Every finding on record at Whitehall Borough Post Acute

Based on facility review of policy, manufacturer's instructions, clinical records, and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 7 of 36 residents (R3, R17, R64, R84, R116, R145, and R148).Findings include: Review of the facility policy, Hypoglycemia Management Policy dated 1/6/26, indicated:Administer 15 grams of fast-acting carbohydrateRecheck blood glucose in 15 minutesIf BG remains less than 70 mg/dl, repeatNotify provider Review of the facility policy, Physician Notification Policy dated 1/6/26, indicated, Notification will be based on resident's condition, clinical judgement, practitioner orders, and applicable regulatory requirements. Documentation should reflect relevant clinical findings, practitioner communication when completed, orders or recommendations received, and actions taken by facility staff as appropriate. Review of the Facility Assessment last reviewed 3/1/26, indicated the facility will provide care for residents diagnosed with diabetes. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/20/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician order dated 1/21/26, indicated that Resident R3 received 18 units of Humalog in addition to a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 380 (mg/dl), 14 units Call MD, subcutaneously before meals for diabetes AND Inject 18 unit subcutaneously before meals. Review of Resident R3's current plan of care for diabetes initiated 1/30/24, indicated Obtain glucometer readings and report abnormalities as ordered. Review of a physician order dated 2/10/26, indicated that Resident R3 received Humalog on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 380 (mg/dl), 14 units Call MD, subcutaneously before meals for diabetes AND Inject 16 unit subcutaneously before meals. Review of Resident R3's blood sugar record for February 2026, through April 2026, revealed the following blood sugar values failed to have documentation of notification or follow-up: 2/3/26 4:43 p.m. 56.0 mg/dL no notes, no notification no recheck2/4/26 5:15 p.m. 41.0 mg/dL no recheck2/05/26 8:54 p.m. 64.0 mg/dL no recheck2/06/26 12:10 p.m. 49.0 mg/dL no notes, no notification no recheck2/07/26 5:17 p.m. 57.0 mg/dL snack was given no recheck2/08/26 5:40 p.m. 50.0 mg/dL snack was given no recheck2/17/26 12:08 p.m. 434.0 mg/dL no notes, no notification no recheck2/17/26 5:31 p.m. 58.0 mg/dL snack was given no recheck2/19/26 12:07 p.m. 60.0 mg/dL hypoglycemia protocol initiated per note, no recheck 3/24/26 3:10 67.0 mg/dL no notes, no notification no recheck3/25/26 3:26 67.0 mg/dL no notes, no notification no recheck3/28/26 17:31 385.0 mg/dL no notes, no notification no recheck4/2/26 17:28 68.0 mg/dL no notes, no notification no recheck4/2/26 21:15 402.0 mg/dL no notes, no notification no recheck4/05/26 21:11 401.0 mg/dL no notes, no notification no recheck4/09/26 20:49 411.0 mg/dL no notes, no notification no recheck4/11/26 17:48 47.0 mg/dL Insulin held per order, BS: 47 no recheck4/13/26 17:52 58.0 mg/dL Resident alert and asymptomatic. snack given. No recheck4/29/26 17:41 51.0 mg/dL insulin held for BS: 51 no recheck4/30/26 3:13 464.0 mg/dL no notes, no notification no recheck Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R17's current plan of care for diabetes initiated 3/1/23, indicated Obtain glucometer readings and report abnormalities as ordered. Review of a physician order dated 12/30/25, and reordered on 2/27/26, and 3/21/26, indicated that Resident R3 received Humalog on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 450 (mg/dl), give 16 additional units and to notify the provider. Review of Resident R17's blood sugar record for February 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 3/29/26 4:35 p.m. 64.0 mg/dL no notes, no notification no recheck3/18/26 10:30 p.m. 61.0 mg/dL no notes, no notification no recheck3/17/26 11:56 a.m. 69.0 mg/dL no notes, no notification no recheck3/17/26 7:30 a.m. 61.0 mg/dL no notes, no notification no recheck3/13/26 11:53 a.m. 68.0 mg/dL no notes, no notification no recheck3/11/26 12:03 p.m. 64.0 mg/dL no notes, no notification no recheck3/09/26 11:58 a.m. 64.0 mg/dL no notes, no notification no recheck3/08/26 11:59 a.m. 55.0 mg/dL no notes, no notification no recheck3/07/26 11:37 a.m. 48.0 mg/dL no notes, no notification no recheck3/06/26 12:05 p.m. 61.0 mg/dL no notes, no notification no recheck3/05/26 12:02 p.m. 57.0 mg/dL no notes, no notification no recheck2/28/26 8:53 a.m. 67.0 mg/dL no notes, no notification no recheck2/19/26 12:09 p.m. 67.0 mg/dL no notes, no notification no recheck2/19/26 7:07 a.m. 67.0 mg/dL no notes, no notification no recheck2/09/26 12:16 p.m. 67.0 mg/dL no notes, no notification no recheck Review of the clinical record indicated that Resident R64 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R64's current plan of care for diabetes initiated 3/14/25, indicated Blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters. Review of a physician order dated 11/22/25, through 3/20/26, indicated that Resident R64 received insulin lispro on a sliding scale. If below 70 (mg/dl) Treat hypoglycemia protocol and notify MD.; 341+ = 6 (341 mg/dl, give 6 units) Notify MD. Review of a physician order dated 4/3/26, indicated that Resident R64 received Humalog insulin on a sliding scale. Call if greater than 400. The order did not include information related to low blood sugar levels. Review of Resident R64's blood sugar record for February 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:4/09/26 12:23 p.m. 412.0 mg/dL no notes, no notification no recheck4/06/26 11:17 a.m. 402.0 mg/dL no notes, no notification no recheck3/06/26 7:05 p.m. 64.0 mg/dL note about refusal of insulin no recheck3/02/26 7:34 a.m. 66.0 mg/dL protocol initiated no recheck2/07/26 12:45 p.m. 437.0 mg/dL no notes, no notification no recheck Review of the clinical record indicated that Resident R84 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and multiple sclerosis (a disease that affects central nervous system). Review of Resident R84's current plan of care for diabetes initiated 4/28/18, indicated Obtain glucometer readings and report abnormalities as ordered. Review of a physician order dated 1/30/24, through 3/26/26, indicated that Resident R84 received Novolog insulin on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 380 (mg/dl), give 18 units and notify the provider. Review of Resident R84's blood sugar record for February 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 4/19/26 2:18 p.m. 64.0 mg/dL Resident asymptomatic. Recheck 2.5 hours later2/10/26 6:46 a.m. 60.0 mg/dL no notes, no notification No recheck Review of the clinical record indicated that Resident R116 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and heart failure. Review of Resident R116's current plan of care for diabetes initiated 4/25/25, indicated Blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters. Review of a physician order dated 4/25/25, discontinued 5/5/26, indicated that Resident R116 received Humalog insulin on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 340 (mg/dl), give 12 units and notify the provider. Review of Resident R116's blood sugar record for March 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:3/11/26 7:52 a.m. 67.0 mg/dL no notes, no notification recheck 4 hours later2/14/26 9:08 a.m. 67.0 mg/dL no notes, no notification recheck 3 hours later Review of the clinical record indicated that Resident R145 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of Resident R145's plan of care for diabetes initiated 3/20/26, indicated Notify provider if blood sugar is below 70 or over 400 or per provider specific guidance. Review of a physician order dated 3/20/26, indicated that Resident R145 received Humalog insulin on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol and notify the provider. If over 380 (mg/dl), give 14 units and notify the provider. Review of Resident R145's blood sugar record for March 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:4/21/26 7:04 a.m. 69.0 mg/dL no notes, no notification no recheck4/14/26 7:58 a.m. 69.0 mg/dL no notes, no notification no recheck4/07/26 7:28 a.m. 64.0 mg/dL Provider notified no recheck04/2/26 7:35 a.m. 61.0 mg/dL no notes, no notification no recheck3/29/26 7:42 a.m. 69.0 mg/dL no notes, no notification no recheck3/25/26 7:35 a.m. 62.0 mg/dL no notes, no notification no recheck Review of the clinical record indicated that Resident R148 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and hemiplegia (paralysis on one side of the body). Review of Resident R148's plan of care for diabetes initiated 4/27/26, indicated Blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters. Review of a physician order dated 4/25/26, through 5/1/26, indicated that Resident R148 received insulin aspart on a sliding scale. Review of the sliding scale coverage in the order revealed unclear directions: Inject as per sliding scale: if 0 - 69 = 0 > 69 Begin hypoglycemia protocol;70 - 139 = 0 0;140 - 179 = 2 2;180 - 219 = 4 4;220 - 259 = 6 6;260 - 299 = 8 8;300 - 339 = 10 10;340 - 999 = 12 12 units and Call MD Review of a physician order dated 5/1/26, through 5/1/26, indicated that Resident R148 received insulin aspart on a sliding scale. Review of the sliding scale coverage in the order revealed unclear directions: Inject as per sliding scale: if 0 - 69 = 0 > 69 Begin hypoglycemia protocol;70 - 139 = 0 0;140 - 179 = 3 2;180 - 219 = 6 4;220 - 259 = 9 6;260 - 299 = 12 8;300 - 339 = 15 10;340 - 999 = 15 12 units and Call MD. Review of Resident R148's blood sugar record for April 2026, through May 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:5/3/26 5:13 p.m. 404.0 mg/dL no notes, no notification no recheck5/2/26 5:18 p.m. 358.0 mg/dL no notes, no notification no recheck4/30/26 5:27 p.m. 427.0 mg/dL no notes, no notification no recheck4/29/26 5:22 p.m. 381.0 mg/dL no notes, no notification no recheck4/27/26 5:02 p.m. 377.0 mg/dL no notes, no notification no recheck Staff Interviews completed on 5/5/26, between 9:00 a.m. through 9:30 a.m. revealed: Registered Nurse (RN) Employee E1 stated, you find the parameters in the orders (eMAR) and if there is a value outside of the parameters they would follow the protocol. The protocol would include calling the MD and if low would start with giving orange juice and rechecking every 15 minutes. All of this would get documented in the progress notes. RN Employee E2 stated, you find the parameters in the eMAR and if there is a value outside of the parameters they would follow the protocol. The protocol would include notifying the provider and following orders. Would recheck frequently if low (15 mins when asked) and follow MD orders if high. Would document all of this in eMAR. Licensed Practical Nurse stated, they find the parameters in orders and would follow the protocol for any values out of parameters. MD would be notified and everything would be documented in progress notes. Policy is to recheck low every 15 mins. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed for residents on 5/5/26, at 11:00 a.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. The Immediate Jeopardy began on 2/1/2026. On 5/5/26, at 2:45 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action Resident (R3) - Provider reviewed blood sugars and due to residents' non-compliance, she will document to liberalize notification to physician to greater than 450. Sliding scale was also updated. Resident (R64) - Provider has been monitoring blood sugars closely, has made insulin adjustments and has consulted with endocrinology. Resident (R84) - Provider reviewed residents blood sugars and chart, he does not wish to make any changes at this time. Resident (R116) - Provider reviewed residents' chart and she increased notification parameters to from 380 to 400. Resident (R17) - Provider reviewed blood sugars and due to residents' non-compliance, she will document to liberalize notification to physician to greater than 450. Provider is slightly adjusting sliding scale. Resident (R145)- Provider is comfortable with resident's current blood sugars, does not want to make any adjustments currently, has been reviewing closely. Resident (R148) - Resident is out to the hospital due to a decline following an oncology treatment, unable to determine at this time if resident will return to the facility. System Correction All professional nursing staff (LPN/RN) will be re-educated by end of day 5/5/26, on how to identify residents experiencing a diabetic emergency and what actions to take, notification to the medical providers of a residents change of condition and document provider response / interventions for blood sugar levels that are out of range. Education will also include re-education for the hypoglycemic protocol created in March and revised diabetes management policy. All education will be posted on agency platforms for review prior to the start of their next shift. A whole-house audit will be conducted by the DON/designee to ensure that every resident has guidelines to notify the physician with a change in condition for blood sugars less than 70 and above 400. Care plans will also be reviewed to ensure all diabetics with insulin have appropriate care plans and interventions. The policies related to hypoglycemia was recently created and reviewed in March of 2026. The diabetic policy was updated today to reflect the ability to change resident specific protocols, as documented by the physician. Facility will review the incident in an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 5/5/26. Monitoring The facility will randomly audit five insulin dependent diabetic residents seven days a week x four weeks to ensure the professional nursing staff are following the facility policy related to physician notification and change in conditions related to blood sugars below 70 or above 400, unless otherwise indicated by physician. Findings of audits will be submitted through facility QAPI program All new hires will be educated on diabetic emergencies and interventions, notification to medical providers and the facilities hypoglycemic protocol. On 5/6/26, the whole house audit of residents with diabetes was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 6:00 a.m. on 5/6/26, 19 staff members were interviewed, and education was confirmed completed. Nursing staff were able to effectively describe appropriate actions to take when blood sugar levels are out of the accepted range for the residents and the need for documentation. On 5/6/26, licensed nursing reeducation was reviewed, revealing its completion. Review of the QAPI meeting document confirmed its completion on 5/5/26. The Immediate Jeopardy was removed on 5/6/26, at 10:40 a.m. when the action plan implementation was verified. During an interview on 5/7/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 7 of 36 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation and resident and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for two of four nursing units as required (TCU 1st. floor, and ARU1). Findings included: Review of the facility policy Homelike Environment, dated 1/6/26, indicated the staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. Observations on 5/4/26 at 10:38 a.m. and 5/725, at 8:30 a.m., revealed the following:Resident rooms122, 125, 129, 133, 137, and 141 had wallpaper peeling off the walls. Resident room126 had a large stain on the ceiling. Resident room145 had a hole in the wall. During an interview on 5/7/26 at approximately 9:15 a.m., the Nursing home Administrator confirmed the conditions of the residents' rooms. Observations on 5/7/26 at 8:45 a.m. revealed the following:Resident rooms404B and 405B had deep scratches in the walls near the window and the bathroom wall with black scratches and chipped drywall. During an interview at approximately 8:30 a.m., the Director of Nursing confirmed the conditions of the residents' rooms. During an interview on 5/7/26, at 9:40 a.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment. 28 Pa. Code: 201.29(k) Resident rights.28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on observations and resident and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the use of ACE wraps (elastic bandages) for 11 of 14 residents (Resident R16, R32, R50, R62, R74, R97, R117, R123, R130, R147, and R174).Findings include: During the observations were completed on 5/4/26, at approximately 12:00 p.m., on 5/4/26, at approximately 2:45 p.m., on 5/5/26, at approximately 2:15 p.m., on 5/6/26, at approximately 11:00 a.m., and on 5/7/26, at approximately 12:00 p.m. All observations on 5/7/26, were confirmed by the Assistant Director of Nursing. Review of Resident R16's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated included diagnoses of dated 4/22/26, included diagnoses of high blood pressure (hypertension) and lymphedema (the build-up of fluid in soft body tissues). Review of a physician order dated 4/2/26, indicated Resident R16 should have Ace wraps to left ankle; on in am off in pm. Review of Resident R16's plan of care for edema reviewed 10/25/25, indicated, Report signs and symptoms of edema. Included in the examples was extremity swelling. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/5/26, 2:15 p.m., the ACE wraps were on, but wrapped on the foot, and then on the calf. There was no coverage at the ankle, and the tissue was visibly swelling between the two sections of wrapping. 5/7/26, 12:00 p.m., the ACE wraps were not on. Review of Resident R32's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of a physician order dated 4/6/26, indicated Resident R32 should have, ACE wraps to BLEs qam (every morning) please. Review of Resident R32's plan of care for risk for alteration in hydration related to dependent dated 11/2/21, indicated Resident R32 should, Show no signs of fluid imbalance and for staff to report changes r/t signs of fluid overload such as SOB (shortness of breath), edema, mental status. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. During an interview at this time, Resident R32 stated, I don't think they have thought about it. It is hit or miss. 5/4/26, 2:45 p.m., the ACE wraps were not on, with Resident R32's feet visibly swollen. 5/6/26, 11:00 a.m., the ACE wraps were not on. 5/7/26, 12:00 p.m., the ACE wraps were not on. Review of Resident R50's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a physician order dated 5/29/25, indicated Resident R50 should have, ACE wrap to left foot on in am off in pm. Review of Resident R50's plan of care for hypertension dated 4/20/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/4/26, 2:45 p.m., the ACE wraps were not on. 5/5/26, 2:15 p.m., the ACE wraps were not on, with Resident R50's feet grossly swollen. 5/7/26, 12:00 p.m., the ACE wraps were on but not wrapped correctly. Review of Resident R62's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure and pulmonary fibrosis (a chronic lung disease characterized by scarring and thickening of lung tissue). Review of a physician order dated 4/28/26, indicated Resident R62 should have Please wrap bilateral legs with ACE wraps from distal to proximal. Apply in A.M. and remove at HS. Start from bottom of toes and wrap to above knee. Review of Resident R62's plan of care for hypertension dated 4/20/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were wrapped loosely. 5/4/26, 2:15 p.m., the ACE wraps were wrapped loosely. 5/5/26, 2:15 p.m., the ACE wraps were not on and Resident R62's legs were visibly swollen. 5/7/26, 12:00 p.m., the ACE wraps were wrapped loosely. Review of Resident R74's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of high blood pressure and kidney failure. Review of a physician order dated 4/28/26, indicated Resident R74 should have Wrap Bilateral legs every A.M. from distal to proximal (Base of toes upward) ending at knee with ACE wraps, remove at HS. Review of Resident R74's plan of care for hypertension dated 4/28/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/5/26, 2:15 p.m., the ACE wraps were on, but wrapped in an up-then-down pattern. Review of Resident R97's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of lymphedema and heart failure. Review of a physician order dated 4/23/26, indicated Resident R97 should have Ace Wraps to BLE. On AM. Off HS. Review of Resident R97's plan of care for hypertension dated 4/14/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on, but wrapped from the knee to the ankle. 5/5/26, 2:15 p.m., the ACE wraps were on, but wrapped loosely.5/7/26, 12:00 p.m., the ACE wraps were on, but wrapped from the ankle. During an interview at this time, Resident R97 stated that his ACE wraps had been on since the previous morning. When questioned, Resident R97 confirmed that nursing staff failed to remove the ACE wraps the previous evening. Observation at this time revealed Resident R97's feet to be grossly swollen and painful to touch. When the ACE wraps were removed by the Assistant Director of Nursing, the wraps had caused a tourniquet effect, with a deep indentation at the ankle. Review of Resident R117's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of high blood pressure and heart failure. Review of the facility diagnosis list included lymphedema. Review of a physician order dated 3/8/26, indicated Resident R117 should have BLE Ace wraps on QAM and OFF qPM Review of Resident R117's plan of care dated 5/1/26, failed to include goals and interventions developed for lymphedema, edema, or the use of ACE wraps. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. Resident R117 stated it was hit or miss if staff put the ACE wraps on him. 5/4/26, 2:45 p.m., the ACE wraps were not on. 5/5/26, 2:15 p.m., the ACE wraps were on, but wrapping started at the ankle, with Resident R117's feet visibly swollen. 5/7/26, 12:00 p.m., the ACE wraps were not on. Review of Resident R123's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of COPD and high blood pressure. Review of an active physician order dated 4/23/26, indicated Resident R123 should have Ace wrap bilateral lower extremities. Every evening and night shift for lymphedema (on in am/ off in pm) Review of Resident R123's plan of care for hypertension dated 4/23/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/7/26, 12:00 p.m., the ACE wraps were not on. Review of Resident R130's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of high blood pressure and heart failure. Review of a physician order dated 4/19/25, indicated Resident R130 should have, BLE Ace Wraps On in AM =(10-6 shift) & Off QHS =(2-10 shift). Review of Resident R130's plan of care lymphedema dated 5/23/23, indicated for staff to, Reports S&S of edema/fluid overload such as change in mental status, weight gain, neck vein distension, abnormal lung sounds, extremity swelling, etc. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/5/26, 2:15 p.m., the ACE wraps were not on, with Resident R130's feet grossly swollen. 5/6/26, 11:00 a.m., the ACE wraps were not on. 5/7/26, 12:00 p.m., the ACE wraps were not on but wrapped from the ankle and painful to touch. Review of Resident R147's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure and cancer. Review of a physician order dated 3/31/26, indicated Resident R147 should have Ace wraps to BLE edema on qam and off qhs. Review of Resident R147's plan of care for hypertension dated 3/27/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/6/26, 11:00 a.m., the ACE wraps were not on. Review of Resident R174's admission record indicated she was admitted to the facility on [DATE]. Review of the facility diagnosis list included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of an active physician order dated 5/1/26, indicated Resident R174 should have ACE wraps to BLE (bilateral lower extremities) on in am, off hs (hour of sleep). Review of Resident R174's plan of care for hypertension dated 5/1/26, indicated for staff to observe for edema. The use of ACE wraps was not addressed in the plan of care. During five observations completed throughout the survey the following was observed: 5/4/26, 12:00 p.m., the ACE wraps were not on. 5/6/26, 11:00 a.m., the ACE wraps were not on. During an interview on 5/7/26, at approximately 12:40 p.m. the Assistant Director of Nursing confirmed the facility failed to follow physicians' orders and/or failed to apply ACE wraps appropriately for 11 of 14 residents. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents (R3, R17, R64, R84, R116, R145, and R148).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The primary purpose of your job position is served as a licensed skilled nursing facility administrator, directing the day-to-day functions of an independent skilled nursing facility in accordance with federal, state, and local requirements that govern skilled nursing facilities, thus seeking to assure that the facility provides a high degree of quality of care to its residents. Review of the facility-provided Director of Nursing (DON) job description indicated the essential duties of the DON include the overall management of the entire nursing department and staffing levels, develop and implement nursing polices and procedures and ensure compliance, responsible for ensuring resident safety. Based on findings identified in this report, the facility failed to ensure that physicians or other advanced practice providers were notified of capillary blood glucose levels beyond the parameters set in the physicians' orders. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 5/7/26, at approximately 3:00 p.m. the NHA and current DON confirmed that facility administration failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for seven of 36 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for three of eight residents (Residents R13, R48 and R75). Findings include: Review of the facility policy, Physician/Practitioner Orders Policy dated 1/6/26, indicated to provide a general process for receiving, reviewing, implementing, clarifying, and documenting physician/practitioner orders while the resident is under the care of the facility. The facility will obtain and implement physician/practitioner orders in a manner to support resident care needs. Review of the facility policy, Wound Management Policy dated 1/6/26, indicated care may be provided by practitioner orders and wound nurse recommendations. Documentation should reflect the care provided and may be completed in the treatment record. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 4/27/26, included diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), heart failure (the heart is unable to pump enough blood to meet the body's need for blood and oxygen), and hypertension (high blood pressure). During rounds on 5/5/26, at approximately 9:30 a.m. Resident R13 was observed in bed with toenails that appeared to be thick, discolored, and fungus-like. Review of a physician's orders for Resident R13 did not reveal an order for podiatry services. During an interview on 5/5/26, at approximately 1:30 p.m. with the Director of Nursing (DON) confirmed there wasn't a podiatry order in the electronic health record (EHR) for the resident, and that the resident is currently followed by podiatry. During an interview on 5/7/26, at approximately 7:45 a.m. the DON provided consultation reports from podiatry, for the dates of 1/6/26, 3/17/26, and 5/5/26 that were not observed in the residents EHR. Review of the clinical record indicated Resident R75 was originally admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) pneumonia (lung infection) and hypertension (high blood pressure). During rounds and an interview on 5/4/26, at approximately 10:30 a.m. with RN Employee E1 confirmed the resident was currently on oxygen at 2 liters. Resident R75 confirmed she uses oxygen most of the time. Review of the care plan initiated 3/25/26, indicated that Resident R75 had shortness of breath or trouble breathing when lying flat. Included in the interventions was Oxygen therapy as ordered. Review of the vital signs' documentation reveals Resident R75 has utilized oxygen during 26 of the thirty days between 4/4/26 and 5/4/25. Review of a physician's orders for Resident R75 did not reveal an order for the resident to be administered oxygen. During an interview on 5/6/26, at approximately 9:00 a.m. the Director of Nursing (DON) confirmed there wasn't an order in the electronic health record (EHR) for the resident's oxygen administration. Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Parkinson's (a neurodegenerative disorder that affects movement) and diabetes. Review of a skin note dated 3/18/26, indicated Resident R48 had a sacral (area of the buttocks) wound and a primary dressing of Therahoney (medical grade honey wound dressing designed to promote healing in wounds, and Border gauze (a specialized wound dressing) to be applied. The clinical record did not include documentation of a physician order or documentation that the treatment was completed in the Treatment Record. During an interview on 5/5/26 at 10:00 a.m., Wound Care Nurse Employee E2 confirmed the above findings that the wound dressing recommendations on 3/18/26, were not entered into the physician orders and not documented in the Treatment Administration Record, and that the facility failed to maintain records that were complete and accurate. During an interview on 5/6/26, at approximately 10:00 a.m. the Nursing Home Administrator and the DON confirmed the facility failed to maintain clinical records that were complete and accurate. 28 Pa. Code: 211.5(f)(g)(h) Clinical records. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the clinical records, staff interviews, facility documents, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively for seven of 36 residents (Resident R3, R17, 64, R84, R116, R145, and R148).Findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Program dated 1/6/26, indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Listed as a Key Component of the process was, monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. During the survey process the following was revealed: -Resident R3 had 20 instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R17 had 15 instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R64 had five instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R84 had two instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R116 had two instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R145 had six instances of high or low blood sugar levels without documentation that the medical provider was notified. -Resident R148 had five instances of high or low blood sugar levels without documentation that the medical provider was notified. During an interview on 5/6/26, at approximately 10:45 a.m. the Nursing Home Administrator confirmed that the facility identified non-notification of low blood sugar levels in February 2026 and addressed it in March 2026. On 5/7/26, at approximately 10:00 a.m. documentation of the performance improvement plan, education sign-in sheets, and audits that were completed in response to the facility identifying the concern related to the lack of blood sugar notifications. Review of the facility-provided QAPI Monitoring of Blood Glucose Levels for Residents with Diabetes Mellitus Diagnosis dated 2/16/26, indicated: Improvement Plan: What needs to be done, who will do it, when and where?Education:Licensed nursing staff will be educated by the Director of Nursing or designee on the hypoglycemic policy.Licensed nursing staff will be educated by the Director of Nursing or designee on documentation and the importance of timely monitoring.Licensed nursing staff will be re-educated on the signs and symptoms of hypoglycemia.Action plans: Director of nursing will randomly audit DM residents throughout the week to review if the facility followed the hypoglycemic protocol and educate as needed. On 5/7/26, the facility provided education sign-in sheets for licensed nursing staff related to the updated hypoglycemia policy. Audit information was not provided by the facility, nor documentation that the facility revaluated the performance improvement plan to ensure effectiveness. During an interview on 5/7/26, at approximately 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility's QAPI committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively for seven of 36 residents. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.18(e)(2)(3)(4) Management.

Based on review of clinical records and staff interview, it was determined that the facility failed to provide adequate supervision to avoid injuries for one of three residents (Resident R1). Findings include:Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/16/25, included diagnoses of COPD, muscle weakness, and the need for aftercare following joint replacement surgery. Review of Section G: Functional Status indicated that Resident R1 required supervision for eating. Review of Resident R1's plan of care for ADL (activities of daily living)/mobility dated 7/11/25, indicated for staff to monitor for changes or decline in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition. Further review of the care plan failed to reveal documentation of the needed assistance level during meals. Review of a progress note dated 8/18/25, at 10:00 a.m. indicated, Resident lying in bed, very lethargic, slow to respond, not responding appropriately, or follow direction. not engaging in conversation, poor eye contact. alert to name and place, not alert to date. not able to recall this nurse. Resident appeared flushed, with slight body tremors, 95/46 (blood pressure)-99.2 (temperature)-72 (heart rate)-16 (respiration rate). 77% on room air, o2 (oxygen) applied at 2L (two liters) with gradual response to 90%, o2 increased to 3L with pox of 96%.Review of a nurse practitioner's note dated 8/18/25, at 11:33 a.m. indicated, Pt (patient) evaluated per request of nursing for acute hypoxia (low level of oxygen in the body tissues). Per nursing, pt was found to be sating (slang to refer to a patient's oxygen saturation level) at 77%, unsure for how long. Nurse further stated pt was confused from baseline.Review of a progress note dated 8/18/25, at 2:35 p.m. indicated that Resident R1 had slurred speech and notable hand tremors. Review of a progress note dated 8/18/25, at 3:05 p.m. indicated Resident R1 had a change in condition, shortness of breath, tired, weak, confused, or drowsy.Review of a progress note dated 8/19/25, at 1:11 p.m. indicated, This nurse was called by CNA (nurse aide) to look at pt's right front thigh that appeared to be pink in color circular shaped 15 cm x 15 cm x 0 cm: intact skin. Pt stated she spilled entire lunch tray with hot soup onto her lap.Review of a grievance filed on 8/19/25, indicated, Resident was passed her lunch tray, it was set up for her by the CNA. While eating chicken noodle soup, [Resident R1] spilled the hot soup on herself and reported to the nursing staff that she spilled the soup and burned herself. The resolution to this grievance included:-Pt cleaned up by nursing staff.-Sensitive area to inner thighs assessed by RN (registered nurse) and CRNP (certified registered nurse practitioner). CRNP ordered to keep OTA (open to air) and monitor for pain/complications.-Tremors seem to be newer onset, NP/MD (doctor of medicine) evaluating for potential cause. In the meantime, hot soups will be removed from the resident's meal trays for safety measures.-Investigation of food temps (temperatures) by [Dietary Manager]. - [Resident R1] agreeable to resolution.Review of facility-submitted information dated 9/5/25, indicated On 8/19/2025 the patient was provided her lunch tray as it was set up for her by her CNA. Patient reported to nursing staff that she had spilled her chicken noodle soup and burned herself. Area to thigh assessed by licensed nurse and CRNP. CRNP ordered area to OTA and report any further pain and or complications. After interview with nursing staff and patient - patient appears to have an onset of tremors. CRNP and MD to assess tremors and determine any interventions that may assist with tremors. Hot soups will be replaced on meal trays. The dietician and dietary manager also temped trays and determined that food and fluids were within the threshold to serve patients. Please note since 8/19/2025 patient has not had any issues and or incidents with her meal tray.During an interview on 9/5/25, at approximately 1:00 p.m. the Director of Nursing confirmed that Resident R1 had been showing symptoms of confusion, lethargy, and tremors prior to 8/19/25, with documentation that Resident R1 was below her baseline, but was not provided additional supervision when served hot soup on 8/19/25. During an interview on 9/5/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide adequate supervision to avoid injuries for one of three residents.28 Pa. Code: 201.18(e) Management.28. Pa Code: 201.29(a)(c)(d) Resident rights.

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set ( MDS - periodic assessment of resident care needs) assessments accurately reflected the resident's status for two of eight residents (Resident R30 and R50). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: -Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days. -Section O: Special Treatments, Procedures, and Programs: Review the resident ' s medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period. Review of the admission record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's MDS dated [DATE] included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and a psychotic disorder. Review of the psychiatric evaluation dated 5/13/25 revealed diagnoses of adjustment disorder and unspecified dementia with behavioral disturbances. During an interview on 5/15/25, at 10:01 a.m. the Assistant Director of Nursing (ADON)confirmed that adjustment disorder and dementia are not types of psychotic disorders, confirmed that Resident R30 has not been diagnosed with a psychotic disorder, and that the MDS was coded inaccurately. Review of the admission record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE] included diagnoses of dementia, malnutrition, and osteoporosis (condition when the bones become brittle and fragile). Review of Section O: Special Treatments, Procedures, and Programs indicated Resident R50 received hospice services. Review of physician orders dated 11/21/24, and reordered on 2/4/25, and 4/24/25, revealed Resident R50 received hospice services while in the facility. Review of an MDS assessment completed on 2/7/25, indicated that Resident R50 did not receive hospice services. During an interview on 5/15/25, at 10:01 a.m. the ADON confirmed that Resident R50 had continuously received hospice services and that the MDS assessment was completed inaccurately on 2/7/25. During an interview on 5/15/25, at approximately 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of eight residents. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy and documents, information provided by the State Ombudsman Office, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization (Resident R6, R89, R123, and R138) and failed to notify the State Ombudsman Office of resident transfers and discharges for two years (11/2023 through 12/2023, 1/2024 through 12/2024, and 1/2025 through 4/2025) as required. Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated: -Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. -The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility ' s policy were to change. -The second notice must be provided to the resident, and if applicable the resident ' s representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident ' s representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Review of facility Bed Hold Policy dated 3/4/25, indicated, In accordance with federal and state guidelines, patients who are hospitalized or absent from the facility at midnight are entitled to hold their bed. Review of the clinical record indicated Resident R6 was readmitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/28/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), anxiety, and depression. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 03. Review of a progress note dated 3/16/25, at 3:32 a.m. indicated, CNA (nurse aide) heard noise come from resident's room, found her sitting on the floor up against her bed, feet out in front of her, shoes on, bleeding from hematoma on right forehead. Pressure dressing applied, Ice pack to right side of face/forehead. Observed large hematoma, bubbled, and draining profusely. LOC (level of consciousness) WNL (within normal limits), resident stated I fell right there, I need to go to the hospital. Left facility enroute to [hospital emergency room ] at 3:15 a.m. Further review of Resident R6's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R6 or the resident representative upon transfer. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's MDS dated [DATE], included diagnoses Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 99, meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated [DATE], also revealed a BIMS score of 99. Review of a progress note dated 12/23/24, at 2:51 p.m. indicated, Residents son, [second emergency contact] was informed [Resident R89] has been admitted to [hospital] with a dx of UTI (urinary tract infection). Further review of Resident 89's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident R89 or the resident representative upon transfer. Review of the clinical record indicated Resident R123 was readmitted to the facility on [DATE]. Review of Resident R123's MDS dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and cancer. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 99, meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a progress note dated 12/26/24, at 1:13 p.m. indicted, Alerted by staff that pt (patient) was off her baseline. Pt assessed and found lying in bed. Lethargic and barely arousable. Per staff, pt is usually OOB (out of bed) and at the nurse ' s station at this time. MD (doctor of medicine) notified and ordered pt sent to ER (emergency room ) for eval. Review of a progress note dated 1/1/25, at 7:34 p.m. indicated, Pt is admitted from [hospital] with diagnosis of RSV (Respiratory syncytial virus, causes infections of the respiratory tract). Further review of Resident 123's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R123 or the resident representative upon transfer. Review of the clinical record indicated Resident R138 was admitted to the facility on [DATE]. Review of Resident R138's MDS dated [DATE], included diagnoses of falls, ileus (inability of the intestine (bowel) to contract normally and move waste out of the body), and muscle wasting. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 07. Review of a progress note dated 2/8/25, at 1:00 a.m. Pt's nurse went to give her scheduled Tylenol 1000 mg in her bedroom, patient pushed nurse in her right breast away and into tv stand, patient became belligerent, cursing at staff, appears paranoid, making statements that she is going to call the police on staff, she is going to kill staff, staff is trying to kill her, patient stated she was going to have staff buried with her, aggressive, yelling a loud on dementia unit, RN registered nurse supervisor (RNS) was called up to unit, [RNS] and [nurse aide] were trying to redirect her/talk to her, unsuccessful, her daughter was called/put on speaker-patient refused to speak with her, supervisor explained above situation to daughter, daughter explained patient has had 3 alcoholic drinks or more a day prior to coming here, patient picked up a large/heavy pill crusher tried to throw it at me and [nurse aide], tried to hit us with it, we were able to take it away from her however she picked up the laptop and tried to use that to hit us, received permission from daughter to send out for evaluation, police officer arrived and [emergency services]came to pick her up, patient went with them willingly to [hospital] for evaluation. Further review of Resident 138's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R138 or the resident representative upon transfer. A request to review facility documents on 5/14/25, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time period of 11/2023 through 4/2025. A review of information on 1/2/25, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 11/2023. During an interview on 5/15/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization and failed to report resident transfers and discharges to the State Ombudsman Office for a two year period from 11/2023 through 4/2025, as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code: 201.29(f)(g) Resident rights.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication rooms (First and Second floor medication rooms) and two of five medication carts (MedBridge A-hall, MedBridge B-hall). Finding include: Review of facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The policy further stated that multiple dose injectable vials and ophthalmics, once opened, require an expiration date shorter than the manufacturer ' s expiration date to insure medication purity and potency. Review of the facility provided document, Medications with Shortened Expiration Dates indicated Aplisol (solution used in skin-testing for tuberculosis): Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of prescribing information for cyanocobalamin (Vitamin B12) injections dated [DATE], indicated that Any unused portion should be used within 30 days of opening. During an observation of the second-floor medication room on [DATE], at 10:35 a.m. the following was observed: -(1) vial of Aplisol, open and undated. -(1) vial of Aplisol, dated as opened on [DATE]. -(1) vial of cyanocobalamin solution, open and undated. -(1) bottle of liquid gabapentin, open and undated. -(22) vacutainers with an expiration date of [DATE]. -(4) IV start kits with an expiration date of [DATE]. -(1) IV start kit with an expiration date of [DATE]. -(1) IV start kit with an expiration date of [DATE]. -(10) IV start kits with an expiration date of [DATE]. -(1) Blood collection set with an expiration date of [DATE]. During an interview on [DATE], at 10:42 a.m. Registered Nurse (RN) Employee E3 confirmed the above items were either undated or expired. During an observation of the second-floor medication room on [DATE], at 10:50 a.m. the following was observed: -(1) IV start kit with an expiration date of [DATE]. -(2) IV start kits with an expiration date of [DATE]. -(1) IV start kit with an expiration date of [DATE]. -(3) IV catheters with and expiration date of [DATE]. -(2) IV catheters with and expiration date of [DATE]. -(1) Huber infusion set with an expiration date of [DATE]. During an interview on [DATE], at 11:01 a.m. the Assistant Director of Nursing confirmed the above items were expired. During an observation of the MedBridge A-hall medication cart on [DATE], at 8:12 a.m. the following was observed: -One container of MedPlus Vanilla , appeared unopened, dated [DATE]. During an interview on [DATE], at 8:14 a.m. RN Employee E1 confirmed that nourishment shake must be labeled with date opened and is only to be used for 24 hours and then disposed of. Employee E1 confirmed the above observations of container being labeled with date of [DATE] and was unopened. During an observation of the MedBridge B-hall medication cart on [DATE], at 8:22 a.m. the following was observed: -One container of MedPlus Vanilla, opened, partially used, and dated [DATE]. During an interview on [DATE], at 8:23 a.m. RN Employee E2 when asked the appropriate process after opening a container stated it is to be labeled with that date and used for 24 hours. Employee E2 confirmed that the above observation of container being labeled with date of [DATE], was partially used and was still sitting on her cart when she started medication administration. During an interview on [DATE], at approximately 2:40 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility failed to make certain that our of date medications were properly stored and/or disposed of in two of three medication rooms and two of five medication carts. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1)(e)(1) Management. 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents (Resident R89). Findings include: Review of the facility policy, Change in Condition Notification dated 3/4/25, indicated the facility will will promptly notify the resident's family or designated representative of any significant change in the resident's physical, mental, or psychosocial condition. Notification will occur as soon as possible and no later than 24 hours from the time the change is identified. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/25, included diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 99, meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated [DATE], also revealed a BIMS score of 99. Review of Resident R89's demographic profile indicated the son as the first emergency contact, daughter-in-law as the second emergency contact, and an additional son also as a second emergency contact, durable power of attorney, and resident representative. Review of the Change in Condition Evaluation form initiated 12/23/24, at 5:05 a.m. revealed all sections of the form to be blank. Review of the Transfer to Hospital form initiated 12/23/24, at 5:06 a.m. revealed under the section Code Status that for the question: Resident/Patient Decision Making Capacity, Resident R89 required a proxy to make her decisions. Under the section Resident Representative that Resident R89 was the resident representative contacted, that she was her caregiver and the next of kin, was notified of the transfer, and aware of the clinical situation. Review of a progress note dated 12/23/24, at 2:51 p.m. indicated Residents son, [second emergency contact] was informed Resident R89 has been admitted to [hospital] with a diagnosis of a urinary tract infection. Further review of Resident R89's progress notes failed to reveal documentation that Resident R89's emergency contacts were notified of the change in condition leading to Resident R89 being transferred to the hospital or the actual transfer to the hospital. During an interview on 5/15/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of clinical records, and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of four residents (Resident R21) Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/23/25, included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness and wasting, and a seizure disorder. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of 99, meaning that Resident R21 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated [DATE], also revealed a BIMS score of 99. Review of Section G: Functional Abilities indicated that Resident R21 required substantial/maximal assistance with bathing, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. Review of Resident R21 ' s care plan for skin integrity indicated, Observe skin condition daily with ADL (activities of daily living) care and report any abnormalities. Review of the nurse aide task list revealed that the skin observation tool is only completed as needed and was not completed on any day in March 2025. Review of Resident R21 ' s Treatment Administration Record (TAR) for March 2025, indicated Resident R21 was ordered weekly skin checks to be done on Wednesdays with her showers. Review of the skin check completed on 5/19/25, by Licensed Practical Nurse (LPN) Employee E4 failed to indicate that any skin alteration was noted. Review of Resident R21 ' s progress notes from 5/19/25, through 5/23/25, failed to reveal documentation that any wounds were noted or reported on Resident R21 ' s ankles. Review of a progress note dated 3/23/25, at 5:00 p.m. indicated, This nurse was approached by the patient's daughter, to tell me that her mother has wounds on her right outer ankle and inner aspect of the left leg and there is no dressing on them. This nurse went to assess the areas in question, I found that both areas are old, dry and scabbed over, the scab on the rt. (right) ankle is measuring 1.5 cm x 0.5 cm and the one Lt. (left) leg is 0.3 cm x 0.3 cm. Daughter voiced that this is not new, I agree with her that, it is not new, is already dry and scabbed over and putting a dressing will make it moist and she agreed. Review of a progress note dated 3/28/25, at 12:49 p.m. indicated, When nurse went to complete scheduled wound care on the RLE (right lower extremity) scabbed area, nurse noticed that sock to the RLE (right lower extremity) has a fresh blood stain. Upon removing the sock and assessing the skin, nurse noted a new skin tear measuring 1.3 cm x 0.3 cm that appears to have been caused by the wheel chair foot pedals. When questioned as to how she sustained the skin tear, pt (patient) could not explain how she got a skin tear to the RLE. During an interview on 5/15/25, at approximately 11:00 a.m. the Assistant Director of Nursing confirmed that Resident R21 ' s wound should have been observed during bathing, dressing, and hygiene assistance by staff prior to the wounds having healed enough for scabbing to have formed, and additionally should not have required family member observations to discover the wounds. During an interview on 5/15/25, at 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide appropriate treatment and care for one of four residents. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d) (1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of two medication carts (Second-floor medication cart for rooms 220-231). Findings include: Review of the facility policy Medication Storage dated 2/10/25, indicated medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access. During an observation on 2/20/25, at 11:50 a.m., the 220-231 medication cart was observed unlocked. The surveyor remained with the medication cart. At approximately 11:54 a.m. the surveyor opened the medication cart drawers and observed that the drawers were not secured. The surveyor reviewed the medication cards. At approximately 11:58 a.m. LPN Employee E2, was requested to confirm the medication cart was unsecured. LPN Employee E2 located Registered Nurse (RN) Employee E1 on the unit who confirmed that the medication cart was unsecured. During an interview on 2/20/25, at approximately 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medications were properly secured in one of two medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to properly secure medication in one medication refrigerator (Family Conference room), and one of three medication carts observed (ARU 1 nursing unit). Findings include: Review of the facility policy Medication Labeling and Storage reviewed 1/30/24, indicated the facility stores all medications and biologicals in locked compartments. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications requiring refrigeration are stored in a refrigerator located in the medication rooms at the nurse ' s station or other secured location. During an observation on 12/12/24, at 9:00 a.m. an unlocked medication refrigerator located in the Family Conference room by the front lobby, was accessible to visitors, family, and residents. The refrigerator contained three unopened vials of influenza vaccine, one opened vial of influenza vaccine, three unopened boxes of 10 pre-filled influenza vaccine syringes, and one opened box of nine pre-filled syringes. During an interview on 12/12/24, at 9:06 a.m. Front Desk Employee E1 confirmed the Family Conference room was never locked and was accessible to residents, family, and visitors at any time of the day and night. During an interview on 12/12/24, at 9:15 a.m. the Nursing Home Administrator confirmed the medications should not have been in the refrigerator, stating she was unsure why the refrigerator was in the conference room and the key was unable to be located to secure it. During an observation on 12/12/24, at 9:42 a.m. a medication cart was unsecured, unattended, with the computer screen open and accessible to residents, family, and visitors. During an interview on 12/12/24, at 9:45 a.m. Registered Nurse Employee E2 confirmed the cart was left unsecured and unattended. During an interview on 12/12/24, at 10:45 a.m. the Director of Nursing confirmed the facility failed to properly secure medications in a medication cart. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, resident interview, observations, and staff interview it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R2). Findings include: Review of facility policy Self-Administration of Medications last reviewed 1/30/24, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. If it is deemed safe and appropriate for a resident to self-administer medications it is documented in the medical record and the care plan. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness, and chronic obstructive pulmonary disease (COPD - caused by swelling and irritation in the airways that limit air going in and out of the lungs). Review of a physician order dated 11/18/24, instructed to give Trelegy Ellipta Inhalation aerosol (used to treat COPD) one puff inhale orally one time a day. During an interview and observation on 12/12/24, at 9:35 a.m. Resident R1 was in bed with her Trelegy inhaler on her over-the-bed table. Review of Resident R1's clinical record revealed it did not contain a physicians order for self-administration, a self-administration assessment, or care planning for self-administration of medications. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included diabetes, muscle weakness, and high blood pressure. Review of a physician order dated 12/5/24, instructed Latanoprost ophthalmic solution 0.005% (eye drops used to treat certain kinds of glaucoma [eye condition that damages the optic nerve leading to vision loss or blindness]) one drop in right eye at bedtime. During an interview and observation on 12/12/24, at 9:40 a.m. Resident R2 was in sitting beside her bed, a bottle of opened Latanoprost eye drops and an open bottle of Muro 5% eye medication (used to reduce swelling of the cornea [front surface of eye]) on Resident R2 ' s nightstand. Resident R2 stated she was unable to correctly use the eye drops due to being legally blind in one eye. Review of Resident R2's clinical record revealed it did not contain a physicians order for self administration, a self-administration assessment, or care planning for self-administration of medications. During an interview on 12/12/24, at 9:50 a.m. Licensed Practical Nurse Employee E2 confirmed the medications were left at the bedside while she continued to pass medication to other residents; further stated Resident R1 was in the bathroom, so she left the inhaler for her to use when she was finished; stated Resident R2 was not scheduled eye medication in the day, she was unsure when or how long they were on the nightstand. During an interview on 12/12/24, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents. 28 Pa. Code: 211.9(d) Pharmacy services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of seven residents (Resident R3). Findings include: Review of the facility policy Abuse Prohibition reviewed on 1/30/24, indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will initiate and investigation within 24 hours. Review of the facility policy Accidents and Incidents - Investigation and Reporting reviewed 1/30/24, indicated all accidents or incidents involving residents, employees, vendors, etc., occurring on our premises shall be investigated and reported by the administrator. A review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, dislocation of right shoulder joint, and diabetes. A review of facility records indicated on 11/27/24, Resident R3 fell while transferring with assistance of one staff in the bathroom, hitting her head and right shoulder. Resident R3 was sent to the local emergency room for evaluation. Witness statements were not completed. The incident was not fully investigated to rule out abuse or neglect. During an interview on 12/12/24, at 11:00 p.m. the Director of Nursing confirmed Resident R3 ' s incident was not fully investigated, and witness statements were not obtained from Resident R3 or staff involved. 28 Pa. Code: 201.149(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in three of three medication carts (Medbridge B-hall, Medbridge A-hall, and the TCU-1 medication carts). Findings include: Review of facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. During an observation of the Medbridge B-hall medication cart on [DATE], at 3:10 p.m. the following was observed: -Two bottles of Fluorometholone eye drops, opened, partially used, and undated. -One bottle of Olopatadine eye drops, opened, partially used, undated, and without a resident name. -One bottle of artificial tears eye drops, opened, partially used, and undated. -One insulin lispro injection pen, opened, partially used, and undated. -One insulin lispro injection pens, opened, partially used, and dated to be used by [DATE]. -One Lantus insulin injection pen, opened, partially used, and undated. -One insulin glargine injection pen, opened, partially used, and undated. During an interview on [DATE], at 3:14 p.m. Registered Nurse (RN) Employee E1 confirmed that insulin must be either used or disposed of by 28 days after opening and eye drops must be either used or disposed of by six weeks after opening. RN Employee E1 further confirmed the above observations of opened and undated insulin injection pens and eye drops, and an insulin injection pen past the use-by date. During an observation of the Medbridge A-hall medication cart on [DATE], at 3:18 p.m. the following was observed: -One insulin aspart injection pen, opened, partially used, and undated. -One insulin Degludec injection pen, opened, partially used, and undated. During an interview on [DATE], at 3:20 p.m. RN Employee E2, when asked the appropriate disposal time for insulin after opening stated, I think two weeks. RN Employee E2 further confirmed the above observations of open and undated insulins injection pens. During an observation of the TCU-1 medication cart on [DATE], at 3:26 p.m. the following was observed: -One insulin aspart injection pen, opened, partially used, and undated. -One insulin aspart vial, opened, partially used, and undated. -Two insulin glargine injection pens, opened, partially used, and undated. -Three insulin lispro injection pens, opened, partially used, and undated. -One Lantus insulin injection pen, opened, partially used, and undated. -One Novolin insulin vial, opened, partially used, and undated. -Two Novolog insulin injection pens, opened, partially used, and undated. During an interview on [DATE], at 3:20 p.m. RN Employee E3, when asked the appropriate disposal time for insulin after opening stated, I really don ' t know. RN Employee E3 further confirmed the above observations of opened and undated insulins injection pens and vials. During an interview on [DATE], at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that out-of-date medications were disposed of in three of three medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of 12 residents (Residents R1, R2, R3, R4, R5, R6, and R7). Findings Include: Review of the facility policy Activity of Daily Living (ADLs) dated 1/30/24, indicated the center must provide the necessary care and services to ensure that a resident's activities of daily living (ADL) abilities are maintained. Activities of daily living include hygiene care and will be recorded in the medical record. During an interview on 9/8/24, at 1:58 p.m. Resident R1, when asked if she felt the facility maintained sufficient staff, stated, No. When asked if call lights took a long time to be answered, stated, Sometimes it's a good while. I pushed it yesterday and waited and waited. During an observation on 9/8/24, at 2:01 p.m. Resident R2 was observed to have untrimmed facial hair on her chin. During an interview on 9/8/24, at 2:04 p.m. Resident R3, when asked if he felt the facility maintained sufficient staff, stated, No, that's that main thing wrong with this place. Today there is only two people (aides). They need help bad. During an interview on 9/8/24, at 2:09 p.m. Residents R4 and R5 both stated that facility staffing was not sufficient. Resident R4 further stated that the evening shift call light response time is poor. During an interview on 9/8/24, at 3:06 p.m. Resident R6, when asked if she felt the facility maintained sufficient staff, stated she was unsure. When asked if she if assisted out of bed timely, Resident R6 stated, I lay in bed until I see someone. During an interview on 9/8/24, at 3:08 p.m. Resident R7, when asked if she felt the facility maintained sufficient staff, stated, No. Observation at this time revealed Resident R6 had unkempt appearing hair. During an interview on 9/8/24, at approximately 3:50 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of twelve residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on clinical record review, observation and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for two of 10 residents reviewed (Resident R1, and R2). Findings include: Review of the facility policy Abuse Prohibition reviewed 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Involuntary seclusion is defined as separation of a resident from other residents or from their room or confinement to their room against the resident's will or the will of the resident's legal representative. Neglect is defined as the failure, indifference, or disregard to provide care, comfort, safety, goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy, Treatment: Considerate and Respectful reviewed 1/30/24, indicated the facility provides patients the right to a quality of life that supports independent expression, decision making, and respect. Staff will show respect when communicating with, caring for, or talking about patients. Review of the Resident Rights Under Federal Law reviewed 1/30/24, indicated the resident has the right to a dignified existence. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that interferes with daily life), anxiety, and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/22/24, indicated the diagnoses remain current. Further review of the MDS, Section C: Cognitive Patterns; Question C0500 BIMS Summary Score indicated 99 (resident scored four or more zeros or gave nonsensical answers). Section GG: Functional Abilities and Goals; Question GG0170 Mobility D: Sit to Stand indicated Resident R1 required substantial/maximal assistance (helper does more than half the effort, lifts or holds trunk or limbs). During an observation on 6/13/24, at 10:22 a.m. a voice was heard yelling help me, please help me coming from behind a locked closed door leading to the main hallway labeled Dining Room. During an observation on 6/13/24, at 10:25 a.m. Resident R1 and Resident R2 were observed in the locked Memory Care Unit sitting in wheelchairs in the dining room by themselves at a far table in the corner by the locked exit door from which the yelling was heard from the other side. Staff were not in sight of the residents. The dining room was accessed through the resident television room which contained eight other residents. Resident R1 was sitting in her wheelchair facing the locked door, with her locked wheelchair pushed all the way in under the table, preventing her from moving around. Resident R2 was sitting in a wheelchair at the same table facing the entrance door, she was backed up against the locked exit door, with the table pushed up against her, preventing her from moving. An empty tall back wheelchair was observed pushed beside the table, preventing exit from the sides of the table, the fourth side of the table was up against a wall. Resident R1 indicated she needed her brief changed. The table contained one small juice box with a straw in front of Resident R1. Review of the progress notes revealed the following: - On 6/8/24, at 10:12 a.m. resident OOB (out of bed) to chair by the dining room. - On 5/17/24, at 2:39 p.m. pt (patient) sitting in dining area (assessment completed in dining room by provider). - On 5/13/24, at 12:00 a.m. pt sitting in dining area (assessment completed in dining room by provider). - On 4/29/24, at 2:43 p.m. pt sitting in dining area (assessment completed in dining room by provider). - On 4/28/24, at 9:08 a.m. OOB to chair by the dining room at this time. Review of the care plan dated 1/12/23, indicated to encourage socialization with others and provide recreational programming, engage in activities/tasks to keep occupied, encourage/assist to reposition frequently to position of comfort, encourage participation in group activities of interest, provide supplies/materials for leisure activities as needed/requested. On 4/25/24, the care plan stated to remove patient from table if she begins hitting lower or upper extremities on table. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of thinking), and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS indicated Resident R2 ' s BIMS score was 09 indicating moderate impairment. Section GG: Functional Abilities and Goals, Question GG0170 D. Sit to Stand indicated Resident R2 required partial/moderate assistance (helper does less than half the effort). Review of the progress notes reveal the following: - On 6/5/24, at 1:35 p.m. patient presents in the dining hall. (assessment completed in dining room by provider). - On 2/2/24, at 12:00 a.m. On exam, pt seen sitting in wheelchair in dining hall. (assessment completed in dining room by provider). Review of the care plan dated 11/10/23, indicate Resident R2 was at risk for falls, to encourage/assist to reposition frequently to position of comfort, remind and assist as needed with toileting at routine times such as upon arising in AM, before/after meals, activities, therapy, and at bedtime. On 11/15/23, the care plan states to provide supplies/materials for leisure activities as needed/requested. During an interview on 6/13/24, at 10:26 a.m. Registered Nurse Employee E1 stated they were not sure why the two ladies were in the dining room by themselves, stating they usually do not work that nursing unit and are unfamiliar with the residents, but they thought that Resident R1 and R2 needed to be kept eyes on them or the residents would get up and fall. During an interview on 6/13/24, at 10:36 a.m. Unit Manager Employee E2 stated the residents yell all the time, and the empty wheelchair is there to prevent them from pulling objects closer to them like they usually do, like the garbage can. During an interview on 6/13/24, at 10:38 a.m. Nurse Aide Employee E3 stated Resident R1 and R2 are put in the dining room because they cause a disturbance when the other residents are watching television because they yell a lot, and they are fall risks. During an interview on 6/13/24, at 12:30 p.m. the Nursing Home Administrator was notified the facility failed to prevent involuntary seclusion for Residents R1 and R2. 28 Pa. Code 201.18(2) Management. 28 Pa. Code 201.29(d) Resident rights.

Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure two of 10 residents observed (Resident R1, and R2) were free from physical restraints by being pushed up to a table with a wheelchair blocking the side exit. Findings include: Review of the facility policy Abuse Prohibition reviewed 1/30/24, indicated the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Involuntary seclusion is defined as separation of a resident from other residents or from their room or confinement to their room against the resident's will or the will of the resident's legal representative. Neglect is defined as the failure, indifference, or disregard to provide care, comfort, safety, goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy Restraints: Use of reviewed 1/30/24, indicated residents have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat resident's medical symptoms. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care, and is not in the resident's best interest. Physical Restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: - Is attached or adjacent to the resident's body, - Cannot be removed easily by the resident, and - Restricts the resident ' s freedom of movement or normal access to their body. Removed Easily means that the manual method, physical or mechanical device, equipment, or material can be removed intentionally by the resident in the same manner as it was applied by staff. Review of the facility policy, Treatment: Considerate and Respectful reviewed 1/30/24, indicated the facility provides patients the right to a quality of life that supports independent expression, decision making, and respect. Staff will show respect when communicating with, caring for, or talking about patients. Review of the facility policy Behavioral Health Care and Services reviewed 1/30/24, indicated residents will be provided the necessary behavioral health care and services including providing an environment and atmosphere that is conductive to mental and psychosocial well-being. Review of the Resident Rights Under Federal Law reviewed 1/30/24, indicated the resident has the right to a dignified existence. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that interferes with daily life), anxiety, and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/22/24, indicated the diagnoses remain current. Further review of the MDS, Section C: Cognitive Patterns; Question C0500 BIMS Summary Score indicated 99 (resident scored four or more zeros or gave nonsensical answers). Section GG: Functional Abilities and Goals; Question GG0170 Mobility D: Sit to Stand indicated Resident R1 required substantial/maximal assistance (helper does more than half the effort, lifts or holds trunk or limbs). During an observation on 6/13/24, at 10:25 a.m. Resident R1 and Resident R2 were observed in the locked Memory Care Unit sitting in their wheelchairs in the dining room by themselves at a table in the corner by the locked exit door. The dining room is assessable through the resident television lounge room which contained eight other residents. Resident R1 was sitting in her wheelchair facing the locked door with her wheelchair pushed all the way in under the table, preventing her from moving around. Resident R2 was sitting at the same table in her wheelchair a facing the entrance door to the resident television room, she was backed up against the locked exit door, with the table pushed up against her, preventing her from moving. An empty tall back wheelchair was observed pushed beside the table, preventing exit from the sides of the table. The fourth table side was against the wall. Resident R1 indicated she needed her brief changed. The residents were unable to move the table due to both of them being pushed up to it and the wheelchair blocking the side exit. At the time of the observation, the residents could not independently move away from the table or manuver the wheelchair on command. Review of the care plan dated 1/12/23, indicated to encourage socialization with others and provide recreational programming, engage in activities/tasks to keep occupied, encourage/assist to reposition frequently to position of comfort, encourage participation in group activities of interest, provide supplies/materials for leisure activities as needed/requested, and indicated Resident R1 was at risk for falls. On 4/25/24, remove patient from table if she begins hitting lower or upper extremities on table. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of thinking), and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS indicated Resident R2 ' s BIMS score was 09 indicating moderate impairment. Section GG: Functional Abilities and Goals, Question GG0170 D. Sit to Stand indicated Resident R2 required partial/moderate assistance (helper does less than half the effort). Review of the care plan dated 11/10/23, indicate Resident R2 was at risk for falls, to encourage/assist to reposition frequently to position of comfort, remind and assist as needed with toileting at routine times such as upon arising in AM, before/after meals, activities, therapy, and at bedtime. On 11/15/23, provide supplies/materials for leisure activities as needed/requested. During an interview on 6/13/24, at 10:26 a.m. Registered Nurse Employee E1 stated they did not know why the two ladies were in the dining room by themselves, stating they usually do not work that nursing unit and are unfamiliar with the residents, but they thought that Resident R1 and R2 needed to be kept eyes on them or the residents would get up and fall. During an interview on 6/13/24, at 10:36 a.m. Unit Manager Employee E2 stated the residents are in the dining room all the time and like to drag objects closer to the table they are sitting at. During an interview on 6/13/24, at 10:38 a.m. Nurse Aide Employee E3 stated Resident R1 and R2 are put in the dining room because they cause a disturbance when the other residents are watching television because they yell a lot, and if they are not pushed against the table they try to stand up and will fall. During an interview on 6/13/24, at 12:30 p.m. the Director of Nursing stated she saw the wheelchair blocking the residents at the dining table the other day but did not think of it as a restraint. During an interview on 6/13/24, at 12:30 p.m. the Nursing Home Administrator was made aware the facility failed to prevent physical restraints of being pushed into the table and having a wheelchair blocking the table for Residents R1 and R2. 28 Pa. Code 201.18(2) Management. 28 Pa. Code 201.29(d) Resident rights.

Based on review of facility policies, facility specific documents, clinical records, and resident family member and staff interviews, it was determined that the facility failed to ensure residents were free from neglect when they failed to monitor one of five residents (Resident R67) identified as an elopement risk, which created the potential for harm and was determined to constitute a past non-compliance immediate jeopardy situation. Findings include: The facility policy, Patient Protection: abuse, neglect, exploitation, mistreatment and misappropriation last reviewed on 4/1/19, indicated that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and defined neglect as the failure of the facility, its employees or service providers to provide services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility policy, Leave of Absence last reviewed on 4/1/19, indicated that if a resident had an order for [REDACTED]. The facility Nurse Supervisor: Registered Nurse/Licensed Practical Nurse job summary, dated (MONTH) (YEAR) indicated that the Nurse Supervisor supervised nursing personnel to deliver nursing care and within scope of practice coordinated care delivery, which ensured that resident's needs were met in accordance with professional standards of practice, followed established safety policies and procedures, and worked in a safety-conscious manner, which ensured that safe work practices were used in order to not pose a risk to self or others in the workplace. The facility Nurse Aide current job description indicated that the Nurse Aide followed established safety policy and procedures and reported all changes in residents' condition to a supervisor as soon as practical. The facility policy, Interdisciplinary Care Planning last reviewed on 4/1/19, indicated that the care plan was a communication tool that guided members of the interdisciplinary team (IDT) in how to meet a resident's needs and included services that the facility was to provide and focused on actual resident problems and risks. The Admission Record Report indicated that Resident R67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission physician orders [REDACTED]. The admission Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 3/27/19, Section C (Cognitive function-the ability to determine attention, orientation and ability to register and recall new information) indicated that Resident R67's Brief Interview for Mental Status (BIMS) score was a three out of 15, which indicated a severe impairment for making decisions. A review of a nurse progress note dated 4/12/19, at 10:05 a.m. indicated that a social service worker spoke with Resident R67's family member about nursing staff concerns regarding resident wandering, that Resident R67 had wandered to the first floor earlier this week and that the resident does have significant cognitive impairment. Resident Family Member RF67 was informed about a potential move to the locked dementia unit (a locked unit located on the second floor of the facility). Resident Family Member RF67 expressed concerns about the resident being placed in the locked unit at this time. A review of the care plan revealed that Resident R67 had cognitive impairment due to dementia however the facility failed to include the resident's observed wandering/exit-seeking behaviors in the care plan. A review of a nurse progress note dated 4/16/19, at 10:25 a.m. indicated that the family requested Resident R67 be moved to room [ROOM NUMBER] today, a room located closer to the nurse station, where resident's exit seeking behavior could be more closely monitored. A review of physician orders [REDACTED]. A review of a nurse progress note dated 4/18/19, indicated that Resident R67 rode the elevator down to the first floor and sat in the lobby, conversing with receptionist and visitors. Resident R67 then walked to the office of the Assistant Director of Nursing and asked that the Wanderguard be cut off, was informed of the need to keep it on, and was later assisted back upstairs to his room. A review of a nurse progress note dated 4/23/19, indicated that the facility contacted Resident Family Member RF67 about Resident R67's continued exit seeking behaviors and that the resident was going to be transferred to the locked dementia unit to which Resident Family Member RF67 agreed. Resident R67 was transferred to a room in the locked dementia unit on 4/23/19. Documentation submitted by the facility indicated that on 4/27/19, Resident R67 eloped from the facility. Resident R67 self-removed the Wanderguard and hid behind a dietary cart to exit the locked dementia unit. Local police, fire, and emergency medical support (EMS) were notified and the police later located Resident R67 at a local bar. The report noted that Resident R67 was seen on surveillance video hiding until the receptionist at the front door was in the business office, to exit the facility. A review of a nurse progress note dated 4/28/19, indicated that Resident R67 eloped from the facility on 4/27/19, at approximately 1:45 p.m. which was verified on surveillance video. Code Purple (elopement code) was initiated on 4/27/19, at 9:30 p.m. (nearly eight hours later) after it was determined that Resident R67 was not on a leave of absence, which was assumed earlier in the day. A review of the Leave of Absence log for Resident R67 did not include a family signature for 4/27/19. A review of a written statement dated 4/28/19, provided by Licensed Practical Nurse (LPN) Employee E3, the supervisor on the dementia unit at the time of Resident R67's elopement, indicated that the LPN assumed that Resident R67 was on a leave of absence. A review of the employee file for LPN Employee E3 indicated that the LPN was terminated on 4/30/19, for unsafe actions that jeopardized the health and safety of Resident R67 when the resident was not on a secured unit and LPN admitted ly voiced that an assumption was made that the resident was on a leave of absence with a family member. A review of a written statement dated 4/28/19, provided by Registered Nurse (RN) Supervisor Employee E6 indicated that on 4/27/19, at approximately 9:30 p.m. Charge Nurse RN Employee E7 stated We have a problem. There is a resident (Resident R67) that's not here. During an interview on 5/7/19, at 9:53 a.m. Nurse Aide (NA) Employee E4 stated that on 4/27/19, Resident R48, who resided on the first floor of the facility, told NA Employee E4 that a resident from upstairs walked out of the facility. Resident R48 gave a description and NA Employee E4 checked the facility Center Watch Book (listing names and pictures of residents identified as elopement risks) and did not tell the Registered Nurse (RN) Supervisor, since the description did not match any pictures so the NA assumed it had been a visitor and not a resident. During an interview on 5/7/19, at 1:44 p.m. the Resident Family Member RF67 reported that on 4/27/19, at 9:44 p.m. he was contacted by a facility staff person who inquired if by chance he had taken Resident R67 on a leave of absence around 2:00 p.m. today. He stated this was his worst nightmare and his father must have walked for five hours, it was cold and rainy, and his father was found tired from the walk. Resident Family Member RF67 reported that he was alerted by a family friend that Resident R67 was seen in a bar and that is where he and police located Resident R67, around 12:00 a.m. on 4/28/19. During an interview on 5/7/19, at 2:59 p.m. NA Employee E2 reported that LPN Employee E3 was told on 4/27/19, at 3:00 p.m. and again at 4:00 p.m. that she was unable to locate Resident R67. LPN Employee E3 told her that Resident R67 was out on a Leave of Absence. During an interview on 5/7/19, at 3:13 p.m. RN Employee E5 stated she was working on the first floor nursing unit when NA Employee E4 informed her that Resident R48 told her earlier in their shift that a resident from the second floor left the facility but the description did not match any resident in the Center Watch Book. RN Employee E5 said that she phoned the 2nd floor nurse (LPN Employee E3) however took no further action such as reporting it to the RN Supervisor. During an interview on 5/7/19, at 2:50 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to monitor Resident R67 and realize that the resident had eloped from the secured unit of the facility and was missing for over seven hours before notifying the proper authorities and family which created the potential for harm to the resident. Resident R67 left the faciity on [DATE], at 1:48 p.m. and returned via police escort on 4/28/19, at 12:38 a.m. A review of the facility's action plan indicated that on 4/28/19, immediate actions were taken which included placing Resident R67 on one-on-one supervision, re-assessing all residents identified as an elopement risk, re-assessing all other residents to be certain they were not elopement risks, the Center Watch Book was reviewed to make certain it was accurate, the Maintenance Director checked the Wanderguard system for proper functioning, and all facility staff were re-educated on the facility's Exit Seeking and Leave of Absence policies. The re-education started on 4/28/19, and was completed by 5/1/19. The facility's Quality Assessment and Assurance Committee met to review and resolve the failure of the facility to provide adequate supervision to prevent the elopement of Resident R67 and prevent further elopements. On 5/7/19, at 2:50 p.m. a past non-compliance immediate jeopardy was identified to the NHA and the DON. The past non-compliance Immediate Jeopardy situation was in effect from 4/27/19 to 5/1/19. The facility submitted the corrective action plan which included one on one supervision for Resident R67, reassessment of all residents at risk and those not at risk, review of the Center Watch Book, and Wanderguard system and provided re-education for all staff. During interviews on 5/7/19, at 9:53 a.m., at 2:59 p.m. and at 3:13 p.m. NA Employees E3, E4 and RN Employee E5 confirmed completion of re-education of the facility's Exit Seeking and Leave of Absence policies. Review of the facility documentation and staff interviews indicated that the corrective action plan had been fully implemented and completed by (MONTH) 1, 2019, at which time, the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/17/18, 5/12/17. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/4/19. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 5/12/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/4/19, 11/17/18, 4/23/18, 5/12/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/17/18, 5/12/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/17/18, 4/23/18, 5/12/17.

Based on review of facility policies, facility specific documents, clinical record, and resident family member and staff interviews, it was determined that the facility failed to provide necessary staff supervision and effective safety measures to prevent a resident's elopement, resulting in elopement for one of five residents reviewed and identified at risk for elopement. Resident R67 eloped, was missing for approximately eight hours before staff noticed, which created the potential for harm and placed residents in immediate jeopardy. The immediate jeopardy was determined to constitute a past non-compliance immediate jeopardy situation for one of five residents identified as an elopement risk (Resident R67). Findings include: The facility policy, Leave of Absence last reviewed on 4/1/19, indicated that if a resident had an order for [REDACTED]. The facility Nurse Supervisor: Registered Nurse/Licensed Practical Nurse job summary, dated (MONTH) (YEAR) indicated that the Nurse Supervisor supervised nursing personnel to deliver nursing care and within scope of practice coordinated care delivery, which ensured that resident's needs were met in accordance with professional standards of practice, followed established safety policies and procedures, and worked in a safety-conscious manner, which ensured that safe work practices were used in order to not pose a risk to self or others in the workplace. The facility Nurse Aide current job description indicated that the Nurse Aide followed established safety policy and procedures and reported all changes in residents' condition to a supervisor as soon as practical. The Admission Record Report indicated that Resident R67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission physician orders [REDACTED]. The admission Minimum Data Set assessment (MDS-periodic assessment of resident care needs) dated 3/27/19, Section C (Cognitive function-the ability to determine attention, orientation and ability to register and recall new information) indicated that Resident R67's Brief Interview for Mental Status (BIMS) score was a three out of 15 which indicated a severe impairment for making decisions. A review of a nurse progress note dated 4/12/19, indicated that Resident R67 had wandered to the first floor earlier this week and that facility had a discussion with Resident Family Member RF67 about a potential move to the dementia unit (a locked unit located on the second floor of the facility). A review of the care plan revealed that Resident R67 had cognitive impairment due to dementia however the facility failed to include the resident's observed wandering/exit-seeking behaviors in the care plan. A review of physician orders [REDACTED]. A review of a nurse progress note dated 4/18/19, indicated that Resident R67 rode the elevator down to the first floor and sat in the lobby conversing with the receptionist and visitors. Resident R67 then walked to the Assistant Director of Nursing office and asked that the Wanderguard be cut off, and was informed of the need to keep it on, and was later assisted back upstairs to his room. A review of a nurse progress note dated 4/23/19, indicated that the facility contacted Resident Family Member RF67 about Resident R67's continued exit seeking behaviors and that the resident was going to be transferred to the locked dementia unit to which Resident Family Member RF67 agreed. Documentation submitted by the facility indicated that on 4/27/19, Resident R67 eloped from the facility, that Resident R67 self-removed the Wanderguard, and hid behind a dietary cart to exit the locked dementia unit. Local police, fire and emergency medical support (EMS) were notified and that the police later located Resident R67 at a local bar. The report noted that Resident R67 was seen on surveillance video hiding until the receptionist at the front door was in the business office, before exiting the facility. A review of a nurse progress note dated 4/28/19, indicated that Resident R67 eloped from the facility on 4/27/19, at approximately 1:45 p.m. which was verified on surveillance video. Code Purple (elopement code) was initiated on 4/27/19, at 9:30 p.m. (nearly eight hours later) after it was determined that Resident R67 was not on a leave of absence, which was assumed earlier in the day. A review of the Leave of Absence log for Resident R67 did not include a family signature for 4/27/19. A review of the incident report dated 4/28/19, indicated Resident R67 had removed and destroyed the previous Wanderguard, prior to elopement. A review of a written statement dated 4/28/19, provided by Licensed Practical Nurse (LPN) Employee E3 indicated that the LPN assumed that Resident R67 was on a leave of absence. A review of the employee file for LPN Employee E3 indicated that the LPN was terminated on 4/30/19, for unsafe actions that jeopardized the health and safety of Resident R67 when the resident was not on the secured unit and LPN admitted ly voiced that an assumption was made that the resident was on a leave of absence with a family member. During an interview on 5/7/19, at 9:42 a.m. the Director of Nursing (DON) confirmed that prior to Resident R67's elopement on 4/27/19, there was no care plan in place about the resident being an elopement risk and interventions about the need to monitor the resident and make certain to document if on a leave of absence from the facility During an interview on 5/7/19, at 9:53 a.m. Nurse Aide (NA) Employee E4 stated that on 4/27/19, Resident R48, who resided on the first floor of the facility, told NA Employee E4 that a resident from upstairs walked out of the facility. Resident R48 gave a description and NA Employee E4 checked the facility Center Watch Book (listing names and pictures of residents identified as elopement risks) and did not tell the Registered Nurse (RN) Supervisor, since the description did not match any pictures so the NA assumed it had been a visitor and not a resident. During an interview on 5/7/19, at 2:22 p.m. the Nursing Home Administrator (NHA) stated the surveillance cameras were not observed during business hours, that there was no security staff in the facility, and the cameras were for review purposes only. During an interview on 5/7/19, at 1:44 p.m. the Resident Family Member RF67 said that he was called by the facility at 9:44 p.m. on 4/27/19. He stated that the facility staff did not check on Resident R67. Resident Family Member RF67 stated he did not locate his father until around 12:00 a.m. on 4/28/19. He stated this was his worst nightmare and his father must have walked for five hours, it was cold and rainy, and his father was found tired from the walk. During an interview on 5/7/19, at 2:59 p.m. NA Employee E2 reported that LPN Employee E3 was told on 4/27/19, at 3:00 p.m. and again at 4:00 p.m. that she was unable to locate Resident R67. LPN Employee E3 told the NA that Resident R67 was out on a leave of absence, did not check the leave of absence sign-out sheet nor make any other attempts to confirm where Resident R67 was. During an interview on 5/7/19, at 3:13 p.m. RN Employee E5 stated she was working on the first floor nursing unit when NA Employee E4 informed her that Resident R48 told her earlier in their shift that a resident from the second floor left the facility but description did not match any resident in the Center Watch Book. RN Employee E5 said that she phoned the 2nd floor nurse (LPN Employee E3) however took no further action such as reporting it to the RN Supervisor. During an interview on 5/7/19, at 2:50 p.m. the NHA and the DON confirmed that the facility failed to provide necessary supervision to Resident R67, and realize that the resident had eloped from the secured unit of the facility and was missing for over seven hours which created the potential for harm to the resident. A review of the facility's action plan indicated that on 4/28/19, immediate actions were taken which included placing Resident R67 on one-on-one supervision, re-assessing all residents identified as an elopement risk, re-assessing all other residents to be certain they were not elopement risks, the Center Watch Book was reviewed to make certain it was accurate, the Maintenance Director checked the Wanderguard system for proper functioning, and all facility staff were re-educated on the facility's Exit Seeking and Leave of Absence policies. The re-education started on 4/28/19, and was completed by 5/1/19. The facility's Quality Assessment and Assurance Committee met to review and resolve the failure of the facility to provide adequate supervision to prevent the elopement of Resident R67 and prevent further elopements. On 5/7/19, at 2:50 p.m. a past non-compliance immediate jeopardy was identified to the NHA and the DON. The past non-compliance Immediate Jeopardy situation was in effect from 4/27/19 to 5/1/19. The facility submitted the corrective action plan which included one on one supervision for Resident R67, reassessment of all residents at risk and those not at risk, review of the Center Watch Book, and Wanderguard system and provided re-education for all staff. During interviews on 5/7/19, at 9:53 a.m., at 2:59 p.m. and at 3:13 p.m. NA Employees E3, E4 and RN Employee E5 confirmed completion of re-education of the facility's Exit Seeking and Leave of Absence policies. Review of the facility documentation and staff interviews indicated that the corrective action plan had been fully implemented and completed by (MONTH) 1, 2019, at which time, the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/17/18, 5/12/17. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/4/19 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 5/12/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/23/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/4/19, 11/17/18, 4/23/18, 5/12/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/17/18, 5/12/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/17/18, 4/23/18, 5/12/17.

Based on review of clinical records, hospital records, manufacturer's guidelines, facility documents, observation and staff interviews, it was determined that the facility failed to follow a physician order, which compromised resident safety and resulted in injury to one of 17 residents of the Transitional Care Unit -1 (Resident R1). Findings include: A review of the most recent Minimum Data Set (MDS - a periodic review of care needs) assessment dated [DATE], indicated that Resident R1 was readmitted from the hospital to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated that these [DIAGNOSES REDACTED]. A review of the hospital records, dated 11/2/11, indicated that Resident R1 had a history of [REDACTED]. A review of the manufacturer's "Rock-N Go Wheelchair Features and Benefits" (a rocking wheelchair designed to provide greater stability and support and can be tilted to ensure optimal body positioning) indicated that the Rock-N-Go wheelchair provides greater stability, has a calming effect on the user, supports the head, shoulders, and lower back, and prevents the resident from sliding out of the chair. A review of the rehabilitation progress notes dated 9/23/11, indicated that Occupational Therapy (OT) Employee E2 recommended that Resident R1 be positioned in a Rock-N-Go wheelchair during daytime hours except for meals, because Resident R1 had a significant pelvic tilt (abnormal placement of the pelvis that can affect balance) and thrusting (pushing forward) out of a standard wheelchair. During an interview on 11/3/11, at 12:00 p.m., OT Employee E2 stated that Resident R1 demonstrated rocking behavior when sitting in a standard wheelchair and there were concerns that Resident R1 could possibly thrust herself out of a standard wheelchair. OT Employee E2 also stated that a Rock-N-Go wheelchair was the safest option for Resident R1. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of Resident R1's plan of care dated 8/17/11, indicated that Resident R1 was at risk for falls and utilized a Rock-N-Go wheelchair. A review of the facility Personal Info Worksheet (a facility document detailing resident care needs which is accessible to all staff), indicated that Resident R1 utilized a Rock-N-Go wheelchair. A review of a reportable event submitted to the State Survey Agency dated 10/29/11, indicated that on 10/28/11, at 3:40 p.m., Resident R1 was found lying on the floor in her room and was bleeding from a laceration (open cut) on the forehead. The reportable event also indicated that Resident R1 was in a standard wheelchair and not in a Rock-N-Go wheelchair as ordered when the incident occurred. Resident R1 was transferred to the hospital on [DATE] at 4:00 p.m. A review of Resident R1's hospital record indicated that Resident R1 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Seven sutures were required to close the laceration on Resident R1's forehead. Resident R1 was discharged back to the facility on [DATE]. During an observation of Resident R1 on 11/3/11, at 10:20 a.m., conducted in the presence of Assistant Director of Nursing (ADON) Employee E1, revealed that Resident R1 had ecchymosis (bruising) surrounding both eyes, on the right lower jaw, on the left elbow, on the left hand, and on both lips. There were also seven sutures present on Resident R1's forehead. During an interview on 11/3/11, at 12:20 p.m., ADON Employee E1 confirmed that Resident R1 had been transported to the beauty salon on 10/28/11, in a standard wheelchair and was not placed in a Rock-N-Go wheelchair as ordered, upon return from the beauty salon and was in a standard wheelchair when the incident occurred. During an interview on 11/3/11, at 12:30 p.m., Nurse Aide(NA) Employee E3 stated that she returned Resident R1 to her room on 10/28/11, sometime before 2:00 p.m., and that Resident R1 was in a standard wheelchair at that time. NA Employee E3 also stated that the nurse aide responsible for caring for Resident R1 was made aware that Resident R1 was back in her room and that she was sitting in a standard wheelchair, not a Rock-N-Go wheelchair as ordered. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 3/7/11. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 3/7/11. 28 Pa. Code: 201.29 (a)(c)(d) Resident rights. Previously cited 4/23/10 and 3/7/11. 28 Pa. Code: 211.10(c) Resident care policies. Previously cited 11/8/10. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/23/10, 11/8/10 and 3/7/11.

Based on review of manufacturer's guidelines, facility policy, clinical and facility records, and staff interviews, it was determined that the facility neglected to provide a safe transfer for a resident resulting in an injury, for one of 21 residents (Resident R1). Findings include: Review of the manufacturer's "Sara 3000 Operating and Product Care Instructions" dated October 2006, indicated that when lifting a patient from a chair, a wheelchair, or sitting position on a bed, a second attendant should support the patient if the patient lacks sitting balance. The facility policy/procedure "Mechanical Lift" last reviewed 1/20/11, indicated that although one person can operate most models of hydraulic lifts, it was advisable to have two staff members present to stabilize and support the patient. Review of the facility policy entitled, "Abuse and Neglect" last reviewed on 1/20/11, indicated that neglect indicates the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 1/5/11, indicated that Resident R1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also indicated that Resident R1 was totally dependent for transfers and required two plus person physical assistance for all transfers. The MDS also indicated that Resident R1's balance when moving from a seated to standing position or from surface to surface was not steady and was only able to be stabilized with assistance. The physician order dated 12/9/10, indicated not to utilize a sit-to-stand lift and a physician order dated 12/10/10, indicated to only use a sling lift for transfers. Review of Resident R1's plan of care, Kardex (a description of the resident's needs for the nursing staff), and ADL (Activities of Daily Living) Patient Information Worksheet, were updated on 12/10/10, to indicate a two person mechanical/sling lift only for transfers. A reportable event submitted to the State Survey Agency dated 3/3/11, indicated that on 3/2/11, at 2:00 p.m., Resident R1 was transferred using a sit-to-stand lift by one staff member, Nurse Aide (NA) Employee E1. During the transfer, Resident R1 pulled her legs up behind her, placing the weight of his/her body on his/her arms. The lift was lowered, removed, and Resident R1 was lowered to the floor. NA Employee E2 assisted NA Employee E1 in getting Resident R1 into the wheelchair. NA Employee E1 again attempted to transfer Resident R1 by him/herself using the sit-to-stand lift. Resident R1 again pulled her legs up behind her, the lift was lowered, and Resident R1's left arm was noted to be twisted in the rope of the lift. NA Employee E2 assisted NA Employee E1 in getting Resident R1 into the wheelchair. Upon assessment, the resident complained of left upper extremity pain. Review of nurses' notes dated 3/2/11, at 2:00 p.m., indicated that NA Employee E1 attempted to transfer Resident R1 using the sit-to-stand lift and the resident lifted up her legs en route and began to fall out of the lift. Resident R1 did not fall on the floor, but the left arm was caught up in the ropes of the lift. The resident's primary care physician was present, assessed the resident, and ordered an evaluation at the emergency room . The Radiology Report dated 3/2/11, indicated a dislocation of the left shoulder. The Emergency Department Report dated 3/2/11, indicated that the resident was given a medication for pain the dislocation was reduced (it was confirmed by an X-ray); a sling was placed on the resident's left arm; and a follow-up exam by an orthopedist was recommended. Review of the facility's staff training records indicated that NA Employee E1 on 1/11/11, received training for Abuse, Neglect, and Misappropriation of Patient Property, and on 4/20/10, received training on Barr Tenor Lift and MaxiMove (mechanical lifts). During an interview on 3/7/11, at 2:30 p.m., NA Employee E1 confirmed that he/she failed to check the Kardex and Activities of Daily Living (ADL) Patient Information Worksheet for the current transfer order for Resident R1. During an interview on 3/7/11, at 8:45 a.m., and at 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the NA Employee E1 neglected to provide a safe transfer resulting in an injury to Resident R1. Refer to F323. 28 Pa. Code: 201.18 (b) (1) Management. 28 Pa. Code: 201.29 (a) (c) (d) Residents rights. 28 Pa. Code: 211.12 (d) (1) (5) Nursing services.

Based on review of manufacturer's guidelines, facility policy, clinical and facility records, and staff interviews, it was determined that the facility failed to provide the necessary staff assistance and ordered transfer assistance device during a resident transfer, which resulted in an injury to one of 21 residents (Resident R1). Findings include: Review of the manufacturer's "Sara 3000 Operating and Product Care Instructions" dated October 2006, indicated that when lifting a patient from a chair, a wheelchair, or sitting position on a bed, a second attendant should support the patient if the patient lacks sitting balance. Review of the facility policy/procedure entitled, "Mechanical Lift" last reviewed 1/20/11, indicated that although one person can operate most models of hydraulic lifts, it was advisable to have two staff members present to stabilize and support the patient. The Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 1/5/11, indicated that Resident R1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also indicated that Resident R1 was totally dependent for transfers and required two plus person physical assistance for all transfers. The MDS also indicated that Resident R1's balance when moving from a seated to standing position or from surface to surface was not steady and was only able to be stabilized with assistance. Review of the physician order dated 12/9/10, indicated not to utilize a sit-to-stand lift and a physician order dated 12/10/10, indicated to only use a sling lift for transfers. Review of Resident R1's plan of care, Kardex (a description of the resident's needs for the nursing staff), and an ADL (Activities of Daily Living) Patient Information Worksheet were updated on 12/10/10, to indicate a two person mechanical/sling lift only for transfers. A reportable event submitted to the State Survey Agency dated 3/3/11, indicated that on 3/2/11, Nurse Aide (NA) Employee E1 transferred Resident R1 alone using a sit-to-stand lift that resulted in an injury to the resident. A Radiology Report dated 3/2/11, indicated that Resident R1 had a dislocation of the left shoulder. During an interview on 3/7/11, at 2:30 p.m., NA Employee E1 confirmed that he/she did not review the plan of care, Kardex, or ADL Patient Information Worksheet to ascertain the ordered transfer method and assistance required for Resident R1 prior to transferring the resident on 3/2/11. During an interview on 3/7/11, at 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that NA Employee E1 performed an unsafe transfer without two staff members present or the use of the ordered sling lift on 3/2/11, resulting in an injury to Resident R1. Refer to F224. 28 Pa. Code: 201.18 (b) (1) Management. 28 Pa. Code: 201.29 (a) (c) (d) Residents rights. 28 Pa. Code: 211.12 (d) (1) (5) Nursing services.