shift, and were able to verbalize understanding of the educations:-Admissions Employee E25, -Nurse Aid (NA) Employee E15, -Therapy Employee E16, -Housekeeping Employee E10, -Licensed Practical Nurse (LPN) Employee E17, -LPN Employee E18, -NA Employee E19, -NA Employee E20, -LPN Employee E21, -LPN Employee E22, -Floor Tech Employee E9, -EVS Director Employee E5, -Maintenance Employee E8, -Housekeeper Employee E23, -Registered Nurse (RN) Supervisor Employee E24, -Therapy Employee E26., -Therapy Employee E27, -Therapy Employee E28, and -Therapy Employee E29.The survey team validated that Immediate Jeopardy was removed on 5/20/26, at 6:38 p.m., through observation, review of the facility training, and staff interviews following the facility's implementation of the plan for removal of the Immediate Jeopardy.During an interview on 5/21/26, at 1:00 p.m. the NHA and DON confirmed the facility' failure to maintain and infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases by failing to have working laundry equipment to ensure clean and sanitized linens/laundry created an Immediate Jeopardy situation for 67 of 67 residents. 28 Pa. Code 201.29(j)(k) Resident rights.28 Pa. Code 205.26(a)(b)(c)(d) Laundry.28 Pa. Code 207.2(a) Administrator's responsibility.28 Pa. Code 211.10(a)(b)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(4)(5) Nursing services.

Based on review of the facility policies, facility submitted data, clinical record and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from verbal and physical abuse which resulted in the harm of Resident R1 to be fearful of staff for one four residents reviewed (Resident R1).Finding include:Review of the facility policy Abuse and Neglect-Clinical Protocol dated 4/1/26, indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 4/20/26, included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), diabetes (chronic condition where your body either doesn't produce enough insulin or can't use it effectively), hemiplegia (severe or complete paralysis on one side) and high blood pressure. Review of Section C: Cognitive Patterns revealed a BIMS score of 11. Section GG, Question GG0130 for Self-Care reveals Shower/bathe self: Resident is marked 1 meaning dependent-helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Review of Resident R1's plan of care dated 4/20/26 reveals Focus- The resident has an ADL self-care performance deficit r/t Activity Intolerance, Hemiplegia, No current goal, Interventions-Shower/Bathe Self- Tues-Fri 7-3 (dependent).Review of facility submitted data, dated 4/17/26, indicated Resident R1 was receiving a shower from Nursing Assistant (NA) Employee E1 when she was abused in the shower. Resident R1 stated that NA Employee E1 sprayed water in her face and started to make derogatory comments to her, she also stated that she was being rough with her and grabbed her by both arms, leaving bruises to both wrists.Review of the information provided by the Nursing Home Administrator (NHA) and subsequent interview on 5/7/26, at approximately 12:30 P.M., did include that Resident R1 reported the incident to another department which in turn notified the Director of Nursing (DON), the facility identified a concern for potential verbal and physical abuse, suspended NA Employee E1 pending investigation, interviewed other residents the NA was assigned to and did skin checks on everyone in her assignment, revealing no other residents. The investigation also did not reveal that staff were interviewed regarding the incident or re-educated on abuse.During an interview on 5/7/26, at approximately 12:40 p.m. another resident that was interviewed but wishes to remain anonymous did not file a grievance or alert staff but stated that she too had been the recipient of verbal abuse with the NA that was suspended. NA Employee E1 was taking care of her the one day and had just changed her brief when the resident realized that she had wet the brief already, when she asked the NA to change her she was told I just changed you, now you have to wait two hours for me to come back. The resident also stated there was another incident where she needed to have a bowel movement and the NA told her, Just go in your brief, she told her she wasn't wearing one and the NA became upset with her and told her she should just let her lay in it. During interviews on 5/7/26, at approximately 1:00 p.m., various staff members to include Registered Nurses (RN), Licensed Practical Nurses (LPN) and aides working the unit on which Resident R1 resides, confirmed they did not recently receive any education on abuse nor were they interviewed regarding any knowledge of any incidents regarding NA Employee E1.During an interview on 5/7/26, at approximately 1:30 p.m. the NHA was alerted to the second resident's interview and her wish to remain anonymous and that there were other residents mentioned in the complaint that also did not want to say anything or be asked about occurrences with this particular aide.During an interview on 5/7/26, at 2:30 p.m. the NHA confirmed that the facility failed to protect residents from potential verbal and physical abuse. This resulted in harm of Resident R1 to be fearful of staff.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 211.12(c)(d)(5) Nursing Services.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON), failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections from resident-to-resident , which created an Immediate Jeopardy for 67 of 67 residents .Findings include:Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of your job is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. As the Administrator, it is your responsibility to organize, develop, and direct resources to maintain the highest degree of quality care is maintained for each resident at all times.Review of the facility-provided Director of Nursing (DON) job description indicated, As the Director of Nursing it is your responsibility to organize, develop, manage, and direct the overall operations of the Nursing Service Department in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community. The Director of Nursing is to work directly with the Administrator and the Medical Director to ensure the highest degree of quality care is maintained for each resident at all times. Follows all health, sanitary, and infection control policies and maintains established standards of practice set forth by the community's administration and Nursing Policies and Procedures.Based on findings identified in this report, the facility failed protect the residents for risk of serious harm. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.During an interview on 5/20/26, at 1:00 p.m. the NHA and DON confirmed the facility's failure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases by failing to have working laundry equipment to ensure clean and sanitized linens/laundry created an Immediate Jeopardy situation for 67 of 67 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations, resident interviews, staff interviews, and review of facility documents it was determined that the facility failed to ensure a clean, sanitary, and functional environment in the laundry room.Findings include:Review of facility policy Homelike Environment dated 4/1/26, indicated residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. This includes clean, sanitary, and orderly environment and clean bed and bath linens that are in good condition. Review of facility policy Laundry and Bedding, Soiled dated 4/1/26, indicated soiled laundry shall be handled, transported, and processed according to best practices for infection prevention and control. All laundry is handled as potentially contaminated standard precautions (gloves and gown when sorting). Contaminated laundry is bagged or contained at the point of collection. Staff handle soiled textiles/linens with minimum agitation to avoid contamination of air, surfaces, and person. During an observation on 5/7/26, between 8:30 a.m. and 6:00 p.m., the following was observed:- At 9:30 a.m. 100 Front Hall Nursing Unit linen cart was observed with no clean linens available for resident use.- At 9:31 a.m. 100 Back Hall Nursing Unit linen cart contained two pillowcases. The 100 Side Hall Nursing Unit linen cart contained four pillowcases, one towel, and one pack of disposable dry wipes.- At 9:33 a.m. Resident R6 was observed laying on the bare mattress, no sheet or blankets were noted on the resident's bed.- At 9:35 a.m. Resident R7 was observed laying on the bare mattress, no sheet or blankets were noted on the resident's bed.- At 9:35 a.m. Resident R8 was observed laying on the bare mattress, no sheet or blankets were noted on the resident's bed.- At 9:36 a.m. Resident R9 was observed laying on the bare mattress, no sheet or blankets were noted on the resident's bed- At 9:36 a.m. Laundry Employee E2 was observed delivering a small number of linens to the nursing units. When asked, they stated they have been using the two washing machines designated for residents' use for personal laundry.- At 9:40 a.m. Resident R9 was observed laying on the bare mattress watching television. Resident R9 stated she was not given a pillow to use on her bedDuring an interview on 5/7/26, at 9:40 a.m. Laundry Employee E1 stated the two facility commercial washers have been down for a 'couple' of weeks. They had been using the two resident laundry machines and taking the soiled linens to the laundry mat. During an interview on 5/7/26, at 1:28 p.m. the Nursing Home Administrator (NHA) confirmed the facility commercial laundry washing machines were not functioning, and confirmed the facility failed to ensure a clean, sanitary, and functional environment for the residents.28 Pa Code: 201.29(k) Resident rights.28 Pa Code: 207.2(a) Administrator's responsibility.28 Pa Code: 205.74 Linen.

Based on review of facility policy, resident interviews, clinical record review, and staff interview it was determined that the facility failed to make certain that residents are free of significant medication errors for two of three residents (Residents R5 and R10).Findings include:Review of facility policy Administering Medications dated 4/1/26, indicated medications are administered in accordance with prescriber orders, including required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.Review of facility policy Adverse Consequences and Medication Errors dated 4/1/26, indicated residents receiving any medications that had potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), long-term use of opiate analgesic (narcotic pain medications), and high blood pressure.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/28/26, indicated the diagnoses remain current. Further review of the MDS Section C - Cognitive Patterns; Question C0500, indicated Resident R5's BIM's score was 15. Review of Resident R5 's physician orders revealed the following:- From 1/21/26 to 2/11/26, oxycodone five milligrams (mg) on tablet by mouth every eight hours for chronic pain.- From 2/11/26 to 3/4/26, oxycodone five mg one tablet by mouth every eight hours for chronic pain.- From 3/4/26 to 3/25/26, oxycodone five mg one tablet by mouth every eight hours for chronic pain.- From 3/25/26 to 4/13/26, oxycodone five mg one tablet every eight hours for chronic pain.- From 4/13/26 to 4/22/26, oxycodone five mg on tablet by mouth every eight hours for chronic pain.Review of a progress note dated 4/22/26, at 10:49 a.m. revealed this RN was asked to remove a small bowl of pills from the resident's room that therapy had noticed at bedside. In this small bowl were oxycodone narcotic pain medication), loratadine (allergy medication), ticagrelor (used with aspirin to prevents blood clots), Celexa (depression medication), and Synthroid (man-made thyroid hormone). MD (doctor) discontinued oxycodone.During an interview on 5/7/26, at 12:20 p.m. Resident R5 stated I was going to take them. She's a thief. She got in my personal stuff and took them.During an interview on 5/7/26, at 12:45 p.m. Therapy Employee E4 stated she was working with Resident R5's roommate and needed some linen. She stated Resident R5 hoards linens, so she went over to that side of the room to get some of the extras. When she lifted the linens, she saw a bowl of medications sitting in a box visible when the linens were lifted. Therapy Employee E4 removed the bowl from the resident's room and reported the find to her director and the nurse supervisor on duty. She stated that she did not go through the medications or count them, she turned them over to administration.During an interview on 5/7/26, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to prevent a significant medication error from occurring by evidence of Resident R5 having an excessive amount of narcotic pain medications in their possession. Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE], with diagnoses that included parkinsonism (term for a group of neurological disorders that cause movement problems, such as tremors, stiffness, slow movements, and balance issues), orthostatic hypotension (sudden drop in blood pressure that occurs when you stand up after sitting or lying down) and anemia (body lacks enough healthy red blood cells to carry oxygen to your tissues).Review of Resident R10's MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS Section C - Cognitive Patterns; Question C0500, indicated Resident R10's BIM's score was 5. Review of Resident R5 's physician orders revealed the following: -Rivastigmine (used to treat mild to moderate dementia associated with Alzheimer's or Parkinson's disease) Transdermal Patch 24-Hour 4.6-Apply one patch transdermally one time a day and remove per schedule. Review of progress notes dated 5/5/26, revealed in a physician assistant's note, It was noted patient's Rivastigmine Transdermal Patch q24h had not been changed since 4/29 and old patches had not been removed. Partners removed old ones and replaced with a new patch. Review of the medication administration records for 4/29/26, through 5/5/26, revealed that the medication was administered on and after 4/29/26. Interview on 5/18/26, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to prevent a significant medication error from occurring by evidence of Resident R10 having multiple days' worth of transdermal medication patches left on his body. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa Code: 201.18(e)(1)(6) Management.28 Pa Code: 201.19 Personnel policies and procedures.28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, documents, clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without physical restraint order for one of six residents (Resident R2).Findings include:Review of facility policy Use of Restraints, reviewed 4/1/26, indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint.Review of the Resident Assessment Instrument User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS score suggests the following distributions:-13-15: Cognitively Intact-8-12: Moderately Impaired-0-7: Severe ImpairmentReview of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS-federally mandated assessment of a resident's abilities and care needs) dated 4/21/26, included diagnoses of malignant neoplasm of the liver (cancerous tumor that invades nearby tissue thus spreading to other parts of the body), high blood pressure, diabetes (chronic condition causing high blood sugar due to insufficient insulin or ineffective insulin use), peripheral vascular disease (circulation disorder where blood vessels outside the heart become narrowed, blocked, or weakened), anxiety disorder (group of mental health conditions characterized by persistent and excessive feelings of worry, fear, or panic that can significantly impact daily life). Review of Section C: Cognitive Patterns, Question C0500: BIMS Summary Score revealed Resident R2's score to be 15.Review of order summary from 4/18/26, revealed an order for the resident to have bolsters placed while the resident was in bed. No documentation was noted if other methods were attempted first (i.e. fall mats, bed rails). Review of plan of care from 4/20/26, revealed: Focus: The resident is high risk for falls r/t Deconditioning, Gait/balance problems, Goal: the resident will not sustain serious injury through the review date, Interventions: Anticipate and meet the resident's needs, Be sure the resident's call light is within reach and encourage the resident to use if for assistance as needed. The resident needs prompt response to all requests for assistance, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Follow facility fall protocol, Pt evaluate and treat as ordered or PRN, Tub/Shower transfer assist x1, Lying/Sitting on side of bed, Roll Left and Right: partial/mod assist (assist x1), Sit/Lying: partial /mod assist (assist x1), Sit to Stand: partial/mod assist (assist x1), Toilet Transfer: partial/mod assist (assist x1), Walk 10 feet: partial/mod assist (assist x1) Chair/Bed-to-chair: partial/mod assist (assist x1). No care plan was executed for bolsters to be used while in bed.Review of progress notes revealed resident was admitted to the facility with history of ground-level falls at home, further review revealed a fall on the evening of 4/18/26 in the facility. Further review of the medical record revealed no additional documentation in Resident R2's medical record regarding falls and interventions.During an interview with the Nursing Home Administrator on 5/7/26, at approximately 2:30 p.m. it was confirmed that the facility failed to make certain the resident was free from the use of physical restraints without trying a least restrictive alternative first for one of six residents reviewed (Resident R2).28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29(a)(c)(d) Resident Rights.28 Pa. Code 211.12(d)(5) Nursing Services.28 Pa. Code 211.8(c.1)((1)(e) Use of Restraints.

Based on review of facility policy, clinical record review, facility submitted data, and staff interview, it was determined that the facility failed to report an allegation of abuse in the required timeframe for one of four residents (Resident R1) and failed to report a significant medication error for two of three residents reviewed (Residents R5 and R10) and failed to report the facility's laundry washing machine were not working.Findings include:Review of the facility policy Abuse and Neglect-Clinical Protocol, dated 4/1/26, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by individuals, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. All serious incidents involving a resident will be reported to the Department of Health (State Agency) within 24 hours. Review of facility policy Adverse Consequences and Medication Errors dated 4/1/26, indicate adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. with diagnoses that included high blood pressure, diabetes (chronic condition causing high blood sugar due to insufficient insulin production or ineffective insulin use), hemiplegia (form of paralysis affecting one entire side of the body usually caused by stroke, brain damage or tumor), and neurogenic bladder (disease like diabetes that can cause disruption in communication between the brain and the bladder preventing proper urine storage or emptying), Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/20/26 stated resident as dependent with shower/bathe self, dependent tub/shower transfer. Review of concern form dated 4/17/26, indicated Resident R1 notified therapy department that she sustained bruises during her shower that morning, the aide was rough with her, made derogatory comments and sprayed water in her face. The report form for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property was not submitted until 4/29/26. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), long-term use of opiate analgesic (narcotic pain medications), and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS Section C - Cognitive Patterns; Question C0500, indicated Resident R5's BIM's score was 15. Review of a progress note dated 4/22/26, at 10:49 a.m. revealed this RN was asked to remove a small bowl of pills from the resident's room that therapy had noticed at bedside. In this small bowl were oxycodone (narcotic pain medication), loratadine (allergy medication), ticagrelor (used with aspirin to prevents blood clots), Celexa (depression medication), and Synthroid (man-made thyroid hormone). MD (doctor) discontinued oxycodone. During an interview on 5/7/26, at 12:20 p.m. Resident R5 stated I was going to take them. She's a thief. She got in my personal stuff and took them. During an interview on 5/7/26, at 12:45 p.m. Therapy Employee E4 stated she was working with Resident R5's roommate and needed some linen. She stated Resident R5 hoards linens, so she went over to that side of the room to get some of the extras. When she lifted the linens, she saw a bowl of medications sitting in a box visible when the linens were lifted. Therapy Employee E4 removed the bowl from the resident's room and reported the finding to her director and the nurse supervisor on duty. She stated that she did not go through the medications or count them, she turned them over to administration. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses of Parkinsonism (a term used for a group of neurological conditions that cause motor symptoms like slowed movement, rigid muscles, tremors and balance issues), orthostatic hypotension (sudden drop in blood pressure that occurs when rising from a sitting or lying position), anemia (condition where there is a lack of healthy red blood cells that are able to carry oxygen to your body's tissues). Review of the MDS Section C - Cognitive Patterns; Question C0500, indicated Resident R10's BIM's score was 5. Review of Resident R10's progress notes e-signed on 5/5/26, 12:50 a.m. state, It was noted patient's Rivastigmine Transdermal Patch (brand name Exelon - used to treat dementia related to Alzheimer's Disease) q24h had not been changed since 4/29/26, and old patches had not been removed. Partners removed old ones and replaced with a new patch. There is no further documentation noting if the resident had any issues related to the multiple patches and there was no additional nursing documentation. Review of Resident's medication administration record revealed the medication was administered from 4/29/26, through 5/5/26 when the documentation was made regarding the discovery of the multiple patches. There were no reports of Investigation of Alleged Abuse, Neglect, and Misappropriation of Property submitted to the state Agency from 5/1/26 through 5/19/26. During an observation on 5/7/26, at 9:40 a.m. the facility's two laundry washing machines were not working. During an interview at the same time Confidential Employee E1 stated the washers have not worked for three to four weeks. During an interview on 5/7/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to report an allegation of abuse in the required timeframe for one of four residents (Resident R1) and failed to report a significant medication error for two of three residents reviewed (Resident R5 and R10), and failed to report the facility's laundry washing machines were not operational 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 201.20(b) Staff Development.28 Pa. Code 211.10(c)(d) Resident Care Policies.

Based on review of facility policy, clinical record, staff and family interview, it was determined that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the nutritional concerns for one of five residents (Resident R11).Findings include:Review of the facility's policy Hydration-Clinical Protocol, dated 4/1/26, indicated the physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). The physician will distinguish various types of fluid and electrolyte imbalance (for example, hyponatremia, hypernatremia, pre-renal azotemia, etc.) from true dehydration (clinically significant loss of total body water). Ther staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (for example, delirium, lethargy, increased thirst, etc) or lab test results (for example, hypernatremia, azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. The physician and staff will identify significant risks for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. Review of the facility's policy Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated 4/1/26, indicated the nursing staff will monitor and document the weight and dietary intake of residents n a format which permits comparisons over time. The staff and physician will define the individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever, and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. The staff will report to the physician significant weight loss or gains or any abrupt or persistent changes from baseline appetite or food intake. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE] for respite stay. Review of Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/29/25, indicated diagnoses of dementia (umbrella term for a decline in mental abilities-such as memory, thinking, and communication-severe enough to interfere with daily life), high blood pressure, acute or chronic diastolic heart failure (chronic develops slowly, acute episodes mark sudden, severe congestion that typically requires immediate medical intervention). Section GG0130 Functional Abilities was coded as 6, which indicated Resident R11 was independent with eating. On 5/7/26, a Mini Nutritional Assessment was completed which indicated that Resident R11 had no decrease in food intake the last three months, no weight loss in the last three months, mobility consists of bed or chair bound. Scores: 12-14: normal nutritional intake, 8-11: at risk of malnutrition, and 0-7: malnourished; Resident R11 scored 12. Review of Resident R11's order summary revealed on 5/7/26, order was placed for regular diet-regular texture, thin consistency. It was also noted that the resident was on an ACE inhibitor medication (lisinopril) and a diuretic (Lasix). Review of the care plan dated 5/8/26, indicated Resident R11's Focus area was that he has a nutritional problem or potential nutritional problem related to overweight. His Goal will be to comply with recommended diet, maintain weight within 5%, have no signs/symptoms of malnutrition or dehydration and consume 50% or more of 3 meals/day through review date. Resident R11's Interventions are to be to provide, serve diet as ordered, monitor intake and record every meal. Registered Dietician to evaluate and make diet change recommendations when necessary. Review of Task sheets (from admission through 5/12/26) for Nutrition documentation revealed:Task-Nutrition Breakfast: -5/9/26-1:51 p.m. 0-25% was consumed -5/11/26-12:49 p.m.-76-100% was consumed Lunch: - 5/9/26-1:51 p.m. 0-25% was consumed -5/11/26-12:49 p.m.-76-100% was consumed Dinner: No documentation was made from 5/7/26, through 5/12/26. Review of Resident 11's clinical progress notes revealed an admission note on 5/7/26 which indicated that Resident alert and oriented, slow to respond to answer questions, food preferences have been updated from previous stay and one on file in dietary. Diet order-Reg diet (5/7/26), Thin liquids (5/7/26), Multivitamin/Minerals (5/7/26), feeds self after set-up with limited assistance. Dental upper and lower natural teeth, a few missing, no noted problems chewing or swallowing current diet and no complaints of mouth pain. No further clinical progress notes were made if resident was eating/how much was consumed or if he was refusing meals during his stay 5/7/26, through 5/12/26. An interview was conducted with Resident R11's daughter on 5/19/26 at 3:50 p.m. regarding a complaint that was made by her that he was not being fed while he was in the facility and she had to take him to the hospital the day after (5/13/26) discharge (5/12/26) since he was not acting like himself which at the hospital it was revealed that the resident was dehydrated and weak, so he was admitted , and as of date of interview remained in the hospital. During an interview on 5/20/26, at approximately 3:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to accurately assess the nutritional status and failed to accurately document meals and percentage consumed, or to notify the physician regarding decrease in nutritional consumption for one of five resident (Resident R11) records reviewed. 28 Pa. Code: 201.18(b)(1)(e )(1) Management.28 Pa. Code: 211.12(d)(5) Nursing services.

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:A review of the facility policy Surveillance for Infections dated 4/1/26, revealed the infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiology significant infections that have substantial impact or potential resident outcome and that may require transmission-based precautions and other preventative interventions.A review of the Facility's Job Description-Infection Preventionist dated 4/1/26, revealed that completion of CDC training for Long Term Care Infection Preventionist (IP) or attainment of other acceptable certification within 30 days of employment. The IP will report to the Director of Nursing. The IP will be responsible for program management by developing, implementing and evaluating the organizational infection prevention program, surveillance, develop an annual surveillance plan based on population(s) served, services provided, and analysis of surveillance data.During an interview on 5/19/26, at 9:30 a.m., the Nursing Home Administrator (NHA) stated that the facility we moved the Infection Control Nurse 0n 5/18/26, into the Director of Nursing (DON) position since the DON resigned the week before (5/15/26), we promoted a nursing supervisor to Assistant Director of Nursing and Infection Control on 5/18/26, but they are not currently certified but have started with training. The NHA confirmed on 5/19/26, at 9:30 a.m. that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units observed (First and Second Nursing Units). This failure resulted in a harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 26 of 41 residents (Residents R1,R8,R14,R15,R18,R19, R22,R24,R25,R32,R38,R40,R44,R48,R51,R52,R61,R67,R69,R70 R72,R73,R74 R77,R78 ) who were identified as having the physical ability to access hot water outlets in the sinks and/or shower rooms throughout the entire facility.Findings include:Review of facility policy titled Safety of Water Temperatures dated 2/18/26, previously dated 1/20/25 revealed tap water in the facility shall be kept within a temperature range to prevent scalding residents.Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit (43 degrees Celsius), or the maximum allowable temperature per state regulation.Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log along with conducting periodic tap water temperature checks and recording the water temperature in a safety log.Direct-care staff should be informed of risk factors for scalding/burns that are more common in the elderly, ongoing resident observations and assessments during prolonged exposure to warm or hot water will help to determine the safety of the situation. Nursing staff will be educated about signs and symptoms of burns (first, second, and third) so that such injuries can be recognized and treated properly. If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. Review of the American Burn Association Scald Injury Prevention Educator's Guide dated 4/25/17, indicated older adults have thinner skin therefore hot liquids cause deeper burns with even brief exposure, and older adults' ability to feel heat may be decreased due to certain medical conditions or medications. The American Burn Association Guide also provided this table:Time and Temperature Required for a 3rd Degree Burn to Occur:155 degrees Fahrenheit 68 degrees Celsius 1 second148 degrees F 64 degrees C 2 seconds140 degrees F 60 degrees C 5 seconds133 degrees F 56 degrees C 15 seconds127 degrees F 52 degree C 1 minute124 degrees F 51 degree C 3 minutes120 degrees F 48 degree C 5 minutes100 degree F 37 degree C Safe Temperature for Bathing Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE].Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/20/26, indicated diagnoses of high blood pressure, diabetes (chronic condition characterized by high blood sugar resulting from insufficient insulin production or ineffective insulin use), viral hepatitis (an often-serious liver infection, causing inflammation, damage, cirrhosis, or liver cancer), depression (a serious, common mood disorder causing persistent sadness, low energy, and loss of interest in life for at least two weeks).Further review of Resident R77's MDS dated [DATE], indicated set up/clean up assist, helper sets up or cleans up, resident completes activity. Helper assists only prior to and following an activity.Review of Resident R77's clinical record indicated, a progress note dated 3/11/26 at 6:56 a.m., indicated that Resident R77 notified the desk and asked for a Band-Aid for his left index finger. His finger was bleeding and the skin was missing. He stated that he burned it on 3/8/26. I cleaned the area and applied a Band-Aid. Supervisor made aware. Staff will continue to monitor.Review of the clinical record, a progress note dated 3/11/26, at 8:49 a.m., indicated Resident R77 reported sustaining a burn to the distal index finger of the left hand from hot water in his bathroom. The resident has neuropathy in his hand with decreased sensation. The resident stated, a blister formed and I popped it. Upon assessment, an open area was noted on the left index finger measuring 1.0 cm x 1.0 cm with a minimal amount of bloody drainage. No redness, swelling, or other abnormalities noted at this time. Resident is alert and oriented x4 and verbalizes understanding of the situation. The nurse practitioner for the facility and the nurse practitioner for the wound agency was notified. Area cleansed and a dry dressing applied.Review of Resident R77's plan of care on 9/5/25, for Skin Integrity indicated to educate resident/family/caregivers of causative factors and measures to prevent skin injury.Review of Resident R77's order summary revealed licensed nurse to perform head to toe skin checks with shower in the evening of Tuesday and Friday. Observations conducted on 4/13/26, at 8:30 a.m. of room [ROOM NUMBER] on Nursing Unit Side Two revealed that the hot water felt uncomfortably too hot to touch. Interviews conducted on 4/13/26, at 8:35 a.m. with Resident R77 and R78 both revealed statements of How hot is that water and It gets hot, real hot. Facility water temperature log indicated that weekly testing was performed and was due on 4/13/26. All previous entries had temperatures noted as 102 F to 117 F. On 4/13/26, at 1:13 p.m., the Maintenance Director Assistant Employee E3 began an audit of all resident rooms, bathing area and clean utility room revealed the following results:-4 out of 36 outlets were at safe temperature.-25 out of 36 outlets were between 111 F and 119 F.-1 out of 36 outlets were between 120 F and 129 F.-0 out of 36 outlets were above 130 F.-6 out of 36 outlets were non-operable. Second Nursing Unit Shower Room Sink:Sink: 113 FSecond Nursing Unit-Clean Utility Room:Sink: 120 FSecond Nursing Unit-Resident Rooms:200: 113 F201: 113 F202: 112 F203: Resident in Isolation204: 117 F205: Resident in bathroom206: 114 F207: 116 F208: 115 F209: Empty210: Empty211: 119 F212: 111 F214: 115 F215: 115 F216: 118 F217: 117 F220: 112 F221: 118 F222: 114 F223: 113 F224: 119 F225: Empty226: 115 F227: Unable to check228: 117 F229: 115 F249: 110 F251: 112 F252: 115 F253: 104 F254: 108 F255: 106 F256: 111 F During an interview on 4/13/26, at approximately 1:30 p.m. Director of Nursing and Assistant Director of Nursing determined which residents had the physical ability and dexterity to access the hot water outlets in the sinks and/or shower rooms independently. (26 out of 41 residents). The Nursing Home Administrator (NHA) and the Regional Director of Nursing were made aware that Immediate Jeopardy existed on 4/13/26, at 2:10 p.m. and a corrective action plan was requested. On 4/13/26, at 4:44 p.m.an acceptable Corrective Action Plan was approved which included the following interventions:The Regional Maintenance Director immediately adjusted the water heater on Side 1 and 2 to 110 degrees at 2:00 p.m. on 4/13/26. At 3:30 p.m. the rooms that were identified as being above 110 degrees are now temping at 110 degrees or below.Whole house skin checks were implemented to ensure no instances of skin alteration related to water temperature will be completed by 4:00 p.m. on 4/13/26.Regional Maintenance Director educated the Maintenance Director and Maintenance Assistant on the water temperature policy and water checks by 4/13/26.Nursing Home Administrator (NHA) or designee will educate whole house on water temps and the reporting process by 9:00 a.m. on 4/14/26 for all staff in the facility. All other staff will be contacted via phone by 9:00 a.m. on 4/14/26.NHA or designee will temp water each shift 5 areas per side weekly x 2 weeks. Maintenance Department will temp 5 areas on each side per Preventative Maintenance 7 days a week and record it on a daily log.If the temperature is out of range, maintenance will adjust the hot water temp and if it doesn't decrease, they will contact the regional maintenance for further guidance and will not use the affected areas.If a staff member identifies that the water is too hot, they will report it to the Nursing Supervisor, and the Nursing Supervisor will contact Maintenance. If it's identified that a resident is burned the Supervisor will assess, complete and incident report, and temp other rooms in the immediate area to ensure no other incidents occur. Maintenance will be notified if above 110 degrees.Audits will be taken to QAPI for review. During staff interviews on 4/14/26, between 9:00 a.m. and 11:00 a.m. 9 direct care nursing staff (Registered Nurse Employee E12, Licensed Practical Nurse Employee E4,E6,E13, Nurse Aide Employee E14,E15,E16,E17,E18) confirmed they had attended trainings, understood how to check water temperature, and knew what to do if water temperatures exceeded 110 F. A review of the documentation received from the facility on 4/14/26, at 11:30 a.m. revealed that all elements of the Corrective Action Plan were substantially completed per the facility's action plan. The Immediate Jeopardy was lifted on 4/14/26, at 12:13 p.m. when the action plan implementation was verified. During an interview on 4/14/26, at 12:13 p.m. the Nursing Home Administrator, Director of Nursing and Regional Director of Nursing confirmed the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units. This failure placed the facility in an Immediate Jeopardy situation for 26 of 41 residents and harmed one resident (Resident R77). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (a)(b) (1)(3) Management.28 Pa. Code 205.63 (c) Plumbing and piping systems required for existing and new construction.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination and failed to make certain staff wore proper hair restraints in the main kitchen. Findings include:During an observation of the main kitchen on 4/12/26, from 9:45 a.m., through 10:02 a.m., the following was observed:The stand-up ice cream freezer had ice buildup, a bottle of ice, and a bowl with food debrisThe freezer had undated juices on a cart, and the air circulation fans had a black substance on the blades.The deep freezer had a plastic bag identified as a roast that appeared freezer burned and totally covered with ice.All dietary staff had hair uncovered and not wearing hairnets. During an interview on 4/12/26, at 11:18 a.m., Certified Dietary Manager Employee E9 confirmed that the facility failed to properly store food products in walk in freezer and deep freezer which created the potential for cross contamination and staff failed to properly wear hair restraints.

Based on observations and staff interview, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include:04/12/2026 observations from 9:45 a.m., through 10:02 a.m., the following was observed: The dish machine is low temp chemical and when chemical testing strip was performed after three runs, did not go above a 10ppm. The recommended level is identified as 50-100ppm. During an interview on 4/12/6, at 11:18 a.m., the Certified Dietary Manager Employee E9 confirmed that the facility failed to ensure the dish machine was in proper working order. 28 Pa Code:201.14(a) Responsibility of Licensee

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of two residents reviewed (Residents R1 and R21).Findings include: Review of the facility policy Dialysis Management (Hemodialysis) dated 1/8/26 with a prior review date of 6/1/25. The policy indicates the facility is to complete Pre-Dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and Facility. Dialysis center personnel to complete Dialysis communication form and return to facility. Dialysis Center may provide their EHR documentation vs manual documentation of treatment on communication form. Upon return from Dialysis Center, review information provided on Dialysis communication form/EHR. Communicate and address as appropriate. Facility to complete post-dialysis information/data and place in resident's medical record. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/14/26, indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R1's physician order dated 12/11/25, indicated dialysis: Tuesday and Saturday at [Dialysis Center]. Pick up time 6:30 a.m. with chair time scheduled at 8:00 a.m. Review of Resident R1's current care plan indicated dialysis two times a week, treatments as scheduled: Tuesday and Saturday at [Dialysis Center]. Resident R1's dialysis communication forms from 12/11/25 through 4/16/26 revealed only a partially completed for dated 3/28/26 existed, all other forms were absent. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated diagnoses of Hypertension (high blood pressure), anxiety disorder (intense, excessive, and persistent feelings of worry, fear, and uneasiness), and end stage renal disease (kidneys fail to filter waste and balance fluids).Review of Resident R21's physician order dated 10/2/24, indicated dialysis: Monday, Wednesday, and Friday at [Dialysis Center]. Pick up time 10:30 a.m. with chair time scheduled at 11:30 a.m. Review of Resident R21's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [Dialysis Center]. Resident R21's dialysis communication forms from the last full health survey of on 6/13/25 through 4/16/26, revealed all forms were absent. During an interview on 4/12/26 at 11:30 a.m. with LPN Employee E11, a request for the dialysis communication forms was made. Employee E11 looked for the binder, requested and received assistance from other staff and the binder could not be located on the nursing unit. Employee E11 was able to find a partially completed dialysis communication form dated 3/28/26 for Resident R1 that the resident had in a folder in his room. Staff were unable to locate a dialysis binder or communication forms for Resident R21. During an interview on 4/14/26, at 10:00 a.m. the Director of Nursing and Regional Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify the physician of increased or decreased Capillary Blood Glucose (CBG) levels and failed to assess residents of hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for three of seven residents (R1, R14, and R77). Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your blood stream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dL). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias, and even death. People with Diabetes Mellitus (DM) may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyper glycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage, and non-healing wounds. Review of the facility policy Diabetes-Clinical Protocol reviewed 2/18/26, with a previous review date of 1/20/25, indicated as part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance; for example, medications including prednisone, thiazide diuretics or some antipsychotic medications. Under section Monitoring and Follow-Up, section four describes that the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will notify the provider if outside the set parameters. The staff will incorporate such parameters into the Medication Administration Record and care plan. Review of the facility policy Change in Resident's Condition or Status reviewed 2/18/26, with a previous review date of 1/20/25, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing. payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication form. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/14/26, indicated diagnoses of high blood pressure, diabetes, and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of the physician's order dated 2/26/26, to notify the physician if CBG is greater than 450. Review of the physician's order dated 4/1/26, indicated to inject Humalog (fast-acting insulin that starts working about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, parameters given to notify physician if CBG is greater than 400 until completion of antibiotic therapy. Review of the clinical record vital signs revealed that the residents' CBG's were as follows: 4/4/26-11:04 p.m.: 469- no documentation the physician was notified. 4/1/26-11:01 a.m.: 522- no documentation the physician was notified. 3/29/26-9:09 p.m.: 475- no documentation the physician was notified. 3/28/26-8:24 p.m.: 473- no documentation the physician was notified. Review of Resident's R1's vital signs and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS-a periodic assessment of care needs) dated 1/1/26, indicated diagnoses of high blood pressure, diabetes, gastro-esophageal reflux disease (chronic condition where stomach acid frequently backs up into the esophagus, causing irritation), renal insufficiency(kidneys are starting to fail to filter waste and balance fluids), dementia(progressive decline in cognitive function-memory, language and problem-solving-severe enough to interfere with daily life). Review of the physician's order dated 4/4/26, indicated to inject Humalog (fast-acting insulin that starts working about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, parameters given to notify physician if CBG is greater than 401. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 4/11/26-8:49 p.m.: 424-no documentation the physician was notified. 4/9/26-12:29 p.m.: 529-no documentation the physician was notified. 4/8/26-3:54p.m.: 425-no documentation the physician was notified. 4/7/26-8:10 p.m.: 553- no documentation the physician was notified. 4/7/26-4:13 p.m.: 600- no documentation the physician was notified. 4/7/26-4:00p.m.: 536- no documentation the physician was notified. 4/6/26-8:32 p.m.: 545- no documentation the physician was notified. 4/6/26-7:45 p.m.: 423- no documentation the physician was notified. 4/4/26-7:21 p.m.: 470- no documentation the physician was notified. 4/4/26-1:39 p.m.: 999- no documentation the physician was notified. 3/31/26-5:36 p.m.: 509- no documentation the physician was notified. 3/31/26-1:15 p.m.: 460- no documentation the physician was notified. 3/28/26-5:16 a.m.: 486- no documentation the physician was notified. 3/26/26-9:11 p.m.: 500- no documentation the physician was notified. 3/26/25-7:26 p.m.: 590- no documentation the physician was notified. Review of Resident's R14's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE]. Review of Resident R77's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, viral hepatitis (an often-serious liver infection, causing inflammation, damage, cirrhosis, or liver cancer), depression (a serious, common mood disorder causing persistent sadness, low energy, and loss of interest in life for at least two weeks). Review of the physician's order dated 9/20/25, indicated to inject Humalog (fast-acting insulin that starts working about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, parameters given to notify physician if CBG is greater than 340. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 4/9/26-7:07 p.m.: 368-no documentation the physician was notified. 4/8/26-1:29 p.m.: 363- no documentation the physician was notified. 4/8/26-11:39 a.m.: 363- no documentation the physician was notified. 4/7/26-6:09 p.m.-350- no documentation the physician was notified. 4/6/26-12:32 p.m.: 400- no documentation the physician was notified. 4/6/29-12:49 a.m.: 369- no documentation the physician was notified. 4/5/26-9:50 p.m.: 384- no documentation the physician was notified. 4/5/26-6:05 a.m.: 377- no documentation the physician was notified. 4/4/26-7:47 a.m.: 370- no documentation the physician was notified. 4/2/26-11:27 a.m.: 404- no documentation the physician was notified. 4/1/26-9:13p.m.: 400- no documentation the physician was notified. 3/20/26-6:20 a.m.: 442- no documentation the physician was notified. 3/11/26-7:56 p.m.: 500- no documentation the physician was notified. 3/1/26-9:07 p.m.: 388- no documentation the physician was notified. Review of Resident R77's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. During an interview on 4/13/26, at approximately 8:30 a.m. Licensed Practical Nurse (LPN) Employee E4 stated if blood glucose was under 70, they would start hypoglycemia protocol and notify doctor. If the blood glucose was greater than 400, they would notify the supervisor and call the doctor. They would document in the MAR and progress notes. During an interview on 4/14/26, at approximately 7:30 a.m. LPN Employee E5 stated if blood glucose was under 70 and patient was symptomatic, would start hypoglycemia protocol and notify the doctor. If the blood glucose was greater than 400, they would administer the ordered insulin and notify the doctor. They would document in the progress notes. During an interview on 4/14/26, at approximately 7:40 a.m. LPN Employee E6 stated she would follow protocol for glucose less than 70, notify MD and recheck CBG, if greater than 400 or per order (ex. >350) would give ordered insulin, notify MD and repeat CBG, document all in progress notes. During an interview on 4/14/26, at 12:11p.m. the Nursing Home Administrator, Director of Nursing and Regional Director of Nursing confirmed the facility failed to notify the doctor of change in condition related to blood glucose for Residents R1, R14, and R77. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (b) (c )(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (Side 1 and Side 2) and failed to provide clean linens, wash cloths and towels to accommodate the needs of the residents of two of two nursing units (Side 1 and Side 2). Findings included: Review of the facility policy Homelike Environment, last reviewed on 6/1/25, indicated that residents are provided with a clean, comfortable homelike environment and encouraged to use their own belongings. The facility staff and management maximize, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary, and orderly environment including clean bed and bath linens that rea in good condition. During observations on 4/12/26 from 10:40 a.m., through 12:27 p.m., the following was observed: The main hall the ceilings have unfinished drywall and spackling, walls have areas with unfinished. Observation of the laundry identified two washers, one working washer has the face removed and is leaking all over the floor, one of three dryers is currently functioning confirmed with the Laundry/ Housekeeping Supervisor Employee E1 that the facility was aware of complaints of linen, washcloths and towels running out and confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (Side 1 and Side 2). During an interview on 4/13/26, at 11:00 a.m. Resident R5 stated they are always short of towels here and sometimes washcloths. During an interview on 4/13/26, at 11:30 a.m. Resident R60 stated the staff scrambles around to try and find towels there never seems to be enough. During an interview on 4/12/26, at 11:25 a.m. Resident R34 stated he is told constantly there are not enough linens because he cannot use diapers as he has psoriasis and is allergic and needs linens changed. Observation of his room during the interview identified soiled privacy curtains, a broken overbed table and soiled over bed tables. Observation of empty rooms identified no linens on beds and staff overheard stating that there not enough linens to place on empty beds. Resident room [ROOM NUMBER] had a brown substance on the floor, a broken chair in room and soiled privacy curtains. During an observation on 4/13/26, from 12:00 through 1:12 the following was observed: Resident room [ROOM NUMBER] wall by the entrance of the bathroom had broken drywall and the bathroom had broken unfinished areas of the walls. Resident room [ROOM NUMBER] has a rectangle hole near the base of the wall, the size of a double electrical outlet. Resident room [ROOM NUMBER] wall behind bed had broken drywall areas. Resident room [ROOM NUMBER] bathroom had unfinished drywall and no floor transition, causing a potential tripping hazard. Resident room [ROOM NUMBER] wall behind bed had broken drywall areas. Resident room [ROOM NUMBER] wall behind bed broken drywall areas. Resident room [ROOM NUMBER] ceiling above B bed had unfinished spackling. Resident room [ROOM NUMBER] had no cover over the bathroom electrical outlet and the privacy curtains were soiled. Resident room [ROOM NUMBER] bathroom floor had no transition causing a potential tripping hazard. Resident room [ROOM NUMBER] had soiled privacy curtains. During an interview on 4/13/26, at 1:12 p.m., confirmed with the Maintenance Assistant Employee E3 that the facility failed to provide a clean, comfortable homelike environment on two for two nursing units (Side 1 and Side 2). 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 205.74 Linens

Based on observations and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on two of four medication carts (medication cart #1 and unused medication cart).Findings include:During an observation on 4/12/26, at 10:00 a.m., Medication cart #1 was left unsecured in the hall and resident identifiable information was observed on the computer screen and on papers on top of the cart. During an interview on 4/12/26, at 10:03 a.m., Registered Nurse Employee E8 confirmed that resident identifiable information was left available for any passerby to see. During an observation on 4/12/26, at 10:38 a.m., of the dayroom, a medication cart identified as not being used was unsecured and had accessible resident identifiable information available.During an interview on 4/12/26, at 10:40 a.m., Assistant Director of Nursing (ADON) confirmed that a narcotic book with resident personal information was accessible to anyone in the dayroom.During an observation on 4/12/26, at 11:10 a.m., of room [ROOM NUMBER], a medication plastic packet was lying on an accessible room identified as closed for repair.During an interview on 4/12/26, at 12:11 a.m., the Nursing Home Administrator confirmed the above findings and confirmed that the facility failed to maintain the confidentiality of resident medical information.28 Pa. Code 201.29(j) Resident rights.28 Pa. Code 211.5(b) Clinical records.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of two residents (Resident R1). This failure created an immediate jeopardy situation for 19 of 91 residents. This was identified as past non-compliance. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and a seizure disorder. Review of Section C: Cognitive Patterns revealed Resident R1 had severe cognitive impairment. Review of an Elopement Risk Assessment completed on 1/31/25, indicated Resident R1 wandered aimlessly/non-goal directed, that her wandering behavior was likely to affect the safety or well-being of self/others, and concluded that Resident R1 had, Risk of Elopement, proceed with identification of resident as an elopement risk including but not limited to wander guard (electronic monitoring bracelet) placement and facility notification. Proceed to the Care Plan and Initiate. Review of the physician's orders indicated Resident R1 was ordered an electronic monitoring bracelet, initially ordered 2/9/17, continuously reordered, and remains a current order. Review of Resident R1's plan of care for At risk for elopement related to: Wandering initiated 8/20/18, undated 8/21/24, included the goal of [Resident R1] will have no incidence of elopement. Review of a late entry progress note dated for 3/12/25, at 3:05 p.m. (created on 3/13/25, at 2:25 p.m.) indicated that the physician was notified of Resident R1's elopement. Further review of Resident R1's progress notes failed to include any other notes on 3/12/25. Review of facility submitted information dated 3/13/25 by the Director of Nursing (DON), indicated that on 3/12/25, at 5:00 p.m. [Resident R1] was observed by a Nurse Aide (NA) Employee E1 outside near [Resident R3's room]. Resident was redirected and brought inside by Registered Nurse (RN) Employee E2. RN Supervisor (RNS) Employee E4 immediately performed assessment on resident with no injury noted. At 5:19 (p.m.) Resident R1 was seen in parking lot by RN Employee E3 and redirected to inside of facility. Resident was dressed appropriately. No injuries noted. Review of an undated employee statement written by the DON indicated, On Wednesday March 12, I had left the building at 3:45 for the day and informed the ADON and RN sup (supervisor). At 4:34 p.m. RN Employee E4 called me and stated there was an elopement. Resident R1 was located outside of a window trying to crawl in. Resident was brought back into the building by NA Employee E1. RN Employee E2 was the med cart nurse, and she was taken back to her. I told RNS Employee E4 to set up a 4 point system to mark all exits to be seen and do an immediate census count. I asked if [ADON, Assistant Director of Nursing] was available, the ADON, she stated yes, and would have her call me. Told her she could assist with this and anyone in the building. Asked her to also complete Wanderguard check and function on all elopement residents I called the [NHA, Nursing Home Administrator] to inform him of the elopement, he stated he would contact [Maintenance Director Employee E5] to assist with alarm system check, as the IDT (inter-disciplinary team) text chain did not have a response from him. He stated he would contact him, Maintenance director Employee E5 has responded back in the text chain on phone and system was reset. ADON stated she had assistance from Social Worker Employee E6, Activities Director Employee E7. I had missed a call from RN Employee E3 while on the phone with RNS Employee E4. Reported that Resident R1 was in the parking lot and had returned her safely. I spoke to RNS Employee E4 again and she had all alarms in place, complete census done/complete. Resident R1 was safe, would continue 1/2 hour checks on Resident R1 and doors thru the night until safety check done on alarm system. Review of an undated employee statement written by the Human Resources Director (HRD) Employee E8 indicated, NA Employee E9 began telling me they just brought Resident R1 back into the building 5 minutes ago, Resident R1 was standing outside the window around I asked her if she was brought back to her room. The answer was yes. 4:43 pm, I called and texted DON to confirm. If she was aware of these things happening. I went look for NA Employee E9 was hallway ADON also was texted and called to find her. As I was looking for I was approached about Resident R3 trying to get out through the lobby around 5:01 pm. ADON told NA Employee E9 to call DON. I was walking toward the lobby when I (saw) that Resident R1 was outside and refused to come in, I ran to side 2 for nursing staff. Everyone was passing trays and told me Resident R1 was in her room. First by Employee E10, then by RN Employee E2 the nurse tells me twice she is too busy, and resident is in her room. I again state no she is not she is outside. I was told I was late that was earlier by RN Employee E2. I told all 200 (unit) staff she is in a car being brought back to the facility by RN Employee E3 then someone checked her bed. Resident R1 was brought back safe with RN Employee E3. Review of an employee statement dated 3/13/25, by Activities Director Employee E7 indicated, On Wed 3/12/25 I was working and heard someone saying we had an elopement. I came to the front and noticed [Resident R2] in the doorway, and the receptionist trying to tell her she needs to get to her room to have dinner. I then took Resident R2 by the hand and she walked back on the unit. A little bit later, I was getting my things together to leave for the day when I heard staff saying Resident R1 was out front. I went to get a wheelchair, they put her in the chair, and I pushed her to her room and got her sitting on her bed and advised her to eat her dinner. She was calm and agreed to eat. I then took the chair back and helped staff make sure all residents were accounted for. Review of an undated employee statement written by RN Employee E3 I was driving on Monroeville Blvd, as I was about to enter [facility name/address] I noticed one of the residents, Resident R1, getting into a caravan [license plate number]. I parked my car at the entrance of Wecare. Monroeville parking lot got out of my car and began to run towards the van, waving my hands yelling stop, stop, wait as the van was driving away. The caravan stopped and I ran up to the van and motioned my hands to put the window down. The lady that was driving put the window down and I asked her to open the door, and I asked her a second time in a stern voice open the door so I could get the resident out of the van. I tried to remove the resident from the caravan, and she said no, I am going home. I asked the driver where she was going, the driver stated East Liberty [neighborhood approximately 11 miles away]. I told the patient I would take her home to East Liberty and the patient exited the caravan, I walked a patient towards my car, she was very resistant to go with me. As she became aggressive. I tried to sit her on the passenger side of my car and proceeded to call the supervisor, DON and ADON. The supervisor responded, I drove into the parking lot and the supervisor and social worker met me outside in the parking lot to assist with getting the resident back inside the building. Review of a community member witness statement indicated, I was driving home on Wednesday 3/12 and turning right onto Monroeville Blvd at the stoplight around 5:15 p.m. I saw a gold minivan parked on Monroeville Blvd with its hazard lights on and an older woman with tied back gray hair wearing a dark pink shirt standing beside the van on the sidewalk. She was standing between the WeCare sign and the speed limit sign. Another car was parked crooked in the facility driveway, and what appeared to be a staff member was walking towards the older woman. I turned my car around up the street on [NAME] Drive back onto Monroeville Blvd and pulled into the facility driveway in front of the crooked car as the staff member was helping put the woman into her car. I asked her if she needed help and who to get for help. She stated to go to the front door and ask for [RN Employee E3's name]. I drove up to the facility and was able to tell the receptionist that a resident was down the driveway with a staff member. At that time, staff had come to the front and were notified that a resident was down the driveway with a staff member at that current time. They brought out a wheelchair to the lobby, and were able to transfer the resident into the wheelchair and back into the facility safely. No further questions were asked and no nursing staff acknowledgment, except the staff member who was with the resident outside saying thank you. I left the facility. Review of an undated employee statement written by RN Employee E2 indicated, On Wednesday March 12th, I was working the 200's hall. During the resident's first elopement, I was told she was outside by one of the CNA's (nurse aides). Assisted her back into the building. Her Wanderguard was again checked for placement and was present. During her second elopement another resident had a choking incident that utilized multiple staff members and again was notified by staff. Review of an undated, handwritten employee statement written by RNS Employee E4 indicated, RN Employee E2 was assigned as the nurse for Resident R1. She eloped twice on the shift. She did not complete a risk management, vitals, 15 min (minute) checks, head to toe assessment, progress note, did not notify family or Md (Doctor of Medicine). RN Employee E2 was the nurse assigned for 16 hours. Review of a second, typed, undated employee statement written by RNS Employee E4 stated, Resident R1 was observed by NA Employee E1 outside near Resident R3's room, the resident was redirected and brought inside by host of staff. Head to toe assessment completed by writer and no injury noted. MD and family notified. At 5:19 Resident R1 was seen in the parking lot by staff FN and redirected to inside of facility by writer and social worker. Head to toe assessment completed. No new injuries noted. New Wanderguard placed on l (left) ankle. Door checks put in place. Resident R1 was placed on q 15 min (every 15 minute) checks. ADON spoke to maintance and checked door and Accutech (alarm system) for proper functionality, had her check q (every) door that magnets where locked, and had Wanderguard system check at each door. Maintenance provided an all clear. Family, DON, and physician notified. During a follow-up interview on 3/28/25, at 11:58 a.m. RNS Employee E4 confirmed she had been terminated by the facility for lack of actions related to Resident R1's elopement. RNS Employee E4 stated that the evening had been extremely busy, with two residents attempting to leave, one resident having a choking episode, one resident found to be smoking in the facility, and one resident having a seizure while unattended in the dining room. RNS Employee E4 confirmed that she had delegated the 15 minute checks and risk assessment form to the cart nurse, RN Employee E2. The NHA and the DON were made aware that an Immediate Jeopardy situation existed for residents on 3/26/25, at 11:36 a.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 11:45 a.m. On 3/26/25, at 4:29 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Immediate action(s) taken for the resident(s) found to have been affected include: -Facility immediately recovered resident and provided safety. RN assessed resident and provided safety. -Physician and Resident Representative was notified of event. -Wander guard device -checked for placement and function. -All door alarms checked for function and lock mechanism to ensure facility is secure. -Resident care plan reviewed and updated to ensure accurate and appropriate interventions in place. -Witness statements were obtained, and immediate headcount checks completed. -On 3/12/25 Supervisor immediately conducted door securement and alarm audit and initiated a 4 point system to monitor doors to ensure security -On 3/12/25 Supervisor posted staff at each door while audit conducted to ensure doors are shut, locked, and alarms are on and functioning -On 3/12/25 DON directed RN supervisor and assigned nurse to ensure Resident receives an assessment, and notify physician and family of incident, as well as ensure resident is monitored to prevent reoccurrence. -On 3/13/25 RN Supervisor immediately performed assessment on the resident for injuries; none noted. -On 3/13/25 Door audits completed to ensure doors are secure every 30 minutes. Door alarm checks are completed to ensure alarms are functioning. -On 3/13/25 New alarms were ordered to ensure that alarm sounds are loud enough to hear. -On 3/13/25, Facility notified the attending physician to report findings and conditions of the resident and the resident's legal representative -On 3/13/24, Documentation of incident in residents record completed -On 3/13/25, resident's care plan and orders were reviewed and updated to ensure Wanderguard and exit seeking behaviors addressed in care plan and orders as appropriate -On 3/13 all residents were assessed for Elopement Risk -On 3/13/25, residents newly identified to have potential for elopement had care plans updated with appropriate interventions. -On 3/13, facility-initiated house audit for exit/entry points to ensure alarm function and doors lock appropriately -On 3/13, facility conducted whole house resident head count to ensure accountability of residents. -On 3/13, house audit conducted on resident wanderguard orders to ensure accuracy. -On 3/13, all Wanderguards placed on residents were assessed for function, care plans updated as needed. -On 3/13, Elopement Books were audited to ensure accuracy and placed at each nurses station and reception area. -On 3/17/25- RN Supervisor was provided a discipline due to not following DON directive to ensure that Resident was assessed and notifications occurred and documented- RN was terminated due to failing to complete these tasks. -On 3/17/25 Nurse assigned to resident on cart also failed to ensure resident was accounted for and skin checks performed following incident. DON provided discipline to this nurse for failure to complete tasks. Termination resulted. 2. Identification of other residents having the potential to be affected was accomplished by: -All residents in house will be assessed for elopement risk by the Director of Nursing or designee by 3/18/25. -All care plans for residents identified with elopement risks will be reviewed and updated with elopement risks will be reviewed and updated with interventions to prevent elopement by the Director of Nursing or designee by 3/18/25. -All residents identified to be elopement risk will have wanderguard placed and added to Elopement Binder per protocol by 3/18/25. -House audit on all doors and exit points will be conducted by Maintenance to ensure that facility is secure and alarms are functional by 3/18/25. -House audit on all wanderguards will be conducted to ensure placement and function by 3/18/25. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: -Facility Director of Nursing or designee will conduct education to all facility staff regarding dementia/behavior in LTC residents, Elopement risk and mitigation, and Elopement Policy and Procedures to include keeping doors secure by 3/21/25. -Education will be completed for all clinical staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee by 3/21/25. -Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee 3/21/25. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: -Audits will be conducted on all doors/exits by Supervisor twice per shift daily for 4 weeks and then weekly thereafter. -Maintenance Director or designee will conduct daily (twice per shift) audit on doors to ensure secure and alarmed. Audit will remain ongoing. -All new admissions will be reviewed for elopement risks by IDT 5 days per week weeks and ongoing. -Elopement assessments will be audited for compliance by IDT 5 days per week and will remain ongoing. -An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee. This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. Review of facility provided information indicated the facility staged an elopement drill on 3/20/24, at 11:40 a.m. to familiarize staff with procedures. During staff interviews on 3/26/25, between 1:00 p.m. and 4:00 p.m. NA Employees E12, E13, E14, E15, E16, E17, and E18 and LPN Employee E19 confirmed they received education on the elopement policy, elopement prevention and actions to take in the instance of elopement. During an observation on 3/27/25, at approximately 10:00 a.m. Resident R1's and Resident R2's pictures and information were present in the elopement book at the entrance/exit of the building. Further review of the elopement book with resident charts revealed all residents identified as elopement risks were included in the elopement book. During staff interviews on 3/27/25, between 9:00 a.m. and 11:00 a.m. LPN Employees E20 and E21, RN Employee E22, NA Employees E23 and E24, Occupational Therapy Employee E25, Dietary Employees E26, E27, and E28, Environmental Services Employees E29, E30, and E31, and Laundry Employee E32 were provided scenarios to test their knowledge on and confirmed they received education on the elopement policy, elopement prevention and actions to take in the instance of elopement. The Immediate Jeopardy was removed on 3/27/25, at 11:00 a.m. when the action plan implementation was verified. The facility had demonstrated compliance as of 3/18/25. During an interview on 3/31/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of two residents. This failure created an immediate jeopardy situation for 19 of 91 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of an elopement for one of two residents (Resident R1). This was identified as past non-compliance. Review of the facility policy Abuse and Neglect - Clinical Protocol dated 1/22/25, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Resident Elopement dated 1/22/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without knowledge of facility staff. Review of the clinical record revealed Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and a seizure disorder. Review of Section C: Cognitive Patterns revealed Resident R1 had severe cognitive impairment. Review of an Elopement Risk Assessment completed on 1/31/25, indicated Resident R1 wandered aimlessly/non-goal directed, that her wandering behavior was likely to affect the safety or well-being of self/others, and concluded that Resident R1 had, Risk of Elopement, proceed with identification of resident as an elopement risk including but not limited to wander guard (electronic monitoring bracelet) placement and facility notification. Proceed to the Care Plan and Initiate. Review of the physician's orders indicated Resident R1 was ordered an electronic monitoring bracelet, initially ordered 2/9/17, continuously reordered, and remains a current order. Review of Resident R1's plan of care for At risk for elopement related to: Wandering initiated 8/20/18, undated 8/21/24, included the goal of [Resident R1] will have no incidence of elopement. Review of a late entry progress note dated for 3/12/25, at 3:05 p.m. (created on 3/13/25, at 2:25 p.m.) indicated that the physician was notified of Resident R1's elopement. Further review of Resident R1's progress notes failed to include any other notes on 3/12/25. Review of facility submitted information dated 3/13/25 by the Director of Nursing (DON), indicated that on 3/12/25, at 5:00 p.m. [Resident R1] was observed by a Nurse Aide (NA) Employee E1 outside near [Resident R3's room]. Resident was redirected and brought inside by Registered Nurse (RN) Employee E2. RN Supervisor (RNS) Employee E4 immediately performed assessment on resident with no injury noted. At 5:19 (p.m.) Resident R1 was seen in parking lot by RN Employee E3 and redirected to inside of facility. Resident was dressed appropriately. No injuries noted. Review of an undated employee statement written by the DON indicated, On Wednesday March 12, I had left the building at 3;45 for the day and informed the ADON and RN sup (supervisor). At 4:34 p.m. RN Employee E4 called me and stated there was an elopement. Resident R1 was located outside of a window trying to crawl in. Resident was brought back into the building by NA Employee E1. RN Employee E2 was the med cart nurse, and she was taken back to her. I told RNS Employee E4 to set up a 4-point system to mark all exits to be seen and do an immediate census count. I asked if [ADON, Assistant Director of Nursing] was available, the ADON, she stated yes, and would have her call me. Told her she could assist with this and anyone in the building. Asked her to also complete Wanderguard check and function on all elopement residents I called the [NHA, Nursing Home Administrator] to inform him of the elopement, he stated he would contact [Maintenance Director Employee E5] to assist with alarm system check, as the IDT (inter-disciplinary team) text chain did not have a response from him. He stated he would contact him, Maintenance director Employee E5 has responded back in the text chain on phone and system was reset. ADON stated she had assistance from Social Worker Employee E6, Activities Director Employee E7. I had missed a call from RN Employee E3 while on the phone with RNS Employee E4. Reported that Resident R1 was in the parking lot and had returned her safely. I spoke to RNS Employee E4 again and she had all alarms in place, complete census done/complete. Resident R1 was safe, would continue 1/2 hour checks on Resident R1 and doors thru the night until safety check done on alarm system. Review of an undated employee statement written by the Human Resources Director (HRD) Employee E8 indicated, NA Employee E9 began telling me they just brought Resident R1 back into the building 5 minutes ago, Resident R1 was standing outside the window around I asked her if she was brought back to her room. The answer was yes. 4:43 pm, I called and texted DON to confirm. If she was aware of these things happening. I went look for NA Employee E9 was hallway ADON also was texted and called to find her. As I was looking for I was approached about Resident R3 trying to get out through the lobby around 5:01 pm. ADON told NA Employee E9 to call DON. I was walking toward the lobby when I (saw) that Resident R1 was outside and refused to come in, I ran to side 2 for nursing staff. Everyone was passing trays and told me Resident R1 was in her room. First by Employee E10, then by RN Employee E2 the nurse tells me twice she is too busy, and resident is in her room. I again state no she is not she is outside. I was told I was late that was earlier by RN Employee E2. I told all 200 (unit) staff she is in a car being brought back to the facility by RN Employee E3 then someone checked her bed. Resident R1 was brought back safe with RN Employee E3. Review of an undated employee statement written by RN Employee E3 I was driving on Monroeville Blvd, as I was about to enter [facility name/address] I noticed one of the residents, Resident R1, getting into a caravan [license plate number]. I parked my car at the entrance of Wecare Monroeville parking lot got out of my car and began to run towards the van, waving my hands yelling stop, stop, wait as the van was driving away. The caravan stopped and I ran up to the van and motioned my hands to put the window down. The lady that was driving put the window down and I asked her to open the door, and I asked her a second time in a stern voice open the door so I could get the resident out of the van. I tried to remove the resident from the caravan, and she said no, I am going home. I asked the driver where she was going, the driver stated East Liberty [neighborhood approximately 11 miles away]. I told the patient I would take her home to East Liberty and the patient exited the caravan, I walked a patient towards my car, she was very resistant to go with me. As she became aggressive. I tried to sit her on the passenger side of my car and proceeded to call the supervisor, DON and ADON. The supervisor responded, I drove into the parking lot and the supervisor and social worker met me outside in the parking lot to assist with getting the resident back inside the building. Review of an undated employee statement written by RN Employee E2 indicated, On Wednesday March 12th, I was working the 200's hall. During the resident's first elopement, I was told she was outside by one of the CNA's (nurse aides). Assisted her back into the building. Her Wanderguard was again checked for placement and was present. During her second elopement another resident had a choking incident that utilized multiple staff members and again was notified by staff. Review of an undated, handwritten employee statement written by RNS Employee E4 indicated, RN Employee E2 was assigned as the nurse for Resident R1. She eloped twice on the shift. She did not complete a risk management, vitals, 15 min (minute) checks, head to toe assessment, progress note, did not notify family or Md (Doctor of Medicine). RN Employee E2 was the nurse assigned for 16 hours. Review of an additional typed, undated employee statement with RNS Employee E4's name typed on it stated, Resident R1 was observed by NA Employee E1 outside near Resident R3's room, the resident was redirected and brought inside by host of staff. Head to toe assessment completed by writer and no injury noted. MD and family notified. At 5:19 Resident R1 was seen in the parking lot by staff RN and redirected to inside of facility by writer and social worker. Head to toe assessment completed. No new injuries noted. New Wanderguard placed on L (left) ankle. Door checks put in place. Resident R1 was placed on q 15 min (every 15 minute) checks. ADON spoke to maintance and checked door and Accutech (alarm system) for proper functionality, had her check q (every) door that magnets where locked, and had Wanderguard system check at each door. Maintenance provided an all clear. Family, DON, and physician notified. During a follow-up interview on 3/28/25, at 11:58 a.m. RNS Employee E4 confirmed she had been terminated by the facility for lack of actions related to Resident R1's elopement. RNS Employee E4 stated that the evening had been extremely busy, with two residents attempting to leave, one resident having a choking episode, one resident found to be smoking in the facility, and one resident having a seizure while unattended in the dining room. RNS Employee E4 confirmed that she had delegated the 15-minute checks and risk assessment form to the cart nurse, RN Employee E2. During an interview on 3/26/25, at 11:36 a.m. the Director of Nursing confirmed that after Resident R1 was brought back into the facility after her first elopement attempt, RNS Employee E4 was provided direction by the DON to notify the physician and Resident R1's emergency contact, ensure a resident assessment was completed, and have 15-minute checks begun on Resident R1. The DON confirmed that RNS Employee E4 and RN Employee E2 neglected to complete the assessment and the 15-minutes checks, which allowed Resident R1 to exit the facility again, and get into an unknown community members car. The DON and the Nursing Home Administrator confirmed that RN Employee E2 and RNS Employee E4 were terminated from their employment to this negligence of duties. Review of facility provided education documents indicated all facility staff were provided electronic education on abuse and neglect on 3/18/25, with confirmations documented that all staff received and understood the provided education. The facility has demonstrated compliance since 3/18/25. During an interview on 3/31/24, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that RN Employee E2 and RNS Employee E4 were terminated from their employment as of 3/17/25, and confirmed that the facility failed to protect residents from neglect that resulted in the actual harm of an elopement for one of two residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services, consistent with professional standards of practice for one of six residents (Resident R74), to prevent the development of pressure ulcer for two of six residents (Resident R12, Resident R41) and worsening of pressure injuries, resulting in the actual harm of a developed pressure injury, for two of six residents (Resident R12, R41). Findings include: Review of facility policy entitled, Skin Integrity Guidelines dated 11/2021, indicated it is the policy to provide a guideline for optimal care to promote healing to patients with all identified alterations in skin integrity and to decrease pressure ulcer and /or wound formation by identifying those patients who are at risk and implementing appropriate interventions. Policy also states will review residents with wounds or at risk on a weekly basis and document the findings, if a decline in skin integrity is noted residents will be repositioned every two hours or as needed, minimal linen under the prone skin areas, positioning devices such as pillows and foam wedges will be recommended, and initiate a positioning schedule for resident needs and minimize concentrated pressure to skin. Review of Resident R12's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. Review of the nursing admission assessment completed on 3/31/22, at 7:05 p.m. indicated that Resident R12 did not have any open areas on her skin. Review of the Braden Scale (a tool to identify patients at-risk for pressure sore development) completed on 3/31/22, at 9:34 p.m. indicated that Resident R12 was scored a 10 (high risk for pressure ulcer development), and also documented that Resident R12 was bedfast (confined to bed). Review of Resident R12's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 4/17/22, Section M - Skin Conditions indicated that Resident R12 did not have any pressure injuries (breakdown of skin integrity due to pressure). Review of Section G - Activities of Daily Living indicted that Resident R12 required extensive assistance of two or more people for bed mobility. Review of Resident R12's baseline care plan dated 4/1/22, indicated that Resident R12 was admitted without wounds and was to be turned and repositioned as needed. This care plan is the plan that is updated 14 days later making it the comprehensive care plan. Review of care plan dated 4/18/22, failed to show any focus, goals, or interventions for skin care or wounds. Review of Resident R12's care plan for skin integrity dated 5/2/22, indicated to document and report to medical provider as needed changes in skin status: appearance, and color and follow facility policies/protocols (nurse will be responsible for documenting weekly skin evaluations/observations, reposition every two hours, refer to therapy for positioning specialty devices restorative plan and wound care as per the plan of care) for the prevention of skin breakdown, and to educate the family and caregivers on the importance of frequent repositioning. Review of a progress note written by RN Employee E5, dated 5/8/22, at 11:18 p.m. indicated a new, opened wound to the right and left outer lower leg on Resident R12. Review of clinical documentation from 5/8/22, fails to show any description of the wounds found on Resident R12 that day. Review of the clinical documentation from 5/8/22 to 5/16/22, failed to show any notification to the doctor, staff, or therapy department for further orders or follow up. Review of a progress note written by RN Employee E6 dated 5/16/22, at 3:18 p.m. indicated a nurse aide had reported to the nurse that Resident R12 has had these open wounds for about a week and RN Employee E6 was not aware of these wounds. Wounds were measured and dressings applied. Wound measurements were left posterior calf 4.4 cm (centimeters) x 2 cm wound bed is necrotic. Right leg distal wound was 1.5 cm x 1 cm slough and necrotic area. Right leg middle wound was 1 cm x 0.75 cm and right leg proximal wound was 8 cm x 3.5 cm x 0.5 cm. All areas cleansed with Dakins (a solution for cleaning wounds), Santyl (a chemical agents for removing dead skin cells), Dakins wet to dry dressing and covered with an ABD pad ( a type of bigger gauze pad), wrapped and secure with Kerlix and tape. Review of Resident R12's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders were for Physical therapy to evaluate for offloading devices, elevating legs, offloading heel protectors, and facility pressure ulcer prevention protocol. These are the first documented wound care orders since Resident R12's admission Review of a Certified Registered Nurse Practitioner (CRNP) Employee E10 note dated 5/23/22, at 9:39 a.m. indicated Apparently on 5/8/22, the Resident R12 developed BLE (bilateral lower extremity) wounds. We have been asked to evaluate today by the WCN (wound care nurse) for the BLE wounds. Left leg wound measured 3.3 cm x 1.2 cm with sero- sanguineous (thin watery fluid) drainage. Right leg wound measurements was 10.3 cm x 3 cm with 25% slough (dead tissue) and 75% granulated tissue (tissue that appears pink and granular). The CRNP Employee E10 note also states the Resident R12 bilateral legs are laterally rotated (both legs are rotated out away from the body) and she does not ambulate. CRNP Employee E10 did not write any change in orders. Review of a subsequent CRNP Employee E10 note dated 6/6/22, at 9:40 a.m. indicated wound measurements are Left leg 1.7 cm length x 1.2 cm width x 0.2 cm depth. Wound bed has 25% slough and 76-100% granulated tissue. Right leg measurements are 8.3 cm x 4 cm x 0.2 cm. The wound is deteriorating. CRNP employee E10 did not write any change in orders. Review of a subsequent CRNP Employee E10 note dated 6/13/22, at 12:16 p.m. indicated wound measurements are Left leg 3.3 cm length x 2.4 cm width x 0.2 cm depth. Wound bed has 25% slough and 76-100% granulated tissue. Right leg measurements are 13.2 cm x 3.1 cm x 0.3 cm. Both wounds are deteriorating. CRNP Employee E10 did not write any change in orders. Review of a subsequent CRNP Employee E10 note dated 6/20/22, at 7:08 p.m. indicated wound measurements are Left leg 3.8 cm length x 1.8 cm width x 0.3 cm depth. Wound bed has 25% slough and 76-100% granulated tissue. Right leg measurements are 10.6 cm x 2.3 cm x 1 cm with necrotic tendon and bone exposed. The wound is deteriorating. CRNP Employee E10 did not write any change in orders. Review of the Treatment Administration Record for the new wounds found on 5/8/22 fails to show any treatment being ordered, documented, or completed before 5/18/22. Review of the Treatment Administration Record for the wound care treatment starting on 5/18/22, failed to indicate that Resident R12's wound treatments were documented as completed on 5/21/22, 5/25/22, 5/29/22, 5/30/22, 6/3/22, 6/9/22, 6/10/22, 6/11/22, 6/12/22, 6/14/22, 6/18/22, 6/22/22, 6/23/22, 6/24/22. During an interview on 6/22/22, at 1:00 p.m., Resident R12 stated that the staff only come into move her in bed once or twice a day. During an interview on 6/24/22, at 3:58 pm., reveled that RN Employee E5 did treat Resident R12's wounds and made a progress note but did not pass it on to the next shift or write a note to the wound nurse. Review of Resident R41's admission record indicated she was admitted to the facility 4/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R41's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 5/8/22, Section M - Skin Conditions indicated that Resident R41 did not have any pressure injuries (breakdown of skin integrity due to pressure). Review of Resident R41's care plan dated 4/25/22 indicated the resident should be repositioned as needed, document and report to the physician any changes in skin status or condition, and follow the policies for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of progress note dated 5/10/22, at 11:52 a.m., indicated a new, opened wound to left outer heel was observed on Resident R41's foot. Review of a CRNP Employee E10 note dated 5/16/22, at 9:37 a.m., indicated that the Resident R41's heel wound was an acute stage three pressure injury (involves full-thickness tissue loss) and to cleanse wound with normal saline and apply Xeroform (a type of non-adherent wound dressing), ABD (a type of gauze pad), and Kerlix (a white gauze dressing). Review of a CRNP Employee E10 note dated 5/23/22, at 10:01 a.m., indicated that heel wound to be cleansed with normal saline and apply Santyl (an ointment used to remove dead tissue from wounds), alginate (a non-adhesive wound dressing), ABD and Kerlix. Review of a CRNP Employee E10 note dated 6/20/22, at 7:00 p.m., indicated a change in treatment/ new order that heel wound should be treated with skin prep (a liquid film-forming dressing that forms a protective barrier) due to the open area status changed. Review of clinical records fails to show any wound care orders transcribed from the CRNP to the Resident R41's order list for the left heel wound from 5/10/22 through 6/28/22. Review of Treatment Administration Records failed to show documented proof that Resident R41 had received any of the treatments that was ordered 5/16/22, 5/23/22, and 6/20/22 Review of Resident R74's admission record indicated she was admitted to the facility 5/19/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of CRNP Employee E10's note dated 5/23/22, indicated that resident admitted with a stage 4 pressure injury (full thickness skin loss with extensive destruction: tissue necrosis; or exposed bone). Review of Resident R74's orders indicated that resident was to receive treatment to the wound two times per day (9:00 a.m. and 5:00 p.m.) that included cleansing with normal saline, apply [MEDICATION(S)] (a wound gel), pack with normal saline moistened gauze, and cover with dry dressing. Review of Treatment Administration Record failed to show documented proof that Resident R74 did receive wound treatments on 5/22/22, 5:00 p.m., 5/26/22, 9:00 a.m., 5/28/22, 5:00 p.m., 5/29/22, 9:00 a.m., 5/29/22, 5:00 p.m., 5/30/22, 9:00 a.m., 6/1/22, 5:00 p.m., 6/2/22, 5:00 p.m., 6/3/22, 5:00 p.m., 6/4/22, 5:00 p.m., 6/9/22, 5:00 p.m., 6/10/22, 9:00 a.m., 6/10/22, 5:00 p.m., 6/11/22, 9:00 a.m., 6/11/22, 5:00 p.m., 6/12/22, 9:00 a.m., 6/12/22, 5:00 p.m., 6/13/22, 5:00 p.m., 6/15/22, 5:00 p.m., 6/18/22, 9:00 a.m., 6/18/22, 5:00 p.m., and 6/19/22, 9:00 a.m During an interview on 6/23/22, at 1:00 p.m. the Clinical Consultant Employee E10 confirmed that the facility failed to provide the prescribed treatments and follow orders for wound care and follow up evaluations for Residents R12, R41, and R74. Clinical Consultant Employee E10 also confirmed as wounds were deteriorating on Resident R12 Employee E10 did not follow up with any other department to prevent wound deterioration. During an interview on 6/27/22, at approximately 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide prescribed treatment and services consistent with professional standards of practice for Resident R74, to prevent the development of pressure ulcers for Residents R12, and R41, and worsening of pressure injuries, resulting in the actual harm of a worsened pressure injury, for Resident R12 and R41 During an interview with the Director of Nursing (DON) on 7/5/22, at 1:05 p.m. verified that the floor nurse is in charge of wound care in the absence of a facility designated wound care nurse and the DON also verified there is no policy in place for communication when a wound that has developed is found. During an interview with RN Employee E6 7/5/22, at 4:00 p.m., revealed that the staff failed to communicate to the wound care nurse RN Employee E6 by email, phone call, written message left to her or by supervisor resulting in the Residents R12's wound care not being done between 5/8/22 and 5/16/22. During an interview on 7/6/22, at 11:53 a.m., LPN Employee E11 confirmed that the Resident R12's wound care was not completed as ordered. During an interview with LPN Employee E12 on 7/6/22 at 2:25 p.m., confirmed Resident R12 did not receive the wound care as ordered and that the weekly skin checks were not being done and documented. During an interview on 7/6/22, at approximately 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide prescribed treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for Residents R12, R41, and R74, and worsening of pressure injuries, resulting in the actual harm of a worsened pressure injury, for Resident R12 and R41. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 2/26/21, 8/25/21, 11/15/21. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 201.29(a) Resident rights. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 211.10 (c) Resident care policies. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited: 2/26/21, 8/25/21, 11/15/21. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited: 2/26/21, 11/15/21. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited: 2/26/21, 8/25/21, 11/15/21.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident was free from accidents and hazards, which resulted in actual harm for one of three residents reviewed (Resident R1). Findings include: A review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], and had current [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of the plan of care last updated 1/2/17, indicated Resident R1 was at risk for injuries related to falls and was to transfer with a Sara lift. During an interview on 3/22/18, at 10:35 a.m. Nurse Aide Employee E2 indicated that nurse aides are informed how to transfer a resident according to the plan of care by reviewing the Focus sheets which are kept at the nurses desk. During an observation on 3/22/18, at 10:35 a.m. it was revealed that the Focus sheets were available to the nurse aides at the nurses desk. A review of the Focus sheet dated 3/7/18, revealed that Resident R1 was to use a Sara lift for transfers. A review of the Focus sheet dated 12/7/17, (prior to the incident), revealed that Resident R1 was to use a Sara lift for transfers. A review of the witness statement dated 1/4/18, revealed that Nurse Aide (NA) Employee E1 indicated that during a transfer on 1/4/18, Resident R1 let go of the wheelchair and let go of NA Employee E1's neck to get food off of his/her chest, then hit leg on the wheelchair. NA Employee E1 indicated he/she was not trained that Resident R1 was a sit to stand (Sara lift). A review of the progress note dated 1/4/18, at 1:51 p.m. indicated that Resident R1 had a laceration on the left lower leg with bloody drainage and was sent to the hospital. A review of information dated 1/5/18, submitted by the facility, indicated that Resident R1 was transferred from the bed to the wheelchair, without the use of the Sara lift, and sustained a laceration which required nine sutures and an antibiotic for seven days. During an interview on 3/22/18, at 1:10 p.m. the Assistant Director of Nursing (ADON) Employee E3, confirmed that documentation for NA Employee E1's orientation and prior to 1/4/18, did not include education on the Sara lifts and Focus sheets. During an interview on 3/22/18, at 2:00 p.m. the ADON Employee E4, confirmed that the facility failed to implement interventions to reduce hazards and risks during a transfer which resulted in harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/26/17, 3/25/16. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 3/25/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 3/25/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/26/17, 3/25/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/26/17, 9/16/16, 3/25/16.

Based on review of facility policy, clinical records and resident and staff interviews, it was determined that the facility failed to administer medications as ordered by the physician for one of 24 residents reviewed (Resident R4). Findings include: The facility pharmacy policy entitled "Medication Administration" dated 1/25/13, indicated that if the medication is unavailable in the facility, the pharmacy is contacted or the medication is removed from the emergency box. The policy also indicated that if two consecutive doses of a vital medication are not available the physician should be notified. The quarterly Minimum Data Set assessment (MDS -a periodic assessment of care needs) dated 2/14/13, indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS indicated that Resident R4 stated he/she had pain frequently, making sleep difficult and rated the pain as a "ten" in severity, when scaled on a one (no pain) to ten (worst pain) severity scale. The quarterly MDS also indicated that Resident R4 was not cognitively impaired and was able to make his/her needs known. Review of a physician consultation report dated 3/21/13, indicated that Resident R4 complained of a headache, possibly resulting from the shingles virus infection. Review of a physician order [REDACTED].) three times daily, at 8:00 a.m., 12:00 p.m., and 4:00 p.m. Review of the March 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the March 2013, MAR indicated [REDACTED]. Review of a physician order [REDACTED].), three times daily at 8:00 a.m., 2:00 p.m., and 10:00 p.m. Review of the March 2013, MAR indicated [REDACTED]. During an interview on 5/10/13 at 2:25 p.m., Resident R4 stated he/she continued to have "very bad" headaches at times and did remember being told by the nursing staff that "they ran out of pain medication." During an interview on 5/10/13 at 1:40 p.m., the Director of Nursing confirmed that the [MEDICATION NAME] was not available and that Resident R4 did not receive the pain medication as ordered by the physician on 3/19/13, 3/20/13, 3/23/13, 3/24/13, and 3/28/13. 28 PA. Code: 201.14(a) Responsibility of Licensee. Previously cited 5/27/11. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 5/27/11. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 5/27/11. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/13/12, 5/27/11.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow a physician order [REDACTED]. Finding include: Resident R23 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the hospital discharge instructions dated 4/24/13, revealed a physician order [REDACTED]. A physician's orders [REDACTED]. The facility "Weight Report" (computer generated record of resident weights) beginning 4/24/13, for Resident R23, did not include documentation that daily weights were recorded. Resident R23's fluid intake and urine output record (document to record fluid intake and urine output) indicated three entries out of 14 total opportunities, from 4/24/13 to 4/29/13. A nurses' note dated 4/29/13, indicated that Resident R23 had a ten pound weight gain since admission (5 days). The note also stated that Resident R23 indicated he/she, "felt heavy in the middle" and had less than 1000 cc's (cubic centimeters) of fluid intake and less than 40 cc's of urine output in a 24 hour period from 4/28/13 at 12:30 p.m., to 4/29/13 at 12:30 p.m. Resident R23 was admitted to the hospital on [DATE], for monitoring of apparent kidney rejection and a [DIAGNOSES REDACTED]. During an interview on 5/9/13, at 1:00 p.m., the Director of Nursing confirmed that the physician's orders [REDACTED]. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 5/27/11. 28 Pa. Code: 211.5(f) Clinical records. Previously cited 4/13/12, 5/27/11. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/13/12, 5/27/11.