Every finding on record at Wesley Village

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations during the initial tour of the kitchen conducted with the facility's Food and Nutrition Services Director on February 10, 2026, at 8:50 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for foodborne illness: The handwashing sink was visibly soiled and there were four small chunks of canned fruit cocktail in the basin of the sink. There was a thick layer of dust on the fins of the hood vent panels located above the stove. There were two broken wall tiles which created a two inch gap located above the floor molding in the food cart storage area. The kitchen floor perimeter had an accumulation of dirt and debris, creating an unsanitary condition which could harbor pests and bacteria. Interview with the Food Service Director at the time of observations confirmed the food and nutrition services department was to be maintained in a sanitary manner. 28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services.

Based on a review of clinical records, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to ensure residents are afforded the opportunity to make informed treatment decisions and choose preferred alternatives for one out of four residents sampled for a closed record review (Resident 128).Findings include: Clinical record review revealed Resident 128 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed Resident 128 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A physician's order for Bisacodyl Laxative Suppository 10 mg with direction to insert one suppository rectally as needed for bowel management protocol was initiated on December 15, 2025. A medication administration record dated December 2025 revealed Resident 128 was administered Bisacodyl Laxative Suppository 10 mg on December 20, 2025, at 6:59 AM. A progress note dated December 20, 2025, at 8:29 PM revealed Resident 128 was upset after she was administered a suppository even though she said no. Resident 128 indicated she had the right to say no to something she did not want. A review of a grievance filed with the facility dated December 20, 2025, at 5:30 PM revealed Resident 128 stated she was sleeping and the nurse supervisor came into her room and said, Wake up, wake up, and proceeded to insert a suppository into her rectum, which she was not ready for nor awake enough to realize what was happening. The grievance indicated Resident 128 had a problem with not being given the opportunity to wake up and fully understand what they wanted to do because she was sleeping before they entered the room. A witness statement provided by Employee 1, Registered Nurse (RN), revealed that Employee 1, RN, entered Resident 128's room on December 20, 2025, at 6:50 AM. Employee 1, RN, explained to the resident that they would be giving her a suppository. Employee 2, Nurse Aide, assisted in turning the resident, and the suppository was given, and the resident tolerated it well. Employee 1, RN, indicated at no time did the resident decline the suppository. A witness statement provided by Employee 2, Nurse Aide, indicated that she remembered entering Resident 128's room with Employee 1, RN, on December 20, 2025. Employee 2, NA, indicated that she did not remember anything out of the normal. Employee 2, NA, indicated that she does not rush residents and is very gentle. During a phone interview on February 13, 2025, at 9:24 AM, Resident 128 indicated she was upset because she was not afforded an opportunity to decline a suppository. She explained that she filed a grievance after nursing staff administered a suppository without providing her an opportunity to decline the medication. During an interview on February 13, 2025, at 11:15 AM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The DON and NHA confirmed that residents are to be afforded the opportunity to choose, accept, or refuse care, including medication and treatments. The facility failed to ensure the resident's right to fully participate in care and treatment when Resident 128 was not afforded the opportunity to refuse a suppository on December 20, 2025. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(7) Medical director. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 25 residents sampled (Resident 83).Findings include: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on March 19, 2025, revealed it is facility policy to maintain an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The policy indicates that diagnostic tests should be used wisely to avoid unnecessary antibiotic therapy or therapy that is unnecessarily broad-spectrum, with consideration to healthcare value. Bacterial cultures with susceptibility testing should be collected, handled, and processed promptly and appropriately to identify specific bacteria causing infection and facilitate the use of narrow-spectrum antibiotics whenever possible. A clinical record review revealed that Resident 83 was admitted to the facility on [DATE], with diagnoses that include chronic heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A progress note dated January 4, 2026, at 4:19 PM indicated the resident had a 101.9 F temperature but was resolved. The resident denied abdominal pain, dysuria (pain, burning, or discomfort during urination), and confusion. The note indicated if clinical infection is suspected, then initiate antibiotics after urine cultures were obtained. A urine culture and sensitivity report (C and S report, which detects, identifies, and determines the best treatment for bacterial or fungal infections in the urinary tract) dated January 4, 2026, and reported on January 7, 2026, at 3:09 PM revealed Resident 83's urine was positive for the organism pseudomonas aeruginosa (a bacterium found in soil and water that thrives in moist environments, frequently causing infections in hospitalized or immunocompromised individuals). The results indicated the organism was resistant (medication type not effective in treating the specific bacteria) to ciprofloxacin (an antibiotic medication). A progress note dated January 7, 2026, at 8:36 PM revealed as a result of the urine culture and sensitivity a new physician order for ciprofloxacin 500 mg twice a day for five days was ordered. A physician's order for ciprofloxacin HCI oral tablet 500 mg with directions to give 1 tablet by mouth two times a day for a culture and sensitivity result was initiated on January 7, 2026. A Medication Administration Record dated January 2026 revealed Resident 83 was administered 1 dose of ciprofloxacin 500 mg on January 7, 2026, at 9:00 PM. A progress note dated January 8, 2026, at 9:00 AM revealed ciprofloxacin 500 mg was discontinued. During an interview on February 11, 2026, at 1:15 PM, the Infection Preventionist (IP) confirmed that Resident 83 was administered ciprofloxacin 500 mg on January 7, 2026, following a culture and sensitivity. The IP confirmed the culture and sensitivity reported on January 7, 2026, indicated the organism identified in Resident 83's urine was resistant to ciprofloxacin. The facility failed to ensure Resident 83's drug regimen was free of an unnecessary antibiotic when the resident received one dose of ciprofloxacin 500 mg on January 7, 2026.28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observations, review of clinical records, resident and staff interviews, and meal test tray results, it was determined the facility failed to serve meals that were palatable and at safe and appetizing temperatures for a test tray completed on the [NAME] Unit during the breakfast meal and for experiences of five of 25 residents sampled (Residents 82, 83, 20, 44, and 105).Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, specifies that food temperatures between 41 F and 135 F allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Hot foods must be maintained at or above 135 F and cold foods at or below 41 F. A review of a facility evaluation form titled Resident Tray Assessment revealed that hot food items were assessed based on being greater than or equal to 135 degrees Fahrenheit and on palatability. Palatable means acceptable to taste, including appropriate temperature, texture, and flavor. A clinical record review revealed Resident 82 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body). A review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 5, 2026, revealed that Resident 82 was cognitively intact with a BIMS (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) score of 15 (a score of 13 to 15 indicates cognition is intact). During an interview on February 10, 2026, at 10:42 AM, Resident 82 explained that the food temperatures are often cold because the meal trays sit for 30 to 45 minutes before staff are able to pass them on to residents. A clinical record review revealed that Resident 83 was admitted to the facility on [DATE], with diagnoses that include chronic heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 83 was cognitively intact with a BIMS score of 15. During an interview on February 10, 2026, at 11:05 AM, Resident 83 indicated that he was frustrated because the food is often cold. He explained that the soup is too cold for him to enjoy. A clinical record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that include heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 20 was cognitively intact with a BIMS score of 15. During an interview on February 10, 2026, at 11:24 AM, Resident 20 stated that he had concerns about food temperatures. He reported that staff frequently served his eggs cold and that he needed to request reheating. During a resident group interview on February 11, 2026, at 10:00 AM, Residents 44 and 105 reported concerns regarding cold food temperatures. Resident 105 stated that staff frequently delivered her meals cold and that she needed to request reheating. Resident 44 stated that she felt upset because staff continued to deliver her meals cold and that she had reported this concern to staff multiple times over the previous weeks. Resident 44 reported that meal trays remain on carts for at least 20 minutes before staff deliver them to residents. She stated that breakfast presents the most frequent problem and that staff regularly serve her eggs cold. Survey staff conducted a test tray evaluation on the [NAME] Unit on February 12, 2026, during the breakfast meal. Dietary staff placed the test tray in the meal delivery cart with resident trays at 7:50 AM. Unit staff began distributing trays from the cart at 8:20 AM, resulting in a 30-minute delay. At 8:30 AM, after the last resident was served, food temperatures were recorded and revealed the following temperatures. The oatmeal was 121 degrees Fahrenheit, the omelet was 115 degrees Fahrenheit, the Canadian bacon was 110 degrees Fahrenheit, and the wheat toast cold and rubbery. The food tasted only lukewarm and was not palatable at the temperature served. Interview with the Nursing Home Administrator (NHA) on February 12, 2026, at 11:00 AM confirmed that food served is to be palatable and served at safe and appetizing temperatures. The NHA confirmed that residents' food trays were to be timely served to residents upon arrival to each nursing unit to help ensure palatable temperatures. 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on clinical record and select policy review, staff and resident interviews, it was determined the facility failed to timely assess and implement interventions to address one of 25 residents' pain (Resident 2).Findings include:A review of the facility's pain management policy dated March 19, 2025, revealed that it was the goal of the facility to promote the highest practicable level of physical, mental, and psychological well-being, in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. The pain management policy also indicated the resident will have pain identified and assessed. The type of pain will be identified for appropriate management approaches to alleviate/eliminate the resident's pain. A review of Resident 2's clinical record revealed the resident had a diagnosis of muscle weakness and diabetes (a chronic condition causing high blood sugar due to insufficient insulin production). An admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2026, revealed a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). Nursing documentation dated January 21, 2026, at 4:41 AM, revealed the resident was up most of the night asking for Tylenol, a mild pain reliever. The note further indicated the facility had no physician orders for the requested Tylenol and staff on the 3 pm-11 pm shift informed the resident there were no orders to administer her Tylenol. A review of the pain assessments completed for January 2026 indicated that on the evening of January 20, 2026, a pain assessment was completed at 5:35 PM which indicated the resident was pain-free. There was no indication that a pain assessment was completed in conjunction with the nurse's note on January 21, 2026, at 4:41 AM, in which the resident requested Tylenol, or that an assessment was completed to further determine why the Tylenol was specifically requested. A nurse's note dated January 22, 2026, at 12:05 PM, indicated the resident had complaints of overnight pain and that the physician assistant ordered the resident Tylenol 650 milligrams every 24 hours as needed. There was no indication the facility attempted to contact the physician for further direction to attempt to manage the resident's discomfort either during the evening or night shift hours. An interview with Resident 2 on February 11, 2026, at 11:55 AM, revealed she was very uncomfortable in the bed and stated the bed mattress is shot. The resident indicated that lying in bed was very uncomfortable, her entire body hurt, and that she wanted medication/intervention to relieve the pain so she could sleep. The resident indicated her pain was a nine out of ten on a ten-point scale, where 1 would indicate mild pain and 10 would indicate severe pain. The resident indicated she was neither given any medication nor non-pharmacologic intervention to relieve/alleviate her pain. Interview with the director of nursing on February 12, 2026, at 1:00 PM was unable to provide evidence the facility accurately and timely assessed this resident's pain, implemented interventions to alleviate pain, and/or documented the effectiveness/outcome of the interventions. 28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services28 Pa. Code 211.10(d)Resident care policies

Based on observation and resident and staff interviews, it was determined the facility failed to post the most recent survey results which include any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility and experiences reported by 5 out of 5 residents interviewed during a group interview (Residents 8, 44, 51, 55, and 105). Findings include: During a resident council interview on February 11, 2026, at 10:00 AM, five alert and oriented residents in attendance (Residents 8, 44, 51, 55, and 105) indicated they did not know where the facility posted the Department of Health survey results. Observation of the facility reception area on February 11, 2026, at 11:19 AM revealed there was state survey inspection results available in a binder in the lobby of the facility. Review of the binder revealed the most recent recertification results were not available in the binder. Recertification survey results from the survey of May 9, 2025, were not available. During an interview on February 11, 2026, at 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the Department of Health survey results were not updated to include the most recent recertification survey results. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medication for one resident (Resident 61) and further failed to develop procedures and criteria for a palliative care program (Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) to provide person-centered care in accordance with the comprehensive person-centered care plan, and the residents' choices for palliative care for two of 28 sampled residents (Residents 14 and 39). Findings include: A review of facility policy titled: Preparing, Administering and Documenting Medications last reviewed by the facility on March 19, 2025, indicated that medications are administered within one hour of their prescribed times, unless otherwise specified. Review of Resident 61's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a progressive disorder that affects movement). A review of the clinical record also revealed a physician's order for Carbidopa-Levodopa (a combination medicine used to treat the symptoms of Parkinson's disease) 50-200 MG, with instructions to administer one tablet by mouth two times a day, was initiated on April 6, 2025. A review of Resident 61's Medication Administration Record for May 2025 revealed that the resident was prescribed and scheduled to receive the following medication: Carbidopa-Levodopa 50-200 milligrams, one tablet by mouth two times a day (8:00 AM and 4:00 PM). A review of the facility's Medication Administration Audit Report for April 6, 2025, through May 6, 2025, revealed the following: April 8, 2025, the medication scheduled for 8:00 AM was not administered until 9:25 AM, 1 hour and 25 minutes after the scheduled time. April 11, 2025, the medication scheduled for 4:00 PM was not administered until 5:30 PM, 1 hour and 30 minutes after the scheduled time. April 13, 2025, the medication scheduled for 8:00 AM was not administered until 9:46 AM, 1 hour and 46 minutes after the scheduled time. April 15, 2025, the medication scheduled for 8:00 AM was not administered until 10:26 AM, 2 hours and 26 minutes after the scheduled time. April 16, 2025, the medication scheduled for 8:00 AM was not administered until 9:12 AM, 1 hour and 12 minutes after the scheduled time. April 16, 2025, the medication scheduled for 4:00 PM was not administered until 5:55 PM, 1 hour and 55 minutes after the scheduled time. April 17, 2025, the medication scheduled for 8:00 AM was not administered until 9:35 AM, 1 hour and 35 minutes after the scheduled time. April 18, 2025, the medication scheduled for 8:00 AM was not administered until 11:32 AM, 3 hours and 32 minutes after the scheduled time. April 20, 2025, the medication scheduled for 8:00 AM was not administered until 10:18 AM, 2 hours and 18 minutes after the scheduled time. April 21, 2025, the medication scheduled for 8:00 AM was not administered until 9:33 AM, 1 hour and 33 minutes after the scheduled time. April 23, 2025, the medication scheduled for 8:00 AM was not administered until 9:22 AM, 1 hour and 22 minutes after the scheduled time. May 1, 2025, the medication scheduled for 8:00 AM was not administered until 9:55 AM, 1 hour and 55 minutes after the scheduled time. May 2, 2025, the medication scheduled for 4:00 PM was not administered until 5:57 PM, 1 hour and 57 minutes after the scheduled time. May 3, 2025, the medication scheduled for 8:00 AM was not administered until 9:28 AM, 1 hour and 28 minutes after the scheduled time. May 4, 2025, the medication scheduled for 8:00 AM was not administered until 9:25 AM, 1 hour and 25 minutes after the scheduled time. May 5, 2025, the medication scheduled for 8:00 AM was not administered until 9:22 AM, 1 hour and 22 minutes after the scheduled time. Interview with the Nursing Home Administrator on May 7, 2025, at approximately 10:00 AM confirmed medications should be administered timely in accordance with physician orders and professional standards of practice. Review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses, which include dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning). A nurses note dated April 22, 2025, indicated the resident representative decided to transition the resident into Palliative Care and orders were placed to reflect the family's request. A physician order dated April 22, 2025, revealed an order for Palliative Care, no weights, oxygen at 2L/min for shortness of breath. A physician order dated April 24, 2025, revealed an order to discontinue by mouth medications. Further review of the clinical chart for Resident 14 revealed there was no palliative care plan, no signed consent for palliative care, and no doctor or social worker note associated with the palliative care for review. A review of the clinical record revealed that Resident 39 was admitted to the facility on [DATE], with diagnoses that included dementia and atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal). A quarterly Minimum Data Set Assessment (MDS-- a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 39, dated March 20, 2025, revealed the resident was severely cognitively impaired. A review of Resident 39's clinical record revealed that they had a designated power of attorney for care who was their resident representative at the facility. A nursing progress note dated April 17, 2025, documented that facility staff held a discussion with the resident representative regarding the resident's ongoing weight loss. During the conversation, the resident's advance directives were reviewed, and the representative expressed a preference for palliative care, including no feeding tube placement and no hospital transfer. A physician's order dated April 17, 2025, included directives for palliative care, no weights, no parenteral or enteral nutrition or hydration (methods of delivering nutrition via feeding tube or intravenous line), and no laboratory testing. However, the order lacked documentation of a clinical diagnosis or rationale supporting the initiation of palliative care. Further review of the clinical record revealed the absence of a comprehensive palliative care plan, no signed consent from the resident representative authorizing palliative care, and no supporting progress notes from a physician or social worker to document interdisciplinary involvement or justification for the change in the resident's plan of care. An interview conducted with the Director of Nursing and the Administrator on May 9, 2025, at approximately 9:00 AM, failed to produce documentation outlining the clinical rationale or medical necessity for the palliative care orders issued. Additionally, the facility was unable to provide evidence of a facility policy or established criteria used to determine a resident's eligibility for palliative care services. 28 Pa. Code 211.10(a)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2) Nursing Services

Based on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to reassess a resident's pain status and medication prescribed on as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 28 residents sampled. (Resident 14). Findings include: A review of the facility's policy for pain assessment and management last reviewed, March 2025, revealed the facility will provide the resident with care and services to address and manage the resident's pain to support his or her highest practicable level of physical, mental, and psychosocial well-being. Using the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences, the resident will have pain identified and assessed, have the type of pain identified along with appropriate management approaches, and have pain adequately managed (eliminated if possible or relieved to a tolerable level). The policy requires a comprehensive pain assessment upon admission, quarterly, annually, with any significant change in status, and with the onset of new pain. Clinical record review revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses including dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) and pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart). An admission Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 13, 2025, revealed a BIMS score (Brief Interview for Mental Status- the BIMS test is used to get a quick snapshot of cognitive function) of 10 (a score of 8-12 indicates moderate impairment), required staff assistance for activities of daily living, no pain the last five days, did not receive scheduled pain medication, and did not exhibit shortness of breath. A physician order initially dated April 11, 2025, noted an order for acetaminophen (pain reliever) 325 mg give two tablets po (by mouth) PRN (as needed) for pain scale of 1-5. Do not exceed 3000 mg/24 hours. A physician order initially dated April 22, 2025, noted an order for oxygen 2L/minute continuous via nasal cannula for shortness of breath. A physician order initially dated April 22, 2025, and discontinued April 28, 2025, noted an order for Morphine Sulfate (narcotic analgesic pain medication) 20 mg/ml give 0.25 mg po every 6 hours PRN for shortness of breath/pain 6-10 for 14 days. A physician order initially dated April 28, 2025, noted an order for Morphine Sulfate 20 mg/ml give 0.25 mg by mouth every 6 hours PRN for shortness of breath for 14 days. A physician order initially dated May 7, 2025, noted an order for Morphine Sulfate Solution 20 mg/ml give 0.25 ml by mouth every 6 hours PRN for shortness of breath for 14 days with instructions to document respiratory assessment. A care plan-initiated April 9, 2025, identified Resident 14 as at risk for pain and included interventions such as administering acetaminophen as ordered, evaluating effectiveness of pain interventions every shift and as needed. Monitor and report to nurse any signs/symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Despite the established plan, the resident's Medication Administration Record (MAR) revealed the following: April 23, 2025, at 10:07 AM the resident received the PRN Morphine Sulfate based /ml 0.25 mg by mouth for a pain level of 4 (despite prescribed for pain level of 6-10). A review of the resident's May 2025 MAR revealed the PRN Morphine Sulfate 20 mg/ml 0.25 mg for shortness of breath was administered on the following dates: May 1, 2025, at 5:45 PM for a pain level of 4 (no shortness of breath noted) May 3, 2025, at 5:28 AM for a pain level of 7 (no shortness of breath noted) May 3, 2025, at 8:53 PM for a pain level of 5 (no shortness of breath noted) May 4, 2025, at 9:22 PM for a pain level of 4 (no shortness of breath noted) May 6, 2025, at 1:15 AM for a pain level of 5 (no shortness of breath noted) Further review of the clinical record revealed no documented evidence of a comprehensive reassessment of the resident's pain status following the onset of pain on April 22, 2025, nor evidence that the pain management plan was reviewed or modified accordingly. During an interview on May 9, 2025, at approximately 10:00 AM the Director of Nursing (DON) confirmed the following. a comprehensive pain assessment was not completed as per facility policy to help identify Resident 14's cause of pain and develop an individualized pain management program for the resident. Staff administered a narcotic prescribed for pain levels 6-10 when pain levels were consistently documented as 4-5. After the April 28, 2025, physician order changed the indication to shortness of breath only, staff continued administering Morphine Sulfate without evidence the resident was experiencing shortness of breath. Staff administered narcotic pain medication on five occasions between May 1, 2025, and May 6, 2025, without a physician order and with no documented evidence the resident was experiencing shortness of breath and there was no evidence of a comprehensive pain reassessment to determine whether the resident's pain management regimen was effective, appropriate, or in need of adjustment. At the time of the survey, there was no documentation that the facility evaluated the cause of Resident 14's pain, reassessed the appropriateness of PRN medications, or modified the care plan to address the resident's emerging symptoms. The facility practice failed to ensure pain management was based on comprehensive reassessment and individual needs. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, observation, and staff interview it was determined the facility failed to provide a physician ordered therapeutic diet (diet ordered by a physician or other delegated provider that is part of tthe treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) for one resident out of 28 sampled (Resident 54). Findings include: A review of the clinical record of Resident 54 revealed the resident had diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) and oral phase dysphagia (difficulty swallowing which includes problems with using the mouth, lips, and tongue to control food or liquid). Review of a Speech Therapy Treatment Encounter Note dated May 14, 2024, revealed a recommendation for the use of lemon ice to facilitate oral movement for AP transfer [anterior-posterior transfer- the movement of the bolus (food or liquid mass) from the front of the mouth to the back, and then down the throat]. A physician order initially dated May 14, 2024, noted an order for a Pureed NAS (no added salt) diet with lemon ice at meals. Observation of the resident's lunch meals on May 6, 2025, at 12:00 PM and May 7, 2025, at 12:10 PM revealed the resident did not receive lemon ice on her meal tray. Review of the resident's meal tray ticket revealed no written order for lemon ice with meals. Interview with employee 1 (LPN) on May 7, 2025, at approximately 12:10 PM confirmed that lemon ice was not designated on the resident's meal tray ticket. During an interview on May 9, 2025, at approximately 9:30 AM the Certified Dietary Manager (CDM) confirmed that Resident 54's current physician orders included lemon ice with each meal. The CDM confirmed the facility failed to provide lemon ice on the resident's meal trays to facilitate swallowing. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 28 sampled (Resident 43). Findings include: A review of the facility policy titled Administration of Oxygen, last reviewed by the facility on March 19, 2025, revealed it is the facility's policy to provide oxygen therapy to residents upon order of the physician. The policy indicates it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen per physician's orders. A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Further clinical record review revealed Resident 43 had an altered respiratory status initiated on February 19, 2025. Interventions implemented to assist Resident 43 with her goal of maintaining a normal breathing pattern included monitoring for signs and symptoms of respiratory distress, reporting to the physician as needed, and providing the resident oxygen via a nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) at 1.0 liters per minute (LPM). However, a discrepancy was identified. Resident 43 has a physician's order to receive oxygen at 2.0 liters per minute via a nasal cannula initiated on March 26, 2025. An observation on May 7, 2025, at 12:10 PM revealed Resident 43 was awake and sitting upright in her chair with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 0.0 liters per minute. Tubing connected the oxygen concentrator to her via a nasal cannula. During an interview at the time of the observation, Resident 43 indicated that she couldn't feel any airflow from the nasal cannula. During an interview on May 7, 2025, at 12:15 PM, Employee 2, Licensed Practical Nurse (LPN), confirmed Resident 43 should be receiving continuous oxygen via a nasal cannula at 2.0 liters per minute. Employee 2, LPN, indicated she would set the oxygenator to correctly administer oxygen and check the resident's vital signs. A progress note dated May 7, 2025, at 12:32 PM revealed Resident 43's oxygen concentrator was checked and the liter flow was set to 0.0 LPM. The flow rate was immediately adjusted, and the resident's blood-oxygen saturation (SpO2) was measured with a pulse oximeter (a device that measures the percentage of oxygen carried by red blood cells in the blood, which is referred to as oxygen saturation). The resident's blood-oxygen saturation (SpO2) was 93% (a normal range is 95-100%; however, individuals with chronic diseases may have levels below 95%). Resident denied shortness of breath or distress. During an interview on May 9, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure oxygen therapy is administered per physician's orders. The NHA also confirmed it is the facility's responsibility to ensure each resident's plan of care is congruent with physician's orders, including orders for oxygen therapy. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent with a resident's documented code status (hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) preference for one of 28 residents reviewed (Resident 75). Findings include: A review of the facility's policy titled Cardiopulmonary Resuscitation, last reviewed on [DATE], indicated that when a resident's resuscitation preference is determined or changed, the facility is responsible for ensuring that the electronic medical record reflects the resident's choice in the Advanced Directives section and that physician orders match the resident's expressed wishes. A review of the clinical record of Resident 75, revealed the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (blood pressure that is higher than normal) and epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). A review of Resident 75's clinical record revealed a completed and signed CPR Status form (cardiopulmonary resuscitation- life-saving procedure performed when the heart or breathing stops), dated [DATE], which indicated the resident elected not to receive cardiopulmonary resuscitation (CPR) in the event their heart or breathing stopped. However, further review of the resident's electronic medical record revealed that physician orders entered on [DATE], listed the resident's code status as CPR, meaning resuscitation should be performed. There was no documentation showing that the resident changed their decision or participated in any discussion suggesting an update to their previously signed CPR Status form Following surveyor inquiry, a physician's order was entered on [DATE], to change the code status to DNR (Do Not Resuscitate-a medical order indicating that CPR should not be administered if the resident's heart or breathing stops). An interview with the Nursing Home Administrator (NHA) on [DATE], at 10:00 AM confirmed that physician orders are expected to match the resident's signed CPR Status form. The Administrator acknowledged that the original physician order indicating CPR did not reflect the resident's expressed wishes documented on [DATE], and stated that the inconsistency should have been corrected prior to surveyor identification. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 28 residents (Resident 24). Findings include: A review of a facility policy titled Psychotropic Medication, last reviewed by the facility on March 19, 2025, revealed it is the facility policy that residents shall not receive psychotropic medications which are not clinically indicated to treat a specific condition. Further policy review revealed that documented consent, given voluntarily and free from coercion, by the resident or resident representative (if applicable), to use a psychotropic medication after being provided with sufficient information regarding general psychotropic use and specific considerations related to the psychotropic medication being considered for use will be obtained. A clinical record review revealed that Resident 24 was admitted to the facility on [DATE], with diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 24, dated December 28, 2024, revealed the resident was severely cognitively impaired with a BIMS score of 05 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). Further review of the clinical record revealed that Resident 24 had a designated power of attorney who was their resident representative at the facility. A review of a physician's order dated December 22, 2024, revealed an order for Seroquel 25 milligrams (mg) (an antipsychotic medication used to treat mood disorders) two times a day. A review of a form titled Psychoactive Medication Informed Consent, dated December 30, 2024, revealed consent for an antipsychotic medication, Seroquel, with a verbal consent checked at the bottom of the form, indicating Resident 24 gave verbal consent. There was no indication that Resident 24's resident representative was made aware of this consent for the antipsychotic medication Seroquel. A review of Resident 24's progress notes revealed no indication that the resident's responsible party were notified of the medication, that the risks and benefits were explained or that the resident was offered alternative treatment options. A review of Medication Administration Records (MARs) from December 2024 to February 2025 for Resident 24 revealed the resident received Seroquel 25 mg twice a day from December 22, 2024, to February 10, 2025. A review of a progress note dated February 10, 2025, revealed the resident representative inquired about discussing Resident 24's medications and was adamant that she did not want her mother to have Seroquel at all and provided a pre-hospital medication list. The physician then re-evaluated and started a gradual dose reduction of Seroquel, and the resident representative was made aware of same. A review of a physician's order dated February 10, 2025, revealed an order for Seroquel 12.5 mg two times a day for 7 days, then 12.5 mg daily for 7 days, then discontinue the medicaion. The facility was unable to provide the pre-hospital list given by the resident representative on February 10, 2025, and it was not part of the clinical record. Interview with the Nursing Home Administrator (NHA) on May 9, 2025, at 9:00 A.M., confirmed there was no documentation available for review at the time of the survey to indicate that Resident 24's responsible party was informed of the psychotropic medication, that the risks and benefits were explained, or that they were offered alternative treatment options. 28 Pa Code 201.29(a) Resident rights

Based on review of the facility's admission agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and resident representative, and the facility agree on the selection of a venue that is convenient to both parties. Findings include: A review of the facility's Admission Agreement packet, specifically Section 19.4 Binding Arbitration Subsection (f) Location of Arbitration, contained Subject to mutual agreement of the parties, the arbitration will be conducted at the facility or at a site within a reasonable distance of the facility. During an interview on May 9, 2025, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed the language of the arbitration agreement does not state that the location of the arbitration will be at a venue that is convenient to both the resident/resident representative and the facility. The NHA confirmed the language of the policy states two options for the location of arbitration (1) at the facility or (2) a site within a reasonable distance of the facility. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for five out of 28 residents reviewed (Residents 1, 20, 87, 90, and 18). Findings include: A review of the clinical record revealed that Resident 1 was transferred to the hospital on March 8, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 20 was transferred to the hospital on April 27, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 87 was transferred to the hospital on March 17, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 90 was transferred to the hospital on January 10, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 18 was transferred to the hospital on September 14, 2024, and was readmitted to the facility on [DATE]. Resident 18 was also transferred to the hospital on January 3, 2025, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the nursing home administrator on May 9, 2025, at approximately 10:00 AM confirmed there was no documented evidence that copies of facility-initiated transfer notices for Residents 1, 18, 20, 87, and 90 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The administrator further confirmed there was no evidence that copies were sent consistently for resident transfers to a representative of the Office of the State Long-Term Care Ombudsman from July 2024 through May 2025. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations, a review of clinical records, select facility policy, resident incident/accident report and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent elopement for two residents (Resident CR1 and Resident 2) out of 4 residents reviewed, The facility further failed to identify staff's reliance on the facility's alarm system to prevent elopements and the deficiencies of this system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits from the facility and the potential for serious bodily injury or death. Findings include: A review of a policy entitled Wandering and Elopement Risk Identification and Management, dated September 2021, states it is the policy of the facility to maintain facility wide systems and resident specific plans of care to minimize resident risk and potential for harm related to wandering and elopement. Definition: Elopement - the act of a resident leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Procedure: general staff and Resident/Resident Representative Education and Training. Provide staff with general and job -specific education regarding wandering identification, management (including information related to the facility's wandering management system), and elopement prevention and response upon hire, annually, and as needed thereafter. A review of the clinical record of Resident CR1 revealed admission to the facility on [DATE], with diagnoses, which included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), syncope and collapse (fainting or passing out), unsteadiness on feet, weakness, and abnormalities of gait. A review of the resident's admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 20, 2024, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status - section of MDS that assesses cognition) of 3 (a score of 0 -7 indicates severely impaired cognition). A review of the Resident's plan of care indicated the resident is an elopement risk related to disorientation to place date-initiated May 15, 2024. An intervention is to identify pattern of wandering, such as is wandering purposeful, aimless, or escapist. Is resident looking for something. Does it indicate the need for more exercise, provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, wander alert (a device to alarm the facility if the resident tries to leave) to the right ankle date-initiated May 15, 2024. A further review of the Resident's plan of care indicated the resident has a behavior of becoming combative with staff, resistant to medication, and frequently asking where husband is, pulling fire alarm, and exit seeking date-initiated May 21, 2024. An intervention is to administer medications as ordered and monitor/document side effects, anticipate and meet the resident's needs, and educate the resident/family/caregivers on successful coping and interaction strategies date-initiated May 21, 2024. A review of a health status note dated May 14, 2024, at 2113 hours (9:13 PM) revealed Resident CR 1 stated she wants to go home and sleep in her own bed, redirection with only mild effect, concerned resident will attempt to leave, wanderguard placed for resident safety. A review of a health status note dated May 16, 2024, at 07:48 hours (7:48 AM) revealing family member called to inquire about her mother's night. Explained that she was up for several hours until approximately 0130 (1:30 AM). Explained that she (resident CR 1) was looking for her mother and her family to tell them where she was. A review of a health status note dated May 19, 2024, at 11:46 AM, resident requires redirection and cues for activity/taking medications. Resident repetitively questioning where she is, where her parents are. A review of a health status note dated May 22, 2024, at 04:16 hours (4:16 AM) the resident was awake until 0130 (1:30 AM). Attempting to ambulate without assist in room. Asking repetitive questions and becoming agitated. Snacks and fluids offered but declined. Attempted to reorient to time with short periods of success. Sat in front of nurse's station with nursing assistant (NA). Continued with questions and statements such as My daughter would not put me here. Who said I have to be here? A review of a health status note dated May 23, 2024, at 2209 hours (10:09 PM) indicated resident asked another resident's family member if they could give her a ride to the bus. This resident presented with wander-guard anklet, so the family member called the facility and made them aware of the request. The nurse responded immediately and redirected the resident to her room and told her that the bus will be back tomorrow for her. This intervention effective thus far, resident has been added to every (q) 15 minute checks for 72 hours for safety. Will continue to monitor and document effectiveness. A review of a health status note dated May 23, 2024, at 2216 hours (10:16 PM) stating MD called, new order received and noted for every (q) 15 minute checks X 72 hours. A review of an incident note dated May 23, 2024, at 2300 hours (11:00 PM) stating that at approximately 2020 hours (8:20 PM) call placed to facility by a visitor. Reported a lady with red hair and a bracelet (wander guard) on her leg is asking for a ride and when is the bus coming. Resident exit seeking, looking for her daughter and attempting to leave the property. Charge nurse was able to redirect resident to her room and informed her the bus will be coming tomorrow. Resident also requested to speak with her daughter. Call placed to daughter and message left. The covering physician notified and an order obtained for q15 minute checks X 72 hours. Above interventions effective at this time with monitoring and documentation on going. Continue to await return call from daughter. A review of facility provided incident report (IR - investigation) entitled Elopement, dated May 23, 2024, at 2020 hours (8:20 PM), indicated the incident location is outside. The IR further indicated the resident presented with exit seeking behavior and had asked another family member to give her a ride or show her where to get the bus. Other family member noticed a bracelet on her ankle (wanderguard) and called the facility. Charge nurse immediately responded and redirected resident back to her room and that the resident is ambulatory without assistance. The IR indicated the resident is confused with impaired memory, and is an active exit seeker. Review of facility provided incident statement (witness statement) dated May 23, 2024, by Employee 1, Nurse Assistant (NA), revealed the resident was last seen at approximately 8:10 PM sitting in the dining room at the table waiting and looking for her daughter. Review of facility provided incident statement (witness statement) undated, by Employee 2, Supervisor Registered Nurse (RN), stating a phone call was received from a visitor stating she was at the doors of the Rehabilitation Unit with a lady with red hair and a bracelet who was asking her for a ride and when was the next bus. Employee 2, RN immediately went to the Rehab unit, and saw Employee 3, RN (the nurse assigned to resident CR 1) and called for her help. Employee 2, and Employee 3 went out the Rehabilitation doors and the visitor was still there, and pointed to the direction the lady with red hair went. Employee 3, RN (the nurse assigned to resident CR 1) went to bring Resident CR 1 back. I (Employee 2, RN) went back to unit for help, overhead paged code green, rehab unit. Security and maintenance notified. Review of a second incident statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), stating visitor called 5229(supervisor facility telephone extension) stating the lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus. Immediately went to Rehabilitation door, door alarm was sounding. Resident CR 1 redirected back to room by nurse. Immediate interventions where every 15 minute safety checks for 72 hours, family aware. Review of a third incident statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), revealing door malfunction, indicating at 9:00 PM maintenance and security came to assess the glitch in inner door of the Rehabilitation entrance. Door not completely closing, latching, and locking post (after) 8:00 PM unless forcibly shut. A review of the clinical record of Resident M 1 (husband of Resident CR 1) revealed admission to the facility on [DATE], with diagnoses to include hypertension, and chronic kidney disease. A review of the resident's quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status a score of 13-15 indicates intact cognition). During an interview with Resident M 1 on August 16, 2024, at approximately 11:25 AM found him sitting in his room, alert, pleasant, and cooperative. In questioning, Resident M 1 stated he has been a resident in the facility for quite sometime and that his wife (Resident CR 1) was also for a short period of time. In further questioning, the alert and oriented resident was not aware of his wife (Resident CR 1) had been outside the facility without staff awareness during her stay at the facility. An observation of the front entrance on August 16, 2024, at approximately 11:40 AM revealed that the entrance to the facility had two sets of sliding, glass doors with a breeze way in between. These doors are alarmed with a keypad, with cameras pointing at the front door. There was a receptionist desk to the right of the front door upon entry into the facility. At approximately 11:50 AM, on August 16, 2024, Employee 4, RN (Assistant Director of Nursing - ADON) obtained a wanderguard upon the request of the state survey team. Employee 4 stated this wanderguard is new, and he personally activated it and confirmed its batteries are charged and that it is fully functioning. At approximately 12:00 PM, on August 16, 2024, in the presence of Employee 4 (RN - ADON), and the Nursing Home Administrator (NHA) after confirmation that the facilities front entrance doors were fully functioning, the state surveyor, while holding the wanderguard in hand, stood at the reception desk, which is approximately 14 - 18 feet away from the first set of the interior, double glass, sliding doors, and slowly proceeded to walk towards the doors. The inner door automatically opened, and the state surveyor continued to slowly walk thru the inner door, and approached the second set of glass sliding doors, which did not automatically open. At this time, the state surveyor applied light pressure to the door, and immediately, without any delay and or sustained pressure, the outer door opened, and the state surveyor proceeded to walk outside the front entrance. An observation of the Rehabilitation unit entrance on August 16, 2024, at approximately 12:08 PM revealed that the entrance also had two sets of glass doors with a breeze way in between. These doors are alarmed with a keypad. There is a glass enclosed nursing station straight ahead of the unit door when entering into the facility. At approximately 12:10 PM, on August 16, 2024, in the presence of Employee 4 (RN - ADON), and the NHA after confirmation that the Rehabilitation entrance doors were fully functioning, the state surveyor, while holding the wanderguard in hand, stood at the glass enclosed nursing station, which is approximately 10 - 14 feet away from the first set of the interior, glass door, and slowly proceeded to walk towards the doors. The inner door automatically opened, and the state surveyor continued to slowly walk thru the inner door, and approached the second set of glass door, which did not automatically open. At this time, the state surveyor applied light pressure to the door, and immediately, without any delay and or sustained pressure, the outer door opened, and the state surveyor proceeded to walk outside the Rehabilitation entrance. During a telephone interview on August 16, 2024, at approximately 12:28 PM, with Employee 3 Registered Nurse (RN), confirmed she had worked on the Rehabilitation unit on May 23, 2024, as the charge nurse of Resident CR 1. Employee 3, RN, stated her memory is a little foggy, however, indicated Resident CR 1 was looking for her family (daughter) and a bus. Employee 3, RN indicated a family member who was visiting another resident in the facility, had been asked by Resident CR 1 to give a ride or show her where to get the bus. After exiting the facility, according to Employee 3, RN, the visitor thought about the request and called the facility to notify them of the request. In questioning if Resident CR 1 had exited the facility, got out the outer glass door, Employee 3, RN, replied no, I don't think so. During a telephone interview on August 16, 2024, at approximately 12:40 PM, in the presence of the NHA, the Maintenance Director, as identified by the facility and caller, indicated the security cameras are programmed to reset every 30 days, and would not be capable at this date (August 16, 2024) to be viewed. In questioning the wanderguard system, the Maintenance Director indicated the inner doors are to lock, not open, when approached by the wanderguard. In further questioning, he confirmed that a resident who is wearing a wanderguard, should not get into the breezeway between the inner and outer doors. Interview with the NHA, and Employee 4 (RN - ADON), on August 16, 2024, at approximately 1:18 PM, confirmed the incident statement (witness statement) which is undated, written by Employee 2, Supervisor Registered Nurse (RN), indicated a code green Rehabilitation unit, which indicates a missing resident according to the NHA. A request for documented evidence of a physician order for the wanderguard, evidence that the facility was checking Resident CR 1's wanderguard for both its presence on the resident (arm - wrist, leg - ankle etc.), and that it is functioning properly. The state survey team also requested the incident statement (witness statement) from Employee 3, RN, who was the charge nurse assigned to Resident CR 1 at the time of the incident. Interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:15 PM, confirmed she had worked as supervisor on May 23, 2024. First in questioning, why a family member who was visiting another resident in the facility, needed to call 5229 (supervisors phone extension as stated by Employee 2, RN) and state a lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus if she was standing inside the building? In reply, Employee 2, RN stated she was outside the building at the Rehabilitation Unit doors along with Resident CR 1 trying to get back into the locked doors - building. Employee 2 further stated that the facility doors lock at 8:00 PM, and a sign on the outer doors instruct guests to call the facility at this number which is the supervisor's phone for assistance. In further questioning, Employee 2, (RN), stated that upon arrival outside the outer (exterior) door with Employee 3, RN (the nurse assigned to resident CR 1) present at the same time, found only the visiting family member of another resident, and that Resident CR 1 was not in sight. At this point the visitor pointed towards a tree line as too the direction Resident CR 1 headed towards. According to Employee 2, RN, directly outside the Rehabilitation unit door is a horseshoe (U) shaped driveway for resident/guest drop off / pick up. Then a roadway into the campus, a grassy area with benches, then beyond that is a tree line which is where the resident headed. (Approximately 80 - 100 yards as visualized by the state survey team). At this time, Employee 3, RN (the nurse assigned to resident CR 1), took off towards the tree line after resident CR 1, because she is faster than me, stated Employee 2. According to Employee 2, RN - Supervisor, she returned into the building for assistance and at this point either overhead paged code green, rehab unit, or had heard the page overhead (unclear at this point she indicated). In questioning how long the search took for Resident CR 1, Employee 2, RN, indicated not long, as when she returned to the unit doors, she (Employee 2, RN) saw Employee 3, RN returning with Resident CR 1. During the interview with Employee 2, (RN), on August 16, 2024, at approximately 2:15 PM, the state surveyor asked how she thought Resident CR 1 was able to exit the facility while wearing a wanderguard? In reply, it is her belief that there are three (3) possibilities. First, a staff member who would have the code, would allow the resident out. Second, a guest/visitor who may have the code themselves, was in the process of leaving the facility with the door open and a wandering resident was to walk out the building at the same time. And third, the system could malfunction. During a second interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:55 PM, the employee stated she was not sure the exact time but, on the evening, shift a visiting family member had exited the building and the resident had exited the building with this visitor. She stated the visitor had then called the nursing supervisor office to let them know they believe a resident is outside who should not be outside since she had a bracelet on her ankle. The employee stated as she was going through the Rehab unit she was yelling for help and saw Employee 3 in the hall. She indicated they ran outside and Resident CR1 was out of sight. The employee stated Employee 3 went running towards the tree line and as she went back inside for more staff to help. The employee indicated at that time she heard a code green called for elopement. As the employee went back outside with more staff, Employee 3 was walking the resident back to the facility. During an interview with the NHA, and Employee 4 (RN - ADON) on August 16, 2024, at approximately 3:55 PM, confirmed that the facility was unable to provide the physician order for the wanderguard, documented evidence that the facility was checking Resident CR 1's wanderguard for both its presence on the resident, and that it is functioning properly, nor an incident statement (witness statement) from Employee 3, RN, who was the charge nurse assigned to Resident CR 1 at the time of the incident. They also confirmed a lack of a functioning operational procedures for monitoring residents who are identified as an elopement risk. During a second telephone interview on August 16, 2024, at approximately 4:00 PM, with Employee 3 Registered Nurse (RN), the employee stated she responded to Employee 2 calling for help due to a visitor calling saying a resident was outside the facility. The employee stated she and Employee 2 went outside and could not see the resident. The employee stated that is when Employee 2 went inside for more help, and she began to look for the resident. The employee stated she found the resident off grounds in a grassy area across from the building. The employee stated she was not aware the resident had eloped because she could not hear the alarms sounding because she was in a resident's room, and they are not audible from in there. A review of the clinical record of Resident 2 revealed admission to the facility on [DATE], with diagnoses, which included dementia and abnormal posture. A review of the resident's Quarterly MDS assessment dated [DATE], revealed that the resident's cognition was severely impaired. A review of an Elopement Evaluation dated May 12, 2024, revealed the resident was at risk for elopement. A review of the resident's current plan of care failed to identify the resident as an elopement risk and had no planned interventions to provide supervision or prevent an elopement. A review of the resident's clinical record revealed there was no documentation that the facility had been checking the residents wanderguard for placement or functioning to ensure the wanderguard bracelet in which the facility was relying on to prevent elopement was on and working correctly. An interview with Employee 5 LPN on August 16, 2024, at approximately 2:00 PM revealed the employee stated there is a book on the unit that has the residents that are at risk for elopement on that unit. She stated other residents on the other units are not in their book. When asked if someone from another unit was over on her unit how would she know if that resident was an elopement risk the employee stated she didn't know. When asked how the facility checks that the wanderguard is functioning the employee stated they don't check that. An interview with Employee 6 LPN on August 16, 2024, at approximately 2:05 PM revealed that the employees do not have a tool to check the wanderguard bracelets to ensure they are functioning. She stated they don't check for functioning of the bracelets. She further stated we can take them by a door to see if they are working but we don't do that every day. An interview with Employee 7 LPN and Employee 8 LPN on August 16, 2024, at approximately 2:15 PM revealed the nursing unit does not have a book to identify elopement residents in the facility. Both employees stated that a picture of a resident on their unit was printed out today and given to them. They both indicated that there was no information on their unit to identify all the elopement risks in the building. The employees stated that they do not know who checks the functioning of the wanderguard bracelets, but it was not them. The facility failed to provide any documentation that the residents wanderguard bracelets were checked to ensure functioning. Further there was no documentation that the facility was checking the wanderguard system or the doors to ensure they were working properly. Immediate Jeopardy was called on August 16, 2024, due to the facility's failure to timely identify resident absences from the facility and prevent elopement beginning on May 23, 2024 at 8:20 PM when Resident CR1 was identified outside of the facility. Lack of functioning operational procedures for monitoring residents who are identified as an elopement risk. The facility was notified of the Immediate Jeopardy on August 16, 2024, at 4:03 PM and the IJ template provided to the facility. An immediate plan of correction was requested and received on August 16, 2024. The plan included: 1. Nursing staff will be educated on how to identify residents who are at risk for elopement and who have wonder guards. 2. Every resident with a wonder guard in place will be checked immediately to ensure proper function. 3. The main lobby entrance, Rehab entrance, elevator and Employee entrance doors wonder guard locking mechanisms were inspected and repaired as necessary by a contracted communication company on August 16, 2024. At 1502 (3:02 PM) the Rehab door entrance had a new magnetic plate installed. 4. Each resident with a wonder guard unit will have their picture posted at those entrances in a discrete way as a part of our Happy Feet Club. This will help ensure that families and staff know to be aware when entering and exiting in these areas. 5. Nursing Supervisor will check each resident to ensure they are safe and that their wonder guard units is functioning appropriately every (Q) shift. 6. Facility will audit and review this plan weekly X 4 weeks and the results will be discussed in QAPI. QAPI team will determine the need for further auditing in the future. Following verification of the implementation of the corrective action plan, a tour of the facility and inspection of the supervision, the Immediate Jeopardy was lifted at on August 16, 2024, at 6:07 PM. Refer F 684 Refer F 835 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on review of clinical records, select resident incident report, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following an elopement from the facility for one resident (Resident CR1) out of 4 residents reviewed. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of the clinical record of Resident CR1 revealed admission to the facility on [DATE], with diagnoses, which included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), syncope and collapse (fainting or passing out), unsteadiness on feet, weakness, and abnormalities of gait. A review of a health status note dated May 23, 2024, at 2209 hours (10:09 PM) indicated the resident asked family member of a resident if they could give her a ride to the bus. This resident presented with wander-guard anklet so the family mamber called facility and made them aware of the request. This nurse responded immediately and redirected the resident to her room and told her that the bus will be back tomorrow for her. This intervention effective thus far, resident has been added to every (q) 15 minute checks for 72 hours for safety. Will continue to monitor and document effectiveness. A review of a health status note dated May 23, 2024, at 2216 hours (10:16 PM) stating MD called, new order received and noted for every (q) 15 minute checks X 72 hours. A review of an incident note dated May 23, 2024, at 2300 hours (11:00 PM) stating that at approximately 2020 hours (8:20 PM) call placed to facility by a visitor. Reported a lady with red hair and a bracelet (wander guard) on her leg is asking for a ride and when is the bus coming. Resident exit seeking, looking for her daughter and attempting to leave the property. Charge nurse was able to redirect resident to her room and informed her the bus will be coming tomorrow. Resident also requested to speak with her daughter. Call placed to daughter and message left. Covering physician notified and order obtained for q15 minute checks X 72 hours. Above interventions effective at this time with monitoring and documentation on going. Continue to await return call from daughter. A review of facility provided incident report (IR - investigation) entitled Elopement, dated May 23, 2024, at 2020 hours (8:20 PM), indicated the incident location is outside. The IR further indicated the resident presented with exit seeking behavior and had asked another family member to give her a ride or show her where to get the bus. Other family member noticed a bracelet on her ankle (wanderguard) and called the facility. Charge nurse immediately responded and redirected resident back to her room and that the resident is ambulatory without assistance. The IR indicated the resident is confused with impaired memory, and active exit seeker. Review of facility provided incident statement (witness statement) undated, by Employee 2, Supervisor Registered Nurse (RN), stating a phone call was received from a visitor stating she was at the doors of the Rehabilitation Unit with a lady with red hair and a bracelet who was asking her for a ride and when was the next bus. I (Employee 2, RN), immediately went to the Rehab unit, and saw Employee 3, RN (the nurse assigned to resident CR 1), and called for her help. We (Employee 2, and 3) went out the Rehabilitation doors and the visitor was still there, and pointed to the direction the lady with red hair went. Employee 3, RN (the nurse assigned to resident CR 1) went to bring Resident CR 1 back. I (Employee 2, RN) went back to unit for help, overhead paged code green, rehab unit. Security and maintenance notified. Review of a second incident investigation statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), stating visitor called 5229 stating lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus. Immediately went to Rehabilitation door, door alarm was sounding. Resident CR 1 redirected back to room by nurse. Immediate interventions where every 15 minute safety checks for 72 hours, family aware. Review of a third incident investigation statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), revealing door malfunction, indicating at 9:00 PM maintenance and security came to assess the glitch in inner door of the Rehabilitation entrance. Door not completely closing, latching and locking post (after) 8:00 PM unless forcibly shut. During a telephone interview on August 16, 2024, at approximately 12:28 PM, with Employee 3 Registered Nurse (RN), confirmed she had worked on the Rehabilitation unit on May 23, 2024, as the charge nurse of Resident CR 1. Employee 3, RN, stated her memory is a little foggy, however, indicated Resident CR 1 was looking for her family (daughter) and a bus. Employee 3, RN indicated a family member who was visiting another resident in the facility, had been asked by Resident CR 1 to give a ride or show her where to get the bus. After exiting the facility, according to Employee 3, RN, the visitor thought about the request and called the facility to notify them of the request. In questioning if Resident CR 1 had exited the facility, got out the outer glass door, Employee 3, RN, replied no, I don't think so. Interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:15 PM, confirmed she had worked as supervisor on May 23, 2024. First in questioning, why a family member who was visiting another resident in the facility, needed to call 5229 (supervisors phone extension as stated by Employee 2, RN) and state a lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus if she was standing inside the building? In reply, Employee 2, RN stated she was outside the building at the Rehabilitation Unit doors along with Resident CR 1 trying to get back into the locked doors - building. Employee 2 further stated that the facility doors lock at 8:00 PM, and a sign on the outer doors instruct guests to call the facility at this number which is the supervisor's phone for assistance. In further questioning, Employee 2, (RN), stated that upon arrival outside the outer (exterior) door with Employee 3, RN (the nurse assigned to resident CR 1) present at the same time, found only the visiting family member of another resident, and that Resident CR 1 was not in sight. At this point the visitor pointed towards a tree line as too the direction Resident CR 1 headed towards. According to Employee 2, RN, directly outside the Rehabilitation unit door is a horseshoe (U) shaped driveway for resident/guest drop off / pick up. Then a roadway into the campus, a grassy area with benches, then beyond that is a tree line which is where the resident headed. (Approximately 80 - 100 yards as visualized by the state survey team). At this time, Employee 3, RN (the nurse assigned to resident CR 1), took off towards the tree line after resident CR 1, because she is faster than me, stated Employee 2. According to Employee 2, RN - Supervisor, she returned into the building for assistance and at this point either overhead paged code green, rehab unit, or had heard the page overhead (unclear at this point she indicated). In questioning how long the search took for Resident CR 1, Employee 2, RN, indicated not long, as when she returned to the unit doors, she (Employee 2, RN) saw Employee 3, RN returning with Resident CR 1. During a second interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:55 PM, the employee stated she was not sure the exact time but, on the evening, shift a visiting family member had exited the building and the resident had exited the building with this visitor. She stated the visitor had then called the nursing supervisor office to let them know they believe a resident is outside who should not be outside since she had a bracelet on her ankle. The employee stated as she was going through the Rehab unit she was yelling for help and saw Employee 3 in the hall. She indicated they ran outside and Resident CR1 was out of sight. The employee stated Employee 3 went running towards the tree line and as she went back inside for more staff to help. The employee indicated at that time she heard a code green called for elopement. As the employee went back outside with more staff, Employee 3 was walking the resident back to the facility. During a second telephone interview on August 16, 2024, at approximately 4:00 PM, with Employee 3 Registered Nurse (RN), the employee stated she responded to Employee 2 calling for help due to a visitor calling saying a resident was outside the facility. The employee stated she and Employee 2 went outside and could not see the resident. The employee stated that is when Employee 2 went inside for more help, and she began to look for the resident. The employee stated she found the resident off grounds in a grassy area across from the building. The employee stated she was not aware the resident had eloped because she could not hear the alarms sounding because she was in a resident's room, and they are not audible from in there. Interview with the Nursing Home Administrator (NHA), and Employee 4 (RN) Assistant Director of Nursing (ADON), on August 16, 2024, at approximately 1:18 PM, confirmed the incident statement (witness statement) which is undated, written by Employee 2, Supervisor Registered Nurse (RN), indicated a code green Rehabilitation unit, which indicates a missing resident according to the NHA. A review of nursing progress notes, and assessments in the resident's clinical record, conducted at the time of the survey ending August 16, 2024, revealed no documented evidence in the resident's clinical record that the facility's licensed and professional nursing staff had fully assessed the resident for injury when the resident returned to the facility following the elopement on May 23, 2024. During an interview with Employee 4 (RN - ADON) on August 16, 2024, at approximately 4:10 PM, the state survey team requested the documented evidence from the facility's licensed and professional nursing staff had fully assessed the resident for injury when the resident returned to the facility following the elopement on May 23, 2024. During an interview with Employee 4 (RN - ADON) on August 16, 2024, at approximately 5:50 PM, confirmed the facility is unable to provide the documented evidence that the resident was fully assessed for injury when the resident returned to the facility following the elopement on May 23, 2024. Interview with the Assistant Director of Nursing on August 16, 2024, at approximately 5:51 PM confirmed the facility failed to thoroughly conduct and document the results of a professional nursing assessment of the clinical status of a resident following an elopement from the facility. Cross Refer F689 F835 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.5 (f) Clinical Records

Based on a review of observations, clinical records, investigate reports, staff interviews, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to monitor resident whereabouts and prevent an elopement for one out of 4 sampled residents (Resident CR 1). Findings include: Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident CR 1) out of 4 sampled residents, placing the 6 residents out of 113 residents residing in the facility, identified at risk for elopement, in immediate jeopardy to their health and safety. A review of the clinical record of Resident CR1 revealed admission to the facility on [DATE], with diagnoses, which included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), syncope and collapse (fainting or passing out), unsteadiness on feet, weakness, and abnormalities of gait. A review of a health status note dated May 23, 2024, at 2209 hours (10:09 PM) indicated resident asked another family member of a different resident if they could give her a ride to the bus. This resident presented with wander-guard anklet so the other family called facility and made them aware of the request. This nurse responded immediately and redirected resident to her room and told her that the bus will be back tomorrow for her. This intervention effective thus far, resident has been added to every (q) 15 minute checks for 72 hours for safety. Will continue to monitor and document effectiveness. A review of a health status note dated May 23, 2024, at 2216 hours (10:16 PM) stating MD called, new order received and noted for every (q) 15 minute checks X 72 hours. A review of an incident note dated May 23, 2024, at 2300 hours (11:00 PM) stating that at approximately 2020 hours (8:20 PM) call placed to facility by a visitor. Reported a lady with red hair and a bracelet (wander guard) on her leg is asking for a ride and when is the bus coming. Resident exit seeking, looking for her daughter and attempting to leave the property. Charge nurse was able to redirect resident to her room and informed her the bus will be coming tomorrow. Resident also requested to speak with her daughter. Call placed to daughter and message left. Covering physician notified and order obtained for q15 minute checks X 72 hours. Above interventions effective at this time with monitoring and documentation on going. Continue to await return call from daughter. A review of facility provided incident report (IR - investigation) entitled Elopement, dated May 23, 2024, at 2020 hours (8:20 PM), indicated the incident location is outside. The IR further indicated the resident presented with exit seeking behavior and had asked another family member to give her a ride or show her where to get the bus. Other family member noticed a bracelet on her ankle (wanderguard) and called the facility. Charge nurse immediately responded and redirected resident back to her room and that the resident is ambulatory without assistance. The IR indicated the resident is confused with impaired memory, and active exit seeker. Review of facility provided incident statement (witness statement) undated, by Employee 2, Supervisor Registered Nurse (RN), stating a phone call was received from a visitor stating she was at the doors of the Rehabilitation Unit with a lady with red hair and a bracelet who was asking her for a ride and when was the next bus. I (Employee 2, RN), immediately went to the Rehab unit, and saw Employee 3, RN (the nurse assigned to resident CR 1), and called for her help. We (Employee 2, and 3) went out the Rehabilitation doors and the visitor was still there, and pointed to the direction the lady with red hair went. Employee 3, RN (the nurse assigned to resident CR 1) went to bring Resident CR 1 back. I (Employee 2, RN) went back to unit for help, overhead paged code green, rehab unit. Security and maintenance notified. Review of 2nd incident statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), stating visitor called 5229 stating lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus. Immediately went to Rehabilitation door, door alarm was sounding. Resident CR 1 redirected back to room by nurse. Immediate interventions where every 15 minute safety checks for 72 hours, family aware. Review of 3rd incident statement (witness statement) dated May 23, 2024, by Employee 2, Supervisor Registered Nurse (RN), revealing door malfunction, indicating at 9:00 PM maintenance and security came to assess the glitch in inner door of the Rehabilitation entrance. Door not completely closing, latching and locking post (after) 8:00 PM unless forcibly shut. An observation of the front entrance on August 16, 2024, at approximately 11:40 AM revealed that the entrance to the facility had two sets of sliding, glass doors with a breeze way type between. These doors are alarmed with a keypad, with cameras pointing at the front door. There was a receptionist desk to the right of the front door when you walk into the facility. At approximately 11:50 AM, on August 16, 2024, Employee 4, RN (Assistant Director of Nursing - ADON) obtained a wanderguard upon the request of the state survey team. Employee 4 stated this wanderguard is new, and he personally activated it and confirmed its batteries are charged and that it is fully functioning. At approximately 12:00 PM, on August 16, 2024, in the presence of Employee 4 (RN - ADON), and the Nursing Home Administrator (NHA) after confirmation that the facilities front entrance doors were fully functioning, the state surveyor, while holding the wanderguard in hand, stood at the reception desk, which is approximately 14 - 18 feet away from the first set of the interior, double glass, sliding doors, and slowly proceeded to walk towards the doors. The inner door automatically opened, and the state surveyor continued to slowly walk thru the inner door, and approached the 2 nd set of glass sliding doors, which did not automatically open. At this time, the state surveyor applied light pressure to the door, and immediately, without any delay and or sustained pressure, the outer door opened, and the state surveyor proceeded to walk outside the front entrance. An observation of the Rehabilitation unit entrance on August 16, 2024, at approximately 12:08 PM revealed that the entrance had two sets of glass doors with a breeze way type between. These doors are alarmed with a keypad. There is a glass enclosed nursing station straight ahead of the unit door when you walk into the facility. At approximately 12:10 PM, on August 16, 2024, in the presence of Employee 4 (RN - ADON), and the NHA after confirmation that the Rehabilitation entrance doors were fully functioning, the state surveyor, while holding the wanderguard in hand, stood at the glass enclosed nursing station, which is approximately 10 - 14 feet away from the first set of the interior, glass door, and slowly proceeded to walk towards the doors. The inner door automatically opened, and the state surveyor continued to slowly walk thru the inner door, and approached the 2 nd set of glass door, which did not automatically open. At this time, the state surveyor applied light pressure to the door, and immediately, without any delay and or sustained pressure, the outer door opened, and the state surveyor proceeded to walk outside the Rehabilitation entrance. Interview with the Nursing Home Administrator (NHA) on August 16, 2024, at approximately 1:18 PM, confirmed the incident statement (witness statement) which is undated, written by Employee 2, Supervisor Registered Nurse (RN), indicated a code green Rehabilitation unit, which indicates a missing resident according to the NHA. Interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:15 PM, confirmed she had worked as supervisor on May 23, 2024. First in questioning, why a family member who was visiting another resident in the facility, needed to call 5229 (supervisors phone extension as stated by Employee 2, RN) and state a lady with red hair and a bracelet is with her at the rehabilitation door asking her for a ride and when was the next bus if she was standing inside the building? In reply, Employee 2, RN stated she was outside the building at the Rehabilitation Unit doors along with Resident CR 1 trying to get back into the locked doors - building. Employee 2 further stated that the facility doors lock at 8:00 PM, and a sign on the outer doors instruct guests to call the facility at this number which is the supervisor's phone for assistance. In further questioning, Employee 2, (RN), stated that upon arrival outside the outer (exterior) door with Employee 3, RN (the nurse assigned to resident CR 1) present at the same time, found only the visiting family member of another resident, and that Resident CR 1 was not in sight. At this point the visitor pointed towards a tree line as too the direction Resident CR 1 headed towards. According to Employee 2, RN, directly outside the Rehabilitation unit door is a horseshoe (U) shaped driveway for resident/guest drop off / pick up. Then a roadway into the campus, a grassy area with benches, then beyond that is a tree line which is where the resident headed. (Approximately 80 - 100 yards as visualized by the state survey team). At this time, Employee 3, RN (the nurse assigned to resident CR 1), took off towards the tree line after resident CR 1, because she is faster than me, stated Employee 2. According to Employee 2, RN - Supervisor, she returned into the building for assistance and at this point either overhead paged code green, rehab unit, or had heard the page overhead (unclear at this point she indicated). In questioning how long the search took for Resident CR 1, Employee 2, RN, indicated not long, as when she returned to the unit doors, she (Employee 2, RN) saw Employee 3, RN returning with Resident CR 1. During a telephone interview on August 16, 2024, at approximately 12:28 PM, with Employee 3 Registered Nurse (RN), confirmed she had worked on the Rehabilitation unit on May 23, 2024, as the charge nurse of Resident CR 1. Employee 3, RN, stated her memory is a little foggy, however, indicated Resident CR 1 was looking for her family (daughter) and a bus. Employee 3, RN indicated a family member who was visiting another resident in the facility, had been asked by Resident CR 1 to give a ride or show her where to get the bus. After exiting the facility, according to Employee 3, RN, the visitor thought about the request and called the facility to notify them of the request. In questioning if Resident CR 1 had exited the facility, got out the outer glass door, Employee 3, RN, replied no, I don't think so. During a second interview with Employee 2, Supervisor Registered Nurse (RN), on August 16, 2024, at approximately 2:55 PM, the employee stated she was not sure the exact time but, on the evening, shift a visiting family member had exited the building and the resident had exited the building with this visitor. She stated the visitor had then called the nursing supervisor office to let them know they believe a resident is outside who should not be outside since she had a bracelet on her ankle. The employee stated as she was going through the Rehab unit she was yelling for help and saw Employee 3 in the hall. She indicated they ran outside and Resident CR1 was out of sight. The employee stated Employee 3 went running towards the tree line and as she went back inside for more staff to help. The employee indicated at that time she heard a code green called for elopement. As the employee went back outside with more staff, Employee 3 was walking the resident back to the facility. During a second telephone interview on August 16, 2024, at approximately 4:00 PM, with Employee 3 Registered Nurse (RN), the employee stated she responded to Employee 2 calling for help due to a visitor calling saying a resident was outside the facility. The employee stated she and Employee 2 went outside and could not see the resident. The employee stated that is when Employee 2 went inside for more help, and she began to look for the resident. The employee stated she found the resident off grounds in a grassy area across from the building. The employee stated she was not aware the resident had eloped because she could not hear the alarms sounding because she was in a resident's room, and they are not audible from in there. An interview with Employee 5 LPN on August 16, 2024, at approximately 2:00 PM revealed the employee stated there is a book on the unit that has the residents that are at risk for elopement on that unit. She stated other residents on the other units are not in their book. When asked if someone from another unit was over on her unit how would she know if that resident was an elopement risk the employee stated she didn't know. When asked how the facility checks that the wanderguard is functioning the employee stated they don't check that. An interview with Employee 6 LPN on August 16, 2024, at approximately 2:05 PM revealed that the employees do not have a tool to check the wanderguard bracelets to ensure they are functioning. She stated they don't check for functioning of the bracelets. She further stated we can take them by a door to see if they are working but we don't do that every day. An interview with Employee 7 LPN and Employee 8 LPN on August 16, 2024, at approximately 2:15 PM revealed the nursing unit does not have a book to identify elopement residents in the facility. Both employees stated that a picture of a resident on their unit was printed out today and given to them. They both indicated that there was no information on their unit to identify all the elopement risks in the building. The employees stated that they do not know who checks the functioning of the wandergaurd bracelets, but it was not them. A review of the job description for the Nursing Home Administrator (NHA) dated May 1, 2023, states the Administrator of the facility directs the daily operations of Skilled Nursing Facility (SNF). Responsible for implementing operational policies, administrative procedures, and rules/regulations for a skilled nursing facility in accordance with State and Federal standards and the mission of the (name of organization). Manages and coordinates all services and departments to establish/maintain an environment and program conducive to a high quality of care for all residents. Coordinate the development and execution of the facility budget. Develops, in partnership with department heads, corporate resources, and other campus administrators, policies and procedures for the effective operation of the facility. Completes periodic and unscheduled rounds of the entire facility to inspect operations and programs, visit residents and families, confer with staff to determine needs/requirements and resolve operating problems in a timely manner to facilitate a quality enhance environment for the facility's residents and staff. Meets with State and Federal surveyors and provides tools/information as required to facilitate surveys. Oversees and coordinate the development of any plan of correction necessitated by a survey outcome. Remains current on changes in State and Federal regulations. Ensures the facility remains in compliance with all State and Federal regulations. Monitors all Quality Measures and the QAPI program, in partnership with the Director of Quality Management, to maintain or exceed a CMS Star rating of 4 for both QMs and Overall. Serves as the resident's advocate on issues that refer to quality of life and residents' rights. A review of the job description for the Director of Nursing (DON) dated July 1, 2023, states the DON is to direct the daily operations of nursing department by planning, directing, organizing, and evaluating the nursing staff in accordance with current federal, state and local standards. Develops, reviews, and implements policies and procedures of the nursing department. Coordinates the staffing plan. Makes final review of incident/accident reports to assure appropriate investigation/follow-up has occurred. Participates in resident selection for facility admission. Reviews concerns, complaints, grievances made by residents, families and staff. Organizes and directs all aspects of reimbursements systems (Medicare determinations and cuts, Medicaid PRI's, MDS). Acts as liaison with the interdisciplinary team. Coordinates and participates in research activities and strives to move the facility in a progressive manner. Participates in Quality Assurance committee. Participates in budget process for the nursing departments. Manages the Assistant Director of Nursing and Unit Managers. Interviews, trains, plans assigns and directs work assignments for nursing staff. Serves as the resident's advocate on issues that refer to quality of life and residents' rights. Performs other assignments as directed. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.12(a)(1) , revealed that the NHA and DON failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines. Refer F689 Refer F 684 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code 211.12 (c) Nursing services

Based on observation, a review of select facility policy, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the kitchen that was conducted with the facility's Director of Food and Nutrition Services on July 16, 2024, at 9:01 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Observations of the inside of the walk-in refrigerator revealed that there was milk spilled underneath the shelves on which the milk was stored. A tour of the dish room area revealed that a significant amount of water was pooling on the floor throughout the around the area. A ceiling tile was bowed and gaps present near the vent. There was a red/brown colored substance splattered on ceiling tiles above the dish machine. Observation during the lunch tray line meal service revealed that the Speech Pathologist entered the kitchen area without a wearing a hairnet. Inside of the tray line reach-in refrigerator, there was a tray of approximately forty (40) 4-ounce cartons of Mighty Shakes that were not dated with a thaw date. The FSD confirmed that shakes were not properly labeled and should have included a use by date as per manufactures instructions (manufacture notes a 14-day shelf life after thawing). In the resident's main dining room, two white plastic cans, used for dirty linens, were coated with splattered substances on the outside of the cans. Observations of the East Unit Medication Room on June 17, 2024, at 10:30 a.m., revealed (13) Mighty Shakes and three (3) nutritional juice drinks that were not labeled or dated. Employee 1, a Licensed Practical Nurse (LPN), confirmed that the nutritional supplements were not properly labeled or dated with thaw, use by or discard dates. A review of a facility policy titled Use By - Dating Guidelines that was provided by the facility on July 17, 2024, indicated that frozen shakes should be labeled with a use by date of fourteen days once thawed, and the day of preparation or opening is considered Day 1 in the use by date. Guidelines apply, regardless of storage location (e.g., kitchen, pantries, etc.). An interview with the Nursing Home Administrator (NHA) on July 17, 2024, at 2:00 p.m., confirmed that sanitary practices should be maintained for labeling supplements and the kitchen areas to prevent foodborne illness. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on clinical record review and staff interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for one resident (Resident 44) and failed to clinically justify the increase of psychoactive medication for one resident (Resident 69) out of five sampled. Findings include: A review of Resident 44's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder and Parkinson's disease. The resident had a physician order initially dated September 2023, for Invega Trinza Intramuscular Suspension Prefilled Syringe 819 MG/2.63 ML (Paliperidone Palmitate - an atypical antipsychotic drug) Inject 2.63 mg/ml intramuscularly one time a day every 90 days for schizoaffective disorder. The resident also had a physician order dated September 2023, for Sertraline HCL (an antidepressant drug, brand name Zoloft) Oral Tablet 50 MG 1 tab daily for depression and Abilify 10 mg (an antipsychotic drug) 1 tab daily for schizoaffective disorder. A pharmacist consult to the physician dated March 19, 2024, revealed that the pharmacist requested that the physician attempt a gradual dose reduction of the Invega Trinza, Zoloft and Abilify. The physician's response was solely to defer to psychiatry with no explanation of the individualized clinical rationale of the necessity of continuing the current dosage each psychoactive drug in the resident' treatment. Further review of the resident's clinical record, conducted during the survey ending July 19, 2024, revealed no current psychiatry visits to provide the clinical rationale for the continued use of the above noted psychoactive medications. The facility was unable to provide documented evidence to support the resident's continued need for the current dosages of Invega, Sertraline, and Abilify or evidence that a gradual dose reduction was attempted for any of these psychoactive medications in the past year. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 17, 2024, at approximately 12:45 PM, these administrative staff members confirmed the lack of GDR attempts for the psychoactive drugs prescribed for Resident 44. Clinical record review revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder, stroke, and aphasia (difficulty with verbal communication). A pharmacy review dated May 15, 2024, at 4:38 PM, revealed a recommendation to decrease the resident's Zyprexa (antipsychotic) to 2.5 mg. A physician order was received to decrease the dose of the antipsychotic medication in response. The resident's clinical record revealed documentation dated May 18, 2024, through May 22, 2024, noted that the resident had no change in mood or behavior noted from the medication reduction, no ill effects or behaviors related to decrease in medication, and the resident was pleasant and cooperative with care. Clinical record revealed documentation dated May 22, 2024, at 6:30 PM, revealed that Resident 69's son called to inform the facility that the resident called him, reporting not feeling well. According to the documentation, the resident told nursing staff that he had discomfort below right breast area, coming from his spine, which he had discomfort in the past and it resolved, and it's the same as he had in the past. Nursing assessment revealed that the resident's blood pressure was 167/93, heart rate 65, and respiratory rate was 18. A call was placed to the covering physician who ordered blood work in the morning and to increase Zyprexa to 5 mg daily (which had just been decreased to 2.5 mg on May 15, 2024). Review of Consultant Pharmacy Medication Review dated May 23, 2024, revealed that upon review from pharmacist, the resident's Zyprexa was decreased on May 15, 2024, to 2.5 mg daily and then increased back to 5 mg daily on May 23, 2024 however there is no documentation supporting the need for the increased dose. According to the pharmacist review, current documentation mentions that the resident is calm and pleasant, appears comfortable, cooperative to care, and no s/s [signs/symptoms] of anxious tendencies. The pharmacist requested supportive documentation to clinically justify the increase in the antipsychotic medication. There was no documented evidence from the prescriber practitioner of the clinical necessity for the increase in the antipsychotic medication, which was confirmed during interview with the Director of Nursing on July 18, 2024, at approximately 1:30 PM. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.2 (d)(3)(9) Medical Director 28 Pa. Code 211.5 (f) Clinical records

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of opioid pain medications prescribed on an as needed basis for one resident out of 24 residents reviewed (Resident 10). Findings include: A review of Resident 10's clinical record revealed a physician's order, initially dated June 24, 2024, and discontinued on July 1, 2024, for Hydrocodone-Acetaminophen 5-325 mg (an opioid pain medication combined with a non-opioid pain reliever used to treat moderate to severe pain), give one tablet by mouth every 4 hours as needed for numeric pain scale 6-10. There was also a physician's order initially dated July 1, 2024, and discontinued July 3, 2024, for Hydrocodone-Acetaminophen 5-325 mg, give one tablet by mouth every 6 ours as needed for pain 6-10. A review of the resident's June 2024, Medication Administration Record (MAR) revealed that staff administered doses of the prn hydrocodone-acetaminophen pain medication 14 times during the month of June 2024. Of the 14 doses given, all were administered with no non-pharmacological interventions attempted prior to administration to reduce the resident's pain. A review of the resident's July 2024, MAR revealed that staff administered doses of the prn hydrocodone-acetaminophen pain medication 5 times during the month of July 2024. Of the 5 doses given, 4 were administered with no non-pharmacological interventions attempted prior to administration. A physician's order, initially dated July 3, 2024, and discontinued July 6, 2024, for Oxycodone HCL 5 mg (a narcotic opioid pain medication), give 5 mg by mouth every 6 hours as needed for severe pain for pain level 6-10. Further, it was noted a physician's order dated July 8 2024, for Oxycodone HCL 5 mg, give one tablet by mouth every 6 hours as needed for pain 6-10. A review of the resident's July 2024, MAR revealed that staff administered doses of the prn oxycodone pain medication 26 times during the month of July 2024. Of the 26 doses given, 23 were administered with no non-pharmacological interventions attempted prior to administration to reduce the resident's pain. Interview with the Nursing Home Administrator and the Assistant Director of Nursing on July 19, 2024, at approximately 11:45 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of an as-needed pain medication. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on review of clinical records and select resident incident/accident reports, observation and staff interview, it was determined the facility failed to provide necessary staff supervision and implement effective person-centered safety measures based on individual resident needs to promote resident safety and prevent falls, which resulted in serious injury, head injuries and fracture, to one resident out of three sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was readmitted to the facility on [DATE], with diagnoses which included, unspecified dementia with behavioral disturbance, unspecified abnormality of gait, and unspecified mental disorder. At the time of the survey ending May 13, 2021, the resident was receiving Hospice services. A review of a significant change Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 15, 2021, revealed that the resident's BIMS score (Brief interview for Mental Status - a tool to assess cognitive function) was 2, indicating that the resident was severely impaired cognitively. Review of Resident 1's fall assessments initiated by the facility on January 5, 2021, and April 14, 2021, and April 15, 2021, indicated the resident was at high risk for falls. The assessments indicated that the resident had multiple risk factors including dementia. A review of the current resident's comprehensive care plan related to falls indicated that the resident was to wear anti-skid socks at all times, fall-falleze mat to left side of the bed and a body pillow was to be placed on the left side of her bed. The date of the implementation of this care plan could not be determined as no dates were identified on the plan of care. A review of a facility incident and accident report dated April 10, 2021, at 10:45 AM revealed that the resident was found on the floor of the resident's room. According to the incident report, the facility surmised that the resident was able to sit herself up on the left side of the her bed, and slid onto the falleze mat on the floor. The resident's body pillow was observed underneath the resident's bed. The resident's legs were outstretched in front of her when found on the floor and the fall was unwitnessed. As a result of this fall, the facility decreased the resident's antianxiety medication [MEDICATION(S)]. An incident accident report dated April 25, 2021, at 4:40 AM revealed that the facility surmised that the resident awakened very early in the morning and put herself in a sitting position on the left side of her bed. The body pillow fell on to the fall mat. The facility concluded that the resident slid from the left side of the bed onto the body pillow because staff observed the resident on the body pillow although the fall was unwitnessed. As a result of this fall on April 25, 2021, the facility planned to provide 15 minute checks to observe the resident between 4 AM and 8 AM. A review of the resident's clinical record dated May 10, 2021, at 2:38 PM revealed that the resident's primary nurse found the resident sitting on her buttocks, with her back leaning on the left side of the resident's bed frame. The resident's legs were straight out in front of her and her non-skid socks were in place. The resident was observed to have sustained an 8 cm (centimeter) x 10 cm hematoma (a solid swelling of clotted blood within the tissues) to the left side of her head with a 5 cm x 2 cm abrasion noted in the middle of the hematoma. Abrasions to left and right knees were also noted along with swelling and bruising to her thumb on the resident's right hand. Neurological checks were attempted, but difficult to complete due the resident not following commands. Staff assisted the resident into a Broda chair (tilt-in-space positioning chair). An order was noted to place a mattress to the left side of her bed at all times when in bed as the resident had a small thinner falleze mat prior to this fall. Review of an incident accident report revealed that the resident fell on [DATE], at 7:25 AM. According to the report, the resident had been up during the night in a Broda chair. The resident became tired at 5:00 AM and staff assisted the resident back to bed. The nurse completing observations at 7:25 AM found the resident sitting on her buttocks next to the left side of her bed with her legs straight out in front of her. A review of the facility's documented record of the 15 minute checks of the resident revealed that the last time staff had observed the resident, prior to the fall, was at 7 AM on May 10, 2021, failing to demonstrate that the resident was checked at 15 minute intervals as planned. An investigation completed by the facility's interdisciplinary team revealed that the team observed the resident's room and noted that there were several red stains on the carpet near the footboard of the resident's bed and not observed on the fall mat. The team concluded based on the observed red stains that the resident had seated herself on the left side of the bed close to the footboard, was able to pull herself up using the footboard to steady herself, but she was unable to maintain this position and she fell forward then made contact with the carpeting. The team concluded that the resident was able to get on to her knees to move herself over the carpeting, back onto the mat and she sat on her buttocks with her back leaning against the bed frame, when staff found her. This fall was an unwitnessed fall. The Director of Nursing (DON) was interviewed on May 13, 2021, regarding the facility's conclusions as to the circumstances surrounding the resident's fall. The DON stated that the above conclusion was an assumption, but there were no witnesses to the fall. Interventions after this fall revealed the facility planned to place a mattress on the left side of her bed and the resident's nightstand was moved to the other side of the room. Additionally, the resident's daughter requested that her mother have an alarm while she was in bed and in the chair to alert staff of any unassisted attempts to stand or get out of bed. On May 11, 2021, the resident's daughter requested an X-ray of te resident's right thumb, which revealed an acute fracture at the distal phalanx (finger bone). On May 12, 2021, the resident's daughter requested that the resident be transferred to the hospital for an evaluation. The resident was transferred to the hospital at approximately 11:30 AM and was discharged from the hospital at 3:46 PM. The evaluation at the emergency room revealed that the resident had a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and possible [MEDICATION(S)] hematoma (when bleeding occurs between the tough outer membrane covering the brain [dura mater] and the skull). The hospital discharge report indicated that a cervical spine CT (A CT scan or computed tomography scan is a medical imaging technique used in radiology to get detailed images of the body noninvasively for diagnostic purposes) was completed, which revealed a Type 2 odontoid fracture (peg of cervical spinal bone is broken. In a Type II fracture, the peg is broken at its base) present on 8/2017 cervical spine CT; however, the C1 vertebral body was now left laterally displaced relative to C2 vertebral body and new dorsal and increased ventral [MEDICATION(S)] space hyperdense material posterior to odontoid process was present, producing severe spinal canal stenosis. These findings were noted as concerning for craniocervical junction injury and [MEDICATION(S)] hematoma. A spinal surgery consultation was recommended based on the above CT scan findings. However, due to the resident currently receiving Hospice services, the resident's family wanted to keep the resident comfortable and declined any surgical intervention. Observation of the resident on May 13, 2021, at approximately 10 AM, accompanied by the Nursing Home Administrator, revealed that this resident was lying in bed. The resident's body pillow was on the left side of the bed, but hanging off the bed. The resident had large ecchymotic (bruised) areas predominantly on the left side of her face down to the left side of the neck and a large hematoma on the left side of her forehead, which was black to blue in color. Black and blue colored bruising was observed around her left eye, which was also swollen. Interview with the Director of Nursing and Nursing Home Administrator on May 13, 2021, at 3:30 PM, confirmed that the facility failed to provide timely and adequate staff supervision and effective safety measures to prevent repeated falls and injury to this resident at risk for falls and known unsafe restless behaviors. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 5/10/19 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(d)(5) Nursing services Previously cited 5/10/19, 7/2/19, 10/4/19, 10/29/19, 10/14/20, 11/6/20, 12/22/20 28 Pa. Code 211.12(c) Nursing services Previously cited 5/10/19, 7/2/19, 10/4/19, 10/29/19, 9/1/20, 10/14/20, 11/6/20, 12/22/20 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 5/10/19, 7/2/19, 10/4/19, 10/29/19, 10/14/20, 11/6/20, 12/22/20

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to consistently meet the medical needs of one resident out four sampled, which compromised the resident's clinical condition and status related to timely and necessary treatment for [REDACTED]. Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. While often referred to simply as heart failure, [MEDICAL CONDITION] specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently). Admission physicians orders dated [DATE], revealed that Resident CR1 was admitted to the facility following a hospital stay. During the resident's hospital stay, and continued at the skilled nursing facility, the resident received [MEDICATION NAME] ( diuretic medication ) 40 mg, by mouth, daily. The resident's clinical record identified the resident's past medical history of [REDACTED]. A review of an admission Minimum Data Set assessment ( MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated [DATE], revealed this resident was cognitively intact and required assistance with activities of daily living. Section I, Active [DIAGNOSES REDACTED]. Review of Resident CR 1's care plan dated [DATE], revealed a problem/need of the resident's risk for dehydration. The identified goals was that the resident will show no signs or symptoms of dehydration. The planned interventions were to monitor resident for clinical signs of dehydration and to follow the hydration standard of care. The care plan also identified the resident's problem/need of being at risk for weight loss. The goal was that the resident will not have any unexpected weight loss. The planned intervention was to weigh this resident daily. Admission physicians orders dated [DATE], also revealed an order for [REDACTED]. A review of lab study results dated [DATE], revealed that the resident's BUN was elevated at 51 mg/dl, normal value ,[DATE] mg/dl ( a measure of kidney function) along with the resident's creatinine ( a measure of kidney function) 1.7 mg\dl, normal value 0XXX,[DATE].0 mg/dl. (The ratio of BUN to creatinine is usually between 10:1 and 20:1. An increased ratio may be due to a condition that causes a decrease in the flow of blood to the kidneys, such as [MEDICAL CONDITION] or dehydration). A review of a physicians assistant ( Pa-C, a Physician extender who works with the Physician ) progress note dated [DATE] revealed that Resident CR1's medications were reviewed, as well as medications and vital signs. The Pa-C noted to continue current treatment plan as ordered and to continue to follow up as needed and as scheduled. There was no reference to the resident's elevated BUN and [MEDICATION NAME] in this progress note. A review of nursing documentation and CRNP (Certified Registered Nurse Practitioner) orders dated [DATE], revealed an order to obtain a comprehensive metabolic panel (laboratory blood studies) on next lab day. A review of a CRNP progress note dated [DATE], noted a review of labs dated [DATE], noting BUN 67 mg/dl and creatinine 1.6 mg/dl, both values were an increase from the previous lab draw. The physical exam indicated normal respiratory rate and rhythm, no chest wall tenderness, lungs clear to auscultation. The noted plan was to continue current medications and treatments, reviewed nursing home record for vital signs, weight, bowel and bladder function and activities of daily living, monitor routine labs and continue to follow up as needed and as scheduled. A physician extender order dated [DATE], was noted to discontinue [MEDICATION NAME] 40 mg by mouth daily. There was no corresponding physician, physician extender or nursing documentation related to Resident CR1's [MEDICATION NAME] discontinuation or any plan related to the management of the resident's fluid balance and history of [MEDICAL CONDITION]. A review of an attending physician initial progress note dated [DATE], revealed that this was the attending physician's initial admission physician visit with Resident CR1. The physician progress notes [REDACTED]. The physician noted the resident's current physical examination indicated that she was doing well, fell ing tired. She denied chest pain, and shortness of breath and lungs clear to auscultation. The physician noted that the resident's plan of care, including medications were reviewed. The physician noted please refer to the facility's medical record for the most up to date medication list, reviewed the nursing home record for vital signs, bowel and bladder function and ADLs, available labs/imaging reviewed, continue current treatment plan as ordered and to follow up as needed and as scheduled. The physician did not specifically address the discontinuation of the resident's diuretic medication, [MEDICATION NAME] 40 mg, on [DATE], in this initial visit progress note. Nursing documentation dated [DATE] at 2 PM revealed that the Teli-medicine ( a contracted physician service with consultations conducted over the telephone) was contacted in response to Resident CR1's family stating that the resident was breathing different today Physician orders [REDACTED]. Nursing documentation dated [DATE] at 7 PM noted that the resident's vital signs were stable and her lungs were clear to auscultation. A review of a chest x-ray dated [DATE] revealed right upper lobe pneumonia superimposed on interstitial lung disease (an umbrella term for a large group of disorders that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe. Some example of ILDs include: Idiopathic [MEDICAL CONDITION] Fibrosis. [DIAGNOSES REDACTED]). A review of a progress note by the physician extender dated [DATE], noted that reviewing Resident CR1's medical issues from the previous day, revealed, that over the weekend, Resident CR1, started not to feel well, had shortness of breath and was not acting herself. The teli-medicine physician was called and a chest xray and labs were ordered. The resident was placed on an antibiotic ([MEDICATION NAME]) and as needed breathing treatments. A review of labs dated [DATE], revealed that the resident's kidney function levels were BUN 32 mg\dl ( BUN on [DATE], was 67 mg\dl) and creatinine 1 mg\dl (1.6 mg\dl on [DATE]) and her serum potassium level was noted to be 5.7 mmol\L. A physician extender order dated [DATE], was noted for Kaxolate ( a medication given when the Potassium level is critically high) 15 gms by mouth for one dose today, duo nebs ( a respiratory treatment) every 6 hours as needed for shortness of breath and to repeat potassium level on [DATE]. A review of nursing documentation dated [DATE], at 7:44 am revealed that Resident CR1 had a weight gain of 3.1 lbs over last 24 hours. The physician was notified and directed that the resident's current plan of care continue. A review of a physician notification of weight change dated [DATE], revealed that Resident CR1 had a 3.1 pound weight increase in 24 hours ([DATE], 1[AGE] lbs and [DATE] 1[AGE].1 lbs). A review of a provider note dated [DATE], from the facility Pa-C revealed that Resident CR1 was complaining of shortness of breath and stated that she is slightly worse. The physician assistance note that The patient is currently being treated for [REDACTED]. The plan of care included to continue the antibiotic for 5 days and to continue the nebulizer treatments. The physician assistant noted that the resident did not have a fever. There were no new orders at that time, noting Nursing to continue with daily weights. A review of a provider note dated [DATE], the Pa-C noted that Resident CR1 had no shortness of breath, however was noted with wheezing in her lungs. The treatment plan was the same as noted the previous progress notes. There was no reference to the discontinuation of the resident's diuretic medication, [MEDICATION NAME], as potential relationship to the resident's weight gain or current lung function. A chest x-ray was ordered for [DATE]. Nursing documentation dated [DATE], 6:45 PM revealed that the CRNP made aware of resident's request for chest x-ray due to recent pneumonia and a new order noted for a chest x-ray [DATE]. A review of chest xray results dated [DATE], revealed that the results were correlated with a prior study from [DATE], mild cardiomegaly. borderline inspiration, mild vascular congestion consistent with [MEDICAL CONDITION]. The appearance is improved from prior study. The impression was noted as, mild [MEDICAL CONDITION], improved from prior study and right upper lobe, also improved from prior study, most likely resolving focal congestion. A review of nursing documentation dated [DATE], revealed that Resident CR1 had a weight gain of 6.2 lbs in 24 hours. The physician extender was contacted and ordered [MEDICATION NAME] 20 mg, by mouth daily. A review of a tele-medicine physician report dated [DATE], revealed that a call was made to inform the physician of Resident CR1's labs results. The report dated [DATE], revealed that the resident's BUN was 35 mg\dl and creatinine 1. 4mg\dl revealing that both were elevated from the lab results dated [DATE]. The report noted Recent treatment for [REDACTED]. The resident is stable. The family and resident are concerned as family member recently passed away from pneumonia, They requested the repeat chest x-ray and provider ordered labs as well. Resident is on daily [MEDICATION NAME] of 20 mg, was on 40 mg prior. BNP (BNP stands for brain natriuretic peptide. It is made inside the pumping chambers of your heart when pressure builds up from heart failure. The test is an important tool for healthcare providers to diagnose heart failure quickly. Heart failure happens when your heart is not pumping blood well) is elevated. However, there is no comparison on the clinical record and recent [MEDICAL CONDITION] changes to be contributing to the elevation. BUN and creatinine are climbing, so will repeat labs on Monday and diuretic may need to be adjusted. A review of a provider progress note by the CRNP dated [DATE], revealed that Resident CR1 recently completed an antibiotic on [DATE], for right upper lobe pneumonia and an abnormal urinalysis. The patient is stable, she denies cough and offers no concerns. The note continues noting review the recent lab values dated [DATE], BUN 45 mg\dl and creatinine 1.7 mg\dl, both elevated from the previous lab study report dated August on [DATE]. A review of nursing documentation dated [DATE], at 1 PM revealed that Resident CR1's lungs were clear to auscultation, but she was complaining of shortness of breath. She received a respiratory, nebulizer treatment with relief. Nursing documentation dated [DATE], at 4:12 PM revealed that Resident CR1 was noted with shortness of breath upon exertion. Breathing treatments were given as per the physicians order. On [DATE], at 11:57 AM the resident's respirations were labored. On [DATE] at 2:30 PM labs and a chest xray were obtained. Labs results dated [DATE], revealed BUN 64 mg\dl, Creatinine 1.7 mg\dl and potassium 6.3 mmol/L. On [DATE], at 11:08 PM the physician was contacted in response to lab results received at the facility. The resident was transferred to the hospital and admitted for urosepsis. A review of a hospital history and physical dated [DATE] revealed that Resident CR1 was hypothalamic (blood potassium too high) and was short of breath, prompting a emergency department visit. Her shortness of breath was noted to be severe in the ED (emergency department), which was constant, worsened by deep breathing and was wheezing. The assessment noted that Resident CR1 was in respiratory distress. She had decreased breath sounds and had rales in the right and left lower field. Labs dated [DATE], at 8:30 pm revealed BUN 64 mg\dl, creatinine 1.7 mg\dl and potassium 6.3 mmol/L. Results from a chest x-ray completed in the emergency department [DATE], at 7:08 PM revealed bilateral pleural effusions, right larger than left with adjacent consolidation and [MEDICAL CONDITIONS]. The impression was noted as [MEDICAL CONDITION] with cardiomegaly, bilateral effusions, right larger than left and [MEDICAL CONDITIONS]. The final emergency department [DIAGNOSES REDACTED]. The resident was then admitted to the hospital. A review of a hospital discharge summary dated [DATE] revealed that the resident's discharge [DIAGNOSES REDACTED]. The history of this illness was documented as the patient noted that she has been short of breath, but it's getting worse. Resident CR1's son noted that her [MEDICATION NAME] had been stopped weeks ago and only recently restarted at 20 mg daily by mouth. He found out that her [MEDICATION NAME] 40 mg was stopped at the facility, but stated that they forgot to put her on 20 mg. The hospital discharge summary noted that the resident had acute [MEDICAL CONDITION]. This patient needed fluid off. She had [MEDICAL CONDITION]. Treatment included intravenous (IV) [MEDICATION NAME]. The discharge summary continued to note that over the course of the hospitalization , Resident CR1 continued to suffer from continued, worsening organ failure, including her kidneys and ongoing [MEDICAL CONDITION] and [MEDICAL CONDITION]. The summary indicated that her heart failure was treated with a thoracentesis ( a procedure where a needle is inserted into the lungs to drain off excess fluid ),which improved her breathing. The resident was discharged home on hospice services and expired on e week later. Interview with the assistant Director of Nursing on [DATE] at approximately 2:15 p.m. confirmed that Resident 31's comprehensive care plan did not identify the resident's recent history [MEDICAL CONDITION] and diuretic therapy and/or active [DIAGNOSES REDACTED]. The facility failed to timely develop and implement a person-centered comprehensive care plan to meet the resident's medical needs and ensure that the resident received timely and necessary services to attain the resident's highest practicable physical well being. 28 Pa. Code 211.11 (e) Resident Care Plan. previously cited [DATE], [DATE] 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services previously cited [DATE], [DATE]