Every finding on record at Westminster Woods at Huntingdo

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of four residents reviewed (Resident 2) resulting in aspiration. This deficiency is being cited as past non-compliance. Findings include: A comprehensive minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated May 11, 2026, revealed that the resident was severely cognitively impaired, required assistance from staff, and had a mechanical diet. A care plan for activities of daily living, dated July 3, 2025, indicated that Resident 2 required set-up by staff to eat, needed to be encouraged to eat meals in the dining room, and to supervise meals and monitor for pocketing of food. A speech therapy discharge summary for Resident 2, dated April 23, 2026, recommended skilled treatment interventions focused on education and training patient and caregivers in safe swallowing strategies in order to safely tolerate least restrictive diet. It was also recommended for the patient to sit at an assist table to help utilize safe swallowing strategies, including rate modification. A nursing note for Resident 2, dated May 15, 2026, at 8:05 p.m. revealed that the resident's dinner tray was sitting at the side of her bed with a small amount of mashed potatoes eaten. She was checked and it was noticed that she had mashed potatoes in her mouth. Resident 2 was gurgling, her eyes were fixed, and she was diaphoretic. Staff immediately sat the resident up and instructed for her to cough and get it out. She coughed until her breathing sounded clear again. A nursing note for Resident 2, dated May 15, 2026, at 8:15 p.m. revealed that the resident was observed gurgling indicating evidence that she had aspirated. Resident 2's lung sounds were diminished in the bases. Resident 2 continued to cough. The Physician's Assistant was contacted. New orders were obtained for a chest x-ray and 40 milligrams Prednisone (corticosteroid medication used to reduce inflammation) daily for five days. A provider's note dated May 18, 2026, at 4:30 p.m. indicated that Resident 2 was evaluated for follow up as she was having wheezing and cough over the weekend. She was found to have pneumonia and was started on scheduled duo nebs (breathing treatment, Robitussin (cough suppressant), and Augmentin (antibiotic medication). She was seen today sitting outside her room and denies any shortness of breath or pain at this time. A witness statement dated May 15, 2026, by Nurse Aide 1 indicated that Resident 2 was not coming to the dining room, her tray was set up at bedside, and Nurse Aide 1 left the room. An interview with Director of Nursing June 9, 2026, at 4:47 p.m. revealed that Resident 2's care plan was multiple pages long and staff did not scroll down enough to see that she also required supervision while eating. The care plan was changed to a language that was easier to read. The Director of Nursing confirmed that Resident 2 should have been supervised while eating on May 15, 2026, as was not. Following the incident on May 15, 2026, the facility's corrective actions included: 1. Involved resident's care plan/Kardex was updated to include eating support interventions by May 20, 2026. 2. The Director of Nursing or designee conducted an audit of current residents to ensure readability of interventions on residents' Kardex by June 5, 2026 3. Education records, dated May 21, 22, and 23 2026, revealed the Director of Nursing or designee will provide re-education to current nurse aides on locating and visualizing the Kardex by May 25, 2026. 4. The Director of Nursing or designee will conduct audits on three nurse aides weekly for four weeks, then monthly for two months to ensure capability of viewing and understanding of Kardex interventions. Results of audits would be brought to QAPI for review and recommendations. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on June 5, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete a thorough investigation for a choking incident that occurred for one of 17 residents reviewed (Resident 17). Findings include:A facility policy for abuse and neglect dated January 9, 2026 , revealed that events involving evidence or reports of physical, sexual, mental or verbal abuse involuntary seclusion, neglect and misappropriation or resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 hours or within the timeframe that has been identified. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 2, 2026, revealed that the resident was cognitively impaired, required a mechanically altered diet, did not have coughing or choking during meals or when swallowing medication, was dependent on staff with daily care needs, and required partial assistance while eating. A care plan for Resident 17 for a swallowing problem, dated August 7, 2025, revealed that the resident is to be fed at assist table when spouse is not feeding her. A nurse's note for Resident 17 dated December 29, 2025, at 5:16 p.m. revealed that the resident was in her room after dinner. She vomited and began to choke on her vomit requiring the nurse aide to pull the mucus and vomit from her mouth, and the resident was transferred to the emergency room for evaluation.A nurse's note for Residet 17 dated January 2, 2026, at 6:22 p.m. revealed that the nurse aide was feeding the resident and was unable to clear her throat. The nurse aide had to perform the Heimlich maneuver to open the airway and brought up a moderate amount of food.A nurse's note for Resident 17 dated April 29, 2026, at 6:04 p.m. revealed that the resident was being fed in the dining room by staff and began to choke on a portion that was fed to her. The Licensed Practical Nurse had to give back blows until food was coughed out. A review of the clinical records for Resident 17 revealed no documented evidence that an investigation was completed for the above choking incidents. Interview with the Director of Nursing and the Nursing Home Administrator on May 7, 2026, at 10:20 a.m. revealed that there was information in a nursing note and that they did not do an investigation into the above incidents. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of investigative reports, and residents' clinical records, observations, as well as staff interviews, it was determined that the facility failed to ensure physician's orders were followed for four of 30 residents Reviewed (Residents 1, 22, 33, and 55). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2026, indicated that the resident was severely cognitively impaired and required supervision or touching assistance for eating, had a unexpected weight loss, and had diagnoses that included malnutrition. A nutritional care plan dated March 22, 2026 indicated that supplements were to be administered as ordered.Physician's orders for Resident 1, dated October 4, 2025 , included an order for the resident to receive a magic cup (nutrient-dense, high-calorie frozen dessert) twice a day for a recent significant weight loss, with additional orders to instructions to include the amount consumed.A review of Resident 1's Medication Administration Record, dated January and May 2026, revealed) that there was no documentation of the amount consumed.Interview with the Director of Nursing on May 6 2026 at 2:09 and 2:21 p.m. confirmed that there was no documentation of the amount of magic cup consumed. A quarterly MDS assessment dated [DATE], for Resident 22, revealed that the resident was cognitively intact, required substantial assistance from staff for daily care, had diagnoses that included diabetes, and received insulin injections.A diabetes care plan for Resident 22, dated September 24, 2025, revealed that physician's orders for diabetes medication would be followed.Physician's orders for Resident 22, dated July 8, 2025, included an order for the physician to be notified if the resident's blood glucose level was below 70 milligrams per deciliter (mg/dL) or above 350 mg/dL.Review of Resident 22's medication administration record for March 2026, revealed that on March 7, 2026, at 6:30 a.m. the resident's blood sugar was 376 mg/dL, on March 8, 2026, at 6:30 a.m. the resident's blood sugar was 357 mg/dL, on March 9, 2026, at 6:30 a.m. the resident's blood sugar was 373 mg/dL, on March 12, 2026 at 6:30 a.m. the resident's blood sugar was 380 mg/dL, and on March 13, 2026 at 6:30 a.m. the resident's blood sugar was 401 mg/dL.There was no documented evidence in Resident 22's clinical record that the physician was notified of the resident's blood sugar levels on the above dates and times.Interview with the Director of Nursing on May 4, 2026, at 1:06 p.m. confirmed that the physician was not notified of Resident 22's blood sugar levels on the above dates and times and should have been per the physician's orders.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated April 1, 2026, revealed that the resident was understood, could understand others but was confused at times, and had diagnoses that included dementia and heart disease.Physician's orders for Resident 33, dated July 8, 2025, included an order for staff to administer one 2.5 milligram (mg) tablet of amlodipine (medication to treat high blood pressure) one time a day, and staff was to hold the medication if the systolic blood pressure (SBP, the top number of a blood pressure reading) was less than 140 millimeters of mercury (mmHg).Review of the Medication Administration Record (MAR) for Resident 33, for the months of March, April, and May 2026, revealed that staff administered one 2.5 mg tablet of amlodipine to the resident on March 10, 2026, with a documented SBP of 139, on March 12, 2026, with a SBP of 121, April 1, 2026, with SBP of 126 mmHg, and May 4, 2026, with SBP of 117 mmHg, despite the physician's orders to hold the amlodipine when SBP less than 140 mmHg. Interview with the Director of Nursing on May 6, 2026, at 1:59 p.m. confirmed that the medications were given but should have been held per physician's orders. A quarterly MDS assessment for Resident 55, dated March 17, 2026, revealed that the resident was cognitively intact, required substantial assistance from staff for daily care, had diagnoses that included chronic obstructive pulmonary disease (COPD) (a progressive long-term lung disease that makes it difficult to breath due to damaged airways).A COPD care plan for Resident 55, dated July 29, 2025, revealed that the resident was to receive aerosol or bronchodilators (a medication that relaxes the muscles around the airways in the lungs to help improve breathing).Physician's orders for Resident 55, dated February 3, 2026, , included an order for the resident to receive trelegy ellipta inhalation aerosol Powder Breath activated 100-62.5-25 mcg/act and to inhale 1 puff orally one time a day for COPD and to rinse and spit after use.Observations of Licensed Practical Nurse (LPN) 1 administering trelegy ellipta to Resident 55 on May 5, 2025, at 8:07 a.m. revealed that LPN 1 did not have the resident rinse and spit after administration per physician's orders.Interview with LPN 1 on May 5, 2025, confirmed that she did not have the resident swish and spit because he never does it.Interview with the Director of Nursing on May 5, 2026, at 10:010 a.m. confirmed that LPN 1 should have followed physician's order and had the resident swish and spit after inhalation.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 30 residents reviewed (Resident 3).Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 8, 2026, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and was taking opioid medication. A care plan for Resident 3 dated January 29, 2026, indicated that she would display pain by yelling out. Nursing was to assess her pain and administer pain medications as ordered. Physician's orders for Resident 3, dated February 3, 2026 , included an order for the resident to receive one 5 milligram (mg) tablet of Oxycodone (narcotic pain medication) every four hours as needed for pain. A review of Resident 3's Controlled Drug Record (a legally required document that tracks every transaction of the medication to prevent diversion and ensure regulatory compliance), dated February through April 2026, revealed that 5 mg of oxycodone was signed out on the controlled drug record on February 4, 2026, at 6:04 a.m.; February 14, 2026, at 3:37 a.m. and 11:00 a.m.; April 4, 2026, at 6:50 a.m.; and April 7, 2026, at 5:30 a.m. However, there was no documented evidence in the medication administration record that medication was administered to the resident on the dates and times listed. Interview with the Director of Nursing on May 7, 2026, at 2:38 p.m. confirmed that there was no documented evidence in Resident 3's clinical record that the oxydocone was administered on the dates and times above, and there should have been. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that that the physician was notified of a weight change for two of 30 residents reviewed (Residents 1 and 22).Findings Include: A facility policy regarding weights, dated December 29, 2025, revealed that variances of plus or minus five pounds or more for residents over 100 pounds requires a reweigh in 24 hours, a report by the charge nurse to the physician, dietician, and responsible party. The dietician will initiate approaches to remedy the change in weight.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2026, indicated that the resident was severely cognitively impaired and required supervision or touching assistance for eating, had a unexpected weight loss, and had diagnoses that included malnutrition. A nutritional care plan for the resident, dated March 22, 2026 indicated the Registered Dietitian would monitor weights and average meal intakes.On November 5, 2025, Resident 1's weight was 135.8 pounds, then on November 12, 2025, Resident 1 weighed 125.0 pounds. Resident 1 had 10.8 lb. weight loss in one week. On December 3, 2025 Resident 1 weighed 129 pounds, then on December 10, 2025 Resident 1 weighed 117.8 pounds. Resident 1 had a 11.2 pound weight loss in one week.There was no documented evidence in the clinical record to indicate that Resident 1 was reweighed within 24 hours. There was no documented evidence that the charge nurse, physician, or dietitian was made aware of the weight loss.Interview with the Director of Nursing on May 6 2026 at 2:09 p.m. and 2:21 p.m. respectively, confirmed that there was no documented evidence that the charge nurse, physician, or dietitian was made aware of Resident 1's weight loss in November and December, 2025, or that a reweigh was completed per facility policy. A quarterly MDS assessment for Resident 22, March 31, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included kidney failure and heart failure. Care plan for Resident 22 dated March 19, 2026, revealed that the resident is at risk for weight fluctuations due to diuretic use, and his weight is to be monitored per physician's orders. Physician's order for Resident 22 dated March 11, 2026, revealed that the resident is to be weighed every Wednesday and the physician is to be notified if there is an increase in 3 pounds in 24 hours or an increase of 5 pounds in a week. A review of the weight records for Resident 22 revealed that on April 29, 2026, he weighed 229 pounds and on May 2, 2026, he weighed 236.4 pounds, an increase of 7.4 pounds in three days. There was no documented evidence that the physician was notified of the weight increase. Interview with the Director of Nursing on May 7, 2026, at 9:04 a.m. revealed that there was no documented evidence that the physician was notified of the resident's weight increase and he should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review, as well as staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for one of 17 residents reviewed (Resident 23).Findings Include: A nursing note for Resident 23 dated February 6, 2026, revealed that the resident was found lethargic, mumbling, diaphoretic, unable to answer questions appropriately, and pupils were non-reactive and fixed. She was subsequently sent to the emergency room for evaluation. Review of Resident 23's clinical record revealed no documented evidence that the resident representative notified in writing of the transfer to the hospital on the above dates and times, and that a bed hold notice was not provided at the time of the transfer. Interview with the Nursing Home Administrator on May 6, 2026, at 10:09 a.m. revealed that she did not notify the resident's representative of the hospital transfer for the resident's above, and that the bed hold notice was not provided at the time of the transfer. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 30 residents reviewed (Resident 4).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 4, 2026, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 4's care plan, dated July 16, 2025, indicated that the resident had PTSD, anxiety, and Traumatic Brain Injury. There was no documented evidence the facility identified Resident 4's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Social Worker on May 6, 2026, at 2:13 p.m. confirmed that she did not do an assessment for PTSD triggers and stated that it was not completed because the old computer system did not have the assessment program. 28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on a review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident 1). Findings include: The facility's abuse policy, dated December 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 2, 2026, indicated that the resident was cognitively intact, was understood and could understand others, was dependent on staff for daily care needs, was incontinent of bowel and bladder and had diagnoses that included vascular Amyotrophic Lateral Sclerosis (a progressive, fatal neurodegenerative disease that destroys motor neurons in the brain and spinal cord, causing loss of movement, speech and breathing). Information submitted by the facility, dated March 17, 2026, revealed that on the evening of March 16, 2026 Resident 1 alleged that he did not receive proper care and had not been changed since about 5:00 p.m. The Nurse Aide assigned to provide his care was Nurse Aide 4. Nurse Aide 2 reported to this to Registered Nurse 1. A registered nurse assessment was conducted on March 16, 2026, at 11:56 p.m. and Registered Nurse 1 noted that Resident 1's brief was saturated, as well as his bedding. It was also noted that his call bell was not within reach, it was located at the top of his bed. A skin assessment revealed an area on the back of Resident 1's left thigh measuring 10.0 cm x 0.1 cm that was purple and did not blanch; an 8.0 cm x 0.1 cm red blanchable area on his left thigh; an open excoriated area on his abdominal fold measuring 5.0 cm x 0.1cm; and an open excoriated area on his right groin that measured 7.0 cm x 0.3 cm. Investigative interview statement from Nurse Aide 2, dated March 17, 2025, revealed that Resident 1 called out to her and stated that he had been laying in his bed for 6 hours and no one came to help him. Nurse Aide 2 and Nurse Aide 3 changed all urine saturated bed linen and the incontinence brief and it was also noted that Resident 1 had a bowel movement. Resident 1 received incontinence care, and all of his bedding was changed to fresh linen. Investigation documents revealed that the Director of Nursing was notified March 17, 2026, at 8:30 a.m. and the Medical Doctor was notified with no new orders being received. Nurse Aide 4 was immediately placed on leave pending investigation. Pennsylvania Department of Health, Area Agency on Aging and the local police were notified of the event. Resident 1 is care planned as his own representative and did not want his spouse notified. Investigation documents revealed an interview with Nurse Aide 4 on March 17, 2026, that confirmed she did not provide care to Resident 1 because he always rings his call bell when he needs care. She did not provide care because he did not ring his call bell. The facility's investigation included interviews with all residents that Nurse Aide 4 cared for on March 16, 2026, and there were no further concerns. A skin assessment for Resident 1 completed March 19, 2026, revealed that all areas of concern were resolved. Education was provided to staff regarding resident care and the importance of ensuring all personal belongings and call bells are within reach prior to leaving a resident's room. Investigation documents revealed that due to Nurse Aide 4 not providing care to Resident 1 the allegation of neglect was substantiated and Nurse Aide 4 was terminated. Interview with the Nursing Home Administrator on April 8. 2026, at 2:45 p.m. confirmed that Resident 1 should have had care provided to him and he did not and that the allegation of neglect was substantiated and Nurse Aide 4 was terminated from employment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to store frozen foods appropriately, failing to keep kitchen equipment clean and sanitary, and failing to have staff wear appropriate hair restraints during food preparation and tray line service. Findings include: The facility's policy regarding food labeling and dating, dated January 22, 2024, revealed staff were to properly seal the container of bulk freezer items like frozen vegetables to maintain their integrity. Observations in the kitchen's walk in freezer on March 31, 2025, at 9:20 a.m. revealed that there was an opened box of frozen fish fillets that was exposed to the air. Interview with the Dietary Director at the time of the observation confirmed that the box of frozen fish should have been sealed and removed the box to have staff cover the fish filets. The facility's policy regarding sanitizing equipment, dated January 22, 2024, revealed that equipment used in meal preparation was thoroughly cleaned and sanitized preventing injury and food-borne illness. Observations in the facility's kitchen on March 31, 2025, at 9:33 a.m. revealed that the deep fryer in the meal preparation area had a large amount of floating fried debris on the oil and the surrounding area. The deep fryer was not used for the morning meal and was turned on and heating up for use during the lunch and dinner meals. Interview with the Dietary Director at the time of the observation confirmed that the deep fryer should have been cleaned after use. The facility's policy regarding dress code guidelines, dated January 22, 2024, revealed that men with beards or full mustaches are not permitted in food production and a beard net must be worn. Observations of the work/prep space in the kitchen during tray line on April 3, 2024, at 11:15 a.m. revealed that two staff were prepping drinks and trays for trays for residents that ate in their rooms. Dietary Staff 3 had a full beard and mustache and was not wearing a beard restraint. Interview with the Dietary Director on March 3, 2025, at 11:24 p.m. revealed that the dietary staff were to have facial hair restraints while in the kitchen. 28 Pa. Code 211.6(f) Dietary Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about changes in diet consistencies for one of 34 residents (Resident 10) reviewed and failed to notify the urologist regarding symptoms of a urinary tract infection (UTI) for one of 34 residents (Resident 22). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated March 11, 2025, indicated that the resident was cognitively intact, was dependent on staff for care needs, and had a mechanically altered diet. A nurse's note for Resident 10, dated October 4, 2024, revealed that the resident was observed choking on water during medication administration and was downgraded from thin liquids to nectar thick as a nursing measure. A note from speech therapy, dated October 29, 2024, revealed that Resident 10 was safe to ingest nectar thick liquids. There was no documented evidence that Resident 10's responsible party was notified of the resident's diet consistency downgrade to nectar thickened liquids after the incident on October 4, 2024, and after receiving speech therapy on October 29, 2024. Interview with the Director of Nursing on April 1, 2025, at 12:48 p.m. confirmed that there was no documented evidence that the resident's responsible party was notified that Resident 10's diet consistency was downgraded. A significant MDS assessment for Resident 22, dated November 28, 2024, revealed that the resident was cognitively intact, required assistance with daily care tasks, and had an indwelling (foley) urinary catheter. A urology consult for Resident 22, dated December 12, 2024, revealed that the resident was to have a voiding trial and to notify the urologist if the resident developed any UTI symptoms. A nursing note for Resident 22, dated December 19, 2024, revealed that the resident was having symptoms of lower back pain, urinary frequency, and that the foley catheter was reinserted. There was no documented evidence that the urologist was notified regarding the UTI symptoms. Interview with the Director of Nursing on April 2, 2025, at 12:21 p.m. confirmed that there was no documented evidence in Resident 22's clinical record that the facility called the urologist to notify him about the UTI symptoms. 28 Pa. Code 211.12(d)(1)(3) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop a care plan for a Peripherally Inserted Central Line (PICC) to treat an infection that required the use of intravenous antibiotics for one of 34 residents reviewed (Resident 66). Findings include: According to admission paperwork for Resident 66, dated March 19, 2025, the resident was admitted from the hospital for further care of his left heel wound on March 19, 2025. Physician's orders for Resident 66, dated March 19, 2025, included an order for the resident to receive 1 gram of Ertapenem (antibiotic) once daily through his PICC line. There was no documented evidence in Resident 66's clinical record to indicate that a care plan was developed for the care and treatment of a PICC line, infection, or IV antibiotics. Interview with the Nursing Home Administrator on April 2, 2025, at 9:02 a.m. confirmed that a care plan for Resident 66's PICC line, infection, and IV antibiotics was not developed. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 16). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated January 22, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included heart failure and high blood pressure. Physician's orders for Resident 16, dated August 17, 2024, included orders for the resident to receive 6.5 milligrams (mg) of Carvedilol (treats high blood pressure) once a day, to be held if his apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) is less than 50 beats per minute (bpm), and to administer 5 mg lisinopril (treats high blood pressure) daily. A review of the January, February, and March 2025 Medication Administration Record (MAR) for Resident 16 revealed the following: On January 6, 2025, no apical pulse was obtained and the carvedilol dose was administered when it should have been held according to the physician's orders. On January 22 and 30, 2025, the lisinopril was held, and should have been administered according to physician's orders. On February 13 and 23, 2025, the lisinopril was held, and should have been administered according to physician's orders. On March 23, 2025, the resident's apical pulse was 71 bpm, and the carvedilol dose was held when it should have been administered according to the physician's orders. Interview with the Director of Nursing on April 3, 2025, at 12:47 p.m. confirmed that the carvedilol and lisinopril were not administered to Resident 16 per physician's orders on the dates listed. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a privacy cover was provided for one of 34 residents reviewed (Resident 54) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine) insertion indicators, dated January 22, 2025, revealed that indwelling urinary catheters must be covered and placed below the bladder for proper drainage. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated March 13, 2025, revealed that the resident was cognitively intact, had an indwelling urinary catheter, and had diagnoses that included obstructive uropathy (normal flow of urine through the urinary tract is blocked) and benign prostatic hyperplasia (BPH - enlarge prostate). Physician's orders for Resident 54, dated March 7, 2025, included an order for the resident to have an indwelling urinary catheter due to neurogenic bladder (a condition that causes loss of bladder control due to damage to the nervous system), to be changed as needed for dislodgement, blockage, or leakage. A care plan, dated March 27, 2025, indicated that Resident 54 required an indwelling urinary catheter related to a neurogenic bladder. Observations of Resident 54 on March 31, 2025, at 11:17 a.m. revealed that the resident was in his wheelchair being transported by Nurse Aide 1 from the 400 hall to the 300 hall. This catheter collection bag did not have a cover and urine was visible. Interview with Nurse Aide 1 on March 31, 2025, at 11:30 a.m. confirmed that there was not a privacy bag on the urine collection bag, and she had been looking for one since this morning. Interviews with the Director of Nursing on April 1, 2025, at 2:28 p.m. confirmed that Resident 54's catheter tubing should not have been in contact with the fall mat. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of 34 residents reviewed (Resident 23). Findings include: The facility's policy regarding medication storage, dated January 22, 2025, indicated that medications for internal use were stored in medication carts or other designated areas. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated March 20, 2025, indicated that the resident was cognitively intact, usually understood and could usually understand, required assistance from staff for daily care needs, and was receiving antipsychotic medication. Physician's orders for Resident 23, dated January 13, 2025, included an order for the resident to receive 25 milligrams (mg) of Seroquel (antipsychotic medication) daily for psychosis. Interview and observations of Resident 23 on March 31, 2025, at 10:55 a.m. revealed that she was in her room and she stated that her only concern was a pink pill on the floor by her toilet. There was a round pink/orange pill on the floor in her bathroom. Interview with Licensed Practical Nurse 2 on March 31, 2025, at 11:17 a.m. confirmed that the medication was identified as 25 mg of Seroquel and Resident 23 was scheduled to receive the medication in the evening. Licensed Practical Nurse 2 further explained that Resident 23 was the only resident in that room that used the toilet, and her morning medication were crushed and served with pudding or applesauce. Interview with the Director of Nursing on April 1, 2025, at 2:28 p.m. confirmed that medication should not be on the floor. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal vaccine (prevents bacterial pneumonia) for one of 34 residents reviewed (Resident 5), and failed to ensure that each resident was offered and/or received the influenza vaccine for two of 34 residents reviewed (Residents 11, 14). Findings include: The facility's policy regarding vaccines, dated January 22, 2025, revealed that the resident or the resident's representative have the opportunity to accept or refuse immunization. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2025, indicated that the resident was cognitively intact and that the resident's pneumococcal was not up to date. A pneumococcal vaccine authorization form signed by Resident 5, dated November 19, 2024, revealed that she wanted to have the pneumococcal vaccine. An interview with the Registered Nurse Assessment Coordinator on April 3, 2025, at 11:34 a.m. confirmed that Resident 5 did not receive a pneumococcal vaccine and that she should have. A quarterly MDS assessment for Resident 11, dated February 20, 2025, revealed that the resident was cognitively intact and that her flu vaccine was not up to date. A flu vaccine consent form for Resident 11, dated October 2, 2024, revealed that the resident consented to receive the flu vaccine; however, a review of Resident 11's clinical record revealed that she did not receive the flu vaccine. An interview with the Director of Nursing on April 3, 2025, at 11:28 a.m. confirmed that Resident 11 did not receive the flu vaccine and should have. A quarterly MDS assessment for Resident 14, dated February 19, 2025, revealed that the resident was understood, could understand, was cognitively intact, and was dependent on staff for her daily care tasks. Section O0250 A of the MDS (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in this facility for this year's influenza vaccination season due to being offered but declining the vaccine. Review of Resident 14's clinical record revealed that there was no documented evidence that the resident was offered the influenza vaccine for the 2024-2025 flu season. Interview with the Director of Nursing on April 3 at 12:29 p.m. confirmed that there was no documented evidence that Resident 14 was offered the seasonal influenza vaccine for 2024-2025 flu season. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from sexual abuse for one of four residents reviewed (Resident 2). This was cited as past non-compliance. Findings include: The facility's abuse policy, dated January 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 10, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and could sometimes understand others, was ambulatory, and had diagnoses that included vascular dementia (memory loss). Review of information submitted by the facility, dated March 7, 2025, indicated that Maintenance Worker 1 was observed by Nurse Aide 2 and Nurse Aide 3 to be straddling Resident 2 while she was seated in her recliner chair, hugging the resident, and rubbing the resident's flank area under her shirt. Investigative interview statements from Maintenance Worker 1, dated March 10, 2025, revealed that he did give Resident 2 a hug because he felt bad she did not have any visitors, but that he could not recall if his hand was under her shirt or not. Nurse Aide 2 then took out her personal cell phone and recorded a video of Maintenance Worker 1 hugging and stroking the resident's flank area with his hand under her shirt. Investigative interview statements from Nurse Aide 2, dated March 7, 2025, revealed that while she was walking past Resident 2's room she observed Maintenance Worker 1 standing over Resident 2 straddling her legs. She stated that it seemed odd and that she then went back to that area to see what he was doing and she then observed him standing next to her straddling the arm rest of the chair that the resident was sitting in. Nurse Aide 1 then grabbed Nurse Aide 2 so that she could confirm that what she saw was what was actually occurring. When the two nurse aides returned to the resident's doorway, they saw Maintenance Worker 1 with his hand under Resident 2's shirt and he was rubbing her side. She stated that Maintenance Worker 1 continued to look over his shoulder toward the door way. She stated that it was at that time that she took out her personal cell phone and recorded what was occurring because she did not think that anyone would believe her. Investigative interview statements from Nurse Aide 3, dated March 7, 2025, indicated that Nurse Aide 2 grabbed her and said that she witnessed Resident 2 touch Maintenance Worker 1's privates. She stated that when she looked into Resident 2's room she observed Maintenance Worker 1 standing to the left of Resident 2 while she was sitting in her recliner chair and they were hugging and that his hand was on her right side at her hips and was under her shirt. Interview with the Nursing Home Administrator on March 15, 2025, at 10:47 a.m. revealed that Maintenance Worker 1 was immediately removed from the building pending the investigation and that he was terminated from employment. Following the incident on March 7, 2025, the facility's corrective actions included: On March 7, 2025 Resident 2 had a Registered Nurse assessment completed and no injuries were identified. The Social Services Director interviewed the resident and no ill emotional effects were identified. Maintenance Worker 1 was placed on administrative leave immediately on March 7, 2025. The police, Area Agency on Aging, and the PA Department of Health were notified immediately. All residents residing in the nursing facility were assessed by a Registered Nurse and no injuries were identified. All residents were interviewed by licensed staff and the social services director and none identified concerns related to sexual behavior. The Director of Nursing or designee educated all staff by March 10, 2025, regarding the facility's abuse policy and reporting abuse. The Social Services Director will conduct an audit weekly for four weeks and monthly for two months. Any identified allegations will be immediately reported to the Nursing Home Administrator or designee. Results of these audits will be forwarded to quarterly quality assurance meetings for review and recommendations. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from being recorded on a personal cell phone without their permission for one of four residents reviewed (Resident 2). Findings include: The facility's abuse policy, dated January 22, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall be protected from mistreatment, neglect exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 10, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and could sometimes understand others, was ambulatory, and had diagnoses that included vascular dementia (memory loss). Review of information submitted by the facility, dated March 7, 2025, indicated that Maintenance Worker 1 was observed by Nurse Aide 2 and Nurse Aide 3 to be straddling Resident 2 while she was seated in her recliner chair, hugging the resident, and rubbing the residents flank area under her shirt. Investigative interview statements from Maintenance Worker 1, dated March 10, 2025, revealed that he did give Resident 2 a hug because he felt bad she did not have any visitors, but that he could not recall if his hand was under her shirt or not. Nurse Aide 2 then took out her personal cell phone and recorded a video of Maintenance Worker 1 hugging and stroking the resident's flank area with his hand under her shirt. Investigative interview statements from Nurse Aide 2, dated March 7, 2025, revealed that while she was walking past Resident 2's room she observed Maintenance Worker 1 standing over Resident 2 straddling her legs. She stated that it seemed odd and that she then went back to that area to see what he was doing and she then observed him standing next to her straddling the arm rest of the chair that the resident was sitting in. Nurse Aide 1 then grabbed Nurse Aide 2 so that she could confirm that what she saw was what was actually occurring. When the two nurse aides returned to the resident's doorway, they saw Maintenance Worker 1 with his hand under Resident 2's shirt and he was rubbing her side. She stated that Maintenance Worker 1 continued to look over his shoulder toward the door way. She stated that it was at that time that she took out her personal cell phone and recorded what was occurring because she did not think that anyone would believe her. The resident's face was not visible in the video and the resident could not be identified in the video. Investigative interview statements from Nurse Aide 3, dated March 7, 2025, indicated that Nurse Aide 2 grabbed her and said that she witnessed Resident 2 touch Maintenance Worker 1's privates. She stated that when she looked into Resident 2's room she observed Maintenance Worker 1 standing to the left of Resident 2 while she was sitting in her recliner chair and they were hugging and that his hand was on her right side at her hips and was under her shirt. Interview with the Nursing Home Administrator on March 15, 2025, at 10:47 a.m. revealed that employees were not to use their personal cell phones for any reason during working hours and that Nurse Aide 2 should not have recording a video of Resident 2, no matter the circumstances. She stated that Nurse Aide 2 stated that she knew she should not have recorded anything prior to showing her the video. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: The facility's policy for abuse, dated Janaury 8, 2025, indicated that the incident report process requires a note in the clinical record and subsequent documentation of all assessments and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 6, 2024, revealed that the resident was cognitively impaired, could usually understand, was understood, was independent with daily care, and had diagnoses of stroke. A nursing note for Resident 1, dated January 18, 2025, at 10:08 a.m., revealed that the resident was found on the floor, had no complaints of pain, no injury was voiced or noted, and neurological checks (a series of tests that assess the function of the nervous system) were ordered. A review of the facility's investigation report, dated January 19, 2025, indicated that the resident was found on the floor on January 18, 2025, at 10:08 a.m. and neurological checks were initiated. At 12:30 p.m. the resident had complaints of a dry mouth and was provided a drink without issue. A breathing treatment was given at that time due to the resident's current diagnosis of pneumonia with a cough. At 2:30 p.m. the resident had issues with answering questions. The Physician's Assistant was notified and arrived at the facility to assess the resident and ordered another breathing treatment. At 4:15 p.m. the family returned the call to the facility and was made aware of the incident and the resident's current status. At 6:44 p.m. the resident was no longer able to raise her arm, and new orders were received to send to the resident to the emergency department for evaluation. There was no documented evidence in Resident 1's clinical record to indicate that registered nurse assessments were conducted on January 18, 2025, at 12:30 p.m. when the resident complained of a dry mouth, at 2:30 p.m. when the resident had issues with answering questions, or at 6:44 p.m. when the resident could no longer raise her arm. Interview with the Director of Nursing on January 29, 2025, at 10:48 a.m. confirmed that the registered nurse assessments of Resident 1 were completed on January 18, 2025; however, they were not documented in the clinical record and should have been. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address a resident's frequent urinary tract infections and medication use for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding care planning, dated March 26, 2024, revealed that the comprehensive care plan was to have input from interdisciplinary team members, and to the extent practicable, the participation of the resident and/or the resident's representative(s). The care plan was to contain interdisciplinary approaches, be oriented toward involving the resident, and address additional areas that are relevant to meeting the resident's needs in the long-term care setting. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 7, 2024, indicated that the resident was understood and could usually understand, required assistance from staff for care needs, and was frequently incontinent of urine and occasionally incontinent of bowel. Physician's orders for Resident 1, dated July 4, 2024, included an order for the resident to be administered one gram D-mannose (Cranberry supplement) daily for urinary tract infection (UTI) prophylaxis (prevention). Physician's orders, dated July 8, 2024, included an order for the resident to be seen by urology related to frequent UTI and burning and painful urination. Physician's orders, dated July 28, 2024, included an order for the resident to be administered 0.01 percent Estradiol (vaginal cream) daily for urinary tract infection prevention. Physician's orders, dated August 3, 2024, included an order for the resident to be administered 100 milligrams (mg) of Macrobid (antibiotic) twice a day for five days. There was no documented evidence that a care plan was created for Resident 1's frequent UTI's and antibiotic use. Interview with the Director of Nursing on August 7, 2024, at 4:29 p.m. confirmed there was no care plan created for the care and treatment of frequent UTI's, antibiotic medication, and preventative medication. 28 Pa. Code 201.24(e)(4) Admission Policy.

Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents reviewed (Residents 3, 14). Findings include: The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendations directed to him/her within 30 days from the date the facility receives the recommendations, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Review of the clinical records for Resident 3 and Resident 14 revealed no documented evidence that the monthly review of medications by the pharmacist were addressed by the physician or designee in December 2023 and January 2024. Interview with the Director of Nursing on May 16, 2024, at 2:57 p.m. confirmed that there was no documented evidence that the December 2023 and January 2024 monthly medication reviews for Residents 3 and 14 were addressed by the medical provider. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(3) Nursing Services.

Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe and accident hazard-free environment related to not removing medications from a resident's possession for one of two residents reviewed (Resident 1), which allowed Residents 1 and 2 to attempt suicide resulting in actual harm, unresponsiveness, and transfer to the hospital for both residents and eventual death for one resident (Resident R2). It was determined that the facility failed to intervene after observing Resident 1 with medications in his possession, which allowed both residents to attempt suicide, resulting in Immediate Jeopardy. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 8, 2022, revealed that the resident was admitted from an acute care hospital; was understood; could understand; reported as feeling down, depressed, or hopeless over the last seven to eleven days; required extensive assistance from staff for her daily care tasks; had a diagnosis which included depression; and received an antidepressant on three days during the review period. A care plan for Resident 2, dated August 2, 2022, revealed that the resident was at risk for psychosocial well being related to medically imposed restrictions due to COVID-19 precautions. Staff was to observe for psychosocial and mental status changes, document, and report as indicated. An admission MDS assessment for Resident 1, dated September 2, 2022, revealed that the resident was admitted to the facility on [DATE], was alert and oriented, had no behaviors, required limited assistance from staff for daily care tasks, had diagnoses that included anxiety, and took an anti-anxiety medication. A social services progress note for Resident 2, dated August 4, 2022, at 4:28 p.m. revealed that the social worker did an assessment with the resident. The resident was very pleasant and cheerful with the social worker. The resident talked about working with her husband recruiting for a college and traveling across the U.S. with him. She had mentioned in the conversation that she does not want to extend her life and she prays that she would go in her sleep. She also talked of her sister having hospice to help her die. The social worker asked if she had thoughts of harming herself in the last two weeks. The resident stated that she has probably had thoughts of dying in the last two weeks. She stated that she would not harm herself but has thought of taking a handful of medications and just falling asleep. The resident stated many times that she had a good life. The resident stated that she is not depressed. The social worker and the resident had a long conversation and the social worker was not alarmed with what the resident said. Her statements seemed more like she was ready when it was her time, she was not sad about dying, and that dying is a natural part of life. A nursing progress note for Resident 2, dated August 4, 2022, at 5:11 p.m. revealed that a phone call was placed to the on-call provider and the resident's passive statements of taking a handful of pills and comments about dying were reported. The provider did not feel that the resident was in immediate danger for self harm. Staff were to monitor and report any concerning comments and to have the physician evaluate the resident for the need for geri-psych tomorrow during rounds. Resident 2 stated that she has been her husband's primary caregiver and has past issues with anxiety. She would normally take Xanax (an antianxiety medication) as needed but currently is not taking it this admission. Communication was sent to Resident 2's physician regarding the on-call provider's recommendations. A nursing progress note for Resident 2, dated August 5, 2022, at 4:11 p.m. revealed that the resident was taking Xanax at home but did not have a current order for it. The physician was aware, but no orders were given for Xanax at this time. The physician was made aware that the resident has made passive statements about being ready for death to other staff members; however, she has made no comments at this time. A social services progress note for Resident 2, dated August 8, 2022, revealed that an admission MDS assessment was completed. The resident did tell a social worker on August 4, 2022, that she had passive thoughts of death and dying. This was reported to the registered nurse. A nursing progress note for Resident 2, dated September 16, 2022, at 11:33 p.m. revealed that staff went in to give the resident her bedtime medications. The resident would not respond even with a sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert). Staff found a pill on her chest. The pill was a 15 milligram (mg) Restoril (used to treat a certain sleep problems). This is the same pill her husband had in his drawer. The CRNP who was covering for the physician was notified. An order was received to send the resident to the Emergency Department. Emergency 9-1-1 was called at 10:45 p.m. The daughter was called at 10:46 p.m. The resident left via ambulance at 11:00 p.m. A witness statement completed by Nurse Aide 1 on September 16, 2022, revealed that she went in around 8:00 p.m. because Resident 2 was ringing her call bell. The nurse aide tried a couple of times to wake the resident. The resident did finally get awake for the nurse aide to take her to the bathroom to get ready for bed. As the nurse aide was taking her in, she noticed that Resident 1 was in the bottom draw of his dresser in a brown box with medicine. The nurse aide saw him take a big bottle out of the box. The nurse aide put Resident 2 to bed and reported to the Registered Nurse Supervisor. The nurse aide did not get a chance to go back in to get the box out. A witness statement completed by Registered Nurse 2 on September 16, 2022, revealed that she went into Resident 1 and Resident 2's room to give bedtime medications and neither resident would respond even with a sternal rub. Registered Nurse 2 found a pill on Resident 2's chest, which was Restoril 15 mg. Nurse Aide 1 told Registered Nurse 2 that she saw medications in Resident 1's bottom drawer, and she was told to take them because he was not allowed to have them. Nurse Aide 1 later told Registered Nurse 2 that she forgot to get them after they were found in the drawer. Nurse Aide 1 said she did see Resident 1 with a bigger pill bottle in his hand. The CRNP who was covering for the physician was notified of the incident and an order was received to send the residents to the Emergency Department. The daughter was notified after. Both residents departed the facility around 11:00 p.m. via ambulance. The medications found included one empty bottle of Trazadone (used to treat depression), four Restoril, four Meloxicam (used to treat arthritis), a bottle of Miralax (used to treat occasional constipation), one bottle of simply sleep (a sleep aide), one package Bronaid (used to treat asthma), one Albuterol Inhaler (used to prevent and treat wheezing and shortness of breath caused by breathing problems), one empty bottle of Xanax, and one bottle Gabapentin (a medicine used to treat partial seizures, nerve pain from shingles, and restless leg syndrome) with Resident 2's name on the bottles of Xanax and Gabapentin. A nursing note, dated September 18, 2022, at 12:43 p.m. revealed that when speaking to the hospital regarding Resident 1's condition, the registered nurse reported that Resident 1 verbalized a plan to carry through with suicide if the means were available. Interview with the Nursing Home Administrator on September 27, 2022, at 1:31 p.m. confirmed that Nurse Aide 1 saw a pill bottle in Resident 1's drawer and told Registered Nurse 2. She indicated that Registered Nurse 2 told Nurse Aide 1 that he was not allowed to have the medications and to take them off of him. She confirmed that Nurse Aide 1 and Registered Nurse 2 did not take the medications off of Resident 1. She indicated that Nurse Aide 1 did not inform Registered Nurse 2 that she did not remove the medications and Registered Nurse 2 never followed up to see if Nurse Aide 1 removed the medications from Resident 1. Both residents were then found unresponsive and were transferred to the hospital, and Resident 2 passed away. On September 27, 2022, at 2:42 p.m. the Nursing Home Adminstrator was given the Immediate Jeopardy template and informed that the health and safety of Residents 1 and 2 were placed in Immediate Jeopardy due to the failure of not removing medications from a resident's possession, which allowed both residents to attempt suicide. An immediate action plan was submitted and contained the following: The facility submitted and implemented an immediate action plan that included completing an audit of the resident's personal belongings to ensure no medications or other items that presented a risk to the resident or other residents. Newly admitted residents or their responsible party, if applicable, would be asked to grant permission for an audit to be conducted by a staff member to ensure residents did not possess medications from the outside (not delivered to the facility by a pharmacy) or have any other items (scissors, knives, etc.) in their possession that could cause harm to a resident who is at risk for self-injury. All facility staff, including agency staff used by the facility, would receive training to ensure that all staff were aware to monitor residents possessing medications from the outside (not delivered to the facility by a pharmacy) or any other items (scissors, knives, etc.) in their possession that could cause harm to a resident, and also education to identify those who are at risk for self-injury, including resident statements and actions indicating the resident may be at risk for suicide attempt, such as statements of death or actions of self-harm. If any staff member identified this behavior, a nursing supervisor will be notified immediately. The Immediate Jeopardy was lifted on September 28, 2022, at 2:56 p.m. when it was confirmed that the facility had completed resident room audits to identify any medications brought in from the outside (not delivered to the facility by a pharmacy) or any other items (scissors, knives, etc.) in their possession that could cause harm to a resident, educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide an environment that was free of hazards to residents who were at risk for elopement and falls for one of five residents reviewed (Resident R1), resulting in a fall with a hip fracture. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated December 20, 2016, revealed that the resident was confused, required extensive assistance from staff for transferring and walking, and had a history of [REDACTED]. However, there was no documented evidence that a care plan was developed to address the resident's risk for elopement. Nursing notes, dated May 20, June 24, August 27, September 8, November 3 and 24, 2016, and January 10, 2017, revealed that the resident was found on the floor. Activities notes, dated September 2 and November 8, 2016, revealed that the resident enjoyed going outside and missed going outside for walks since the temperature had been chilly. An incident report and investigation, dated January 17, 2017, revealed that the door in the activities room, that led to the outside courtyard, was propped open and the resident attempted to walk unassisted in the courtyard, lost her balance, and fell . A nursing note, dated January 17, 2017, revealed that the resident was transferred to the hospital and admitted with a fractured right hip. An interview with Activity Worker 2 on January 24, 2017, at 7:05 p.m. revealed that when she entered the activity room, the door to the outside courtyard was propped open with a small table. She indicated that she was working on the computer and did not see Resident R1 go outside. She confirmed that the door should not have been propped open. An interview with Activity Worker 1 on January 24, 2017, at 8:15 p.m. revealed that she propped the door in the activity room, open with a small table, due to the room being too hot. She confirmed that the door was not secured or monitored, could be opened further, and that she did not see Resident R1 go out the door. An interview with the Nursing Home Administrator on January 24, 2017, at 9:15 p.m. revealed that she did not know that Resident R1 was an elopement risk, and she confirmed that the door in the activity room that led to the courtyard should not have been propped open. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/8/16, 8/13/15.

Based on review of policies, clinical records, and incident reports, as well as staff interviews, it was determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, resulting in an injury for one of two residents reviewed (Resident R1). Findings include: The facility's policy regarding fall management, dated December 16, 2013, indicated that each resident was to have an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. A resident who was identified as at risk for falls was to have ongoing evaluations and revisions documented on his or her care plan, and the care plan interventions were to be re-evaluated after each fall. The Minimum Data Set assessment dated [DATE], for Resident R1 revealed that the resident was confused, required assistance with activities of daily living, had a history of [REDACTED]. An incident report dated June 14, 2014, indicated that the resident was observed transferring and walking without assistance and was found sitting on the floor in front of her recliner. Following this incident, the resident's care plan indicated that the resident was not to be left alone in her room in her chair or was to be placed in bed when her husband was on leave of absence. Interview with the Director of Nursing on January 13, 2015, at 7:30 p.m. revealed that the resident's husband used to live in the facility and when he went on leave of absences, Resident R1 would attempt to get up and look for him. Interview with the Nursing Home Administrator on January 13, 2015, at 8:15 p.m. confirmed that Resident R1 and her husband were roommates, and the resident's husband moved from the facility in August 2014. There was no documented evidence that Resident R1's interventions regarding falls were updated to include what staff were to do after her husband moved out of the facility in August 2014. A nursing note and incident report, dated December 28, 2014, revealed that the resident was left alone in her room in her wheelchair and was later found lying on the floor in front of her wheelchair. On December 29, 2014, the resident was admitted to the hospital with [REDACTED]. Interview with Nurse Aide 1 on January 14, 2015, at 11:40 a.m. revealed that she was not aware that Resident R1 was not to be left unattended in her room or placed into bed. Interview with the Director of Nursing on January 13, 2015, at 7:30 p.m. confirmed that Resident R1 was unsafe to be left unattended in her room, and the care plan was not reevaluated and updated when her husband was discharged from the facility. She indicated that the care plan should have included to place the resident in bed or in a wheelchair in a common area and not leave the resident alone in her room in a wheelchair. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 11/19/14, 7/10/14.