Every finding on record at Willow Terrace

Based on review of clinical records, facility documents, and interviews with staff, it was determined the facility failed to ensure one of ten residents reviewed were free from verbal abuse. (Resident R1)Findings Include: Review of the facility policy titled Abuse Policy-Prevention and Management last revised September 2022 states verbal abuse is defined as, Verbal Abuse- Oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: Harassing a resident, Mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidate, threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends, and isolating a resident from social interaction or activities. Review of facility documentation revealed Resident R1 was admitted to the facility on [DATE] with the following diagnosis: Type Two Diabetes (a chronic condition causing high blood sugar because the body doesn't produce enough or effectively use insulin, leading to insulin resistance), Chronic Kidney Disease Stage 3(involves moderate loss of kidney function, requiring management of complications like high blood pressure, anemia, and bone disease), Anemia (a medical condition defined by a deficiency in the number of healthy red blood cells or the hemoglobin concentration within them, reducing the blood's capacity to transport oxygen throughout the body), Generalized Anxiety a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things-like health), and Neuromuscular Dysfunction of Bladder (occurs when nerve damage from diseases or injuries disrupts signals between the brain and bladder, causing loss of bladder control). Review of Resident R1's physician orders revealed an order dated September 24, 2025 Empty Foley drainage bag every shift and record output. Review of facility Incident/Accident Witness statement, dated March 21, 2026 states, Resident reported that this he/she requested for his/her foley bag to be emptied because it was almost full. He/She stated nurse aide Employee E3 always comes into his/her room fussing. Nurse Aide Employee E3 refused to empty the bag. Nurse aide Employee E3 stated it was not full enough. I told nurse aide Employee E3 I still needed it emptied because I can get an infection. Employee E3 persisted in saying it was not full enough and it began to become uncomfortable because he/ she was yelling so I asked him/her What are you a witch. Employee E3 then said your mother. I told him/her if he/she did not want to do it I will get someone else to do it. I began to yell for a nurse loudly and several nurses came to my room. Review of facility Incident Investigation questionnaire signed March 23, 2026 stated, Did anything happen recently that was upsetting to you? YES- see attached. An attached typed statement from Resident R1 states, I asked the nurse aide Employee E3 to empty my foley bag because is was ninety-five percent full. The aide pressed the issue that it was not ready to be dumped yet. I told him/her that this is how I get an infection before behind the bag not being emptied. The aide kept pressing the issue about the bag not being full. He/She was combative towards me. He/She called me a liar and I asked him/her was he/she a witch and nurse aide Employee E3 said no your mother is I hollered down the hall for the nurse and two nurses came in, and stating he/she cannot be talking to me like that. The nurse aide Employee E1 went to dump my bag and was going to dump it in a basin. The nurse stated that it needs to be dumped in a urinal she cannot dump it in a basin and to put it back. I feel that this was an abuse situation. Review of facility Incident/Accident Witness statement dated March 21, 2026 taken from licensed nurse Employee E4 states, Resident R1 heard screaming out for a nurse. I immediately went to see what was going on. When approaching the room I heard the resident screaming to get out of my room. Upon entering room, nurse aide Employee E3 observed arguing with Resident R1. I asked the nurse aide Employee E3 to please leave but he/she continued to argue with the resident. I asked Resident R1 to try to calm down and tell me what happened. Resident R1 told me that he/she called my mother a witch. After saying that, nurse aide Employee E3 went close to Resident R1's face pointing his/her finger and screaming you're a liar. Resident was shaking and became increasingly agitated. Nurse aide Employee E3 was asked to stop yelling but he/she continued to scream. Nurse aide Employee E1 then used resident basin to empty his/her foley out. When there was two urinals in his/her bathroom. Nurse aide employee E3 was asked to leave the room and he/she finally left. A phone interview was held with license nurse Employee E4 on April 30, 2026 at 12:14 p.m. Licensed Nurse Employee E4 stated that he/she was the oncoming nurse for the shift so him/her and licensed nurse Employee E5 were at the nurses station counting medications when they heard a call out loud for a nurse from down the hall. Employee E4 stated he/she and Employee E5 went down the hall immediately and upon entering heard and witnessed nurse aide Employee E3 yelling at Resident R1. Employee E4 stated that he/she asked Employee E5 to leave the room but he/she would not. Employee E4 stated he/she attempted to calm down Resident R1 because he/she was visibly upset but nurse aide Employee E3 would not stop yelling, you're a liar, you're a liar! and got up in Resident R1's face, pointing his/her finger in Resident R1's face. Employee E4 stated that Employee E3 continued to the bathroom and emptied out the residents foley improperly before being asked to leave again and finally leaving. Review of facility Incident/Accident Witness statement, undated from licensed nurse Employee E5 states, I heard a loud yelling at the end of the hallway, walked down to figure out what happened. Resident R1 and nurse aide Employee E3 was arguing. I couldn't understand how it started but I was able to break it up and came down resident R1. Review of facility Incident/Accident Witness statement, dated March 26, 2026 from nurse aide Employee E5 states, I nurse aide Employee E1 was assigned to the sixth floor. Resident R1 was one of my clients. I responded to a call bell for Resident R1 around 1:00 a.m. Resident R1 stated he/she needed pain medication and the nurse was informed about same. Another call was made by another client, on my way to this client, Resident R1 call bell rang for the second time. I stopped at the other client's room to answer their call I left without being able to change him/her as he/she requested. I told him/her I would find out what another client was calling about and I would be right back to meet his/her needs. On my arrival to Resident R1's room, he/she stated that his/her urine bag was full and was going to burst any minute now and he/she will get kidney infection and he was going to file law-suit. The urine bag wasn't full as he had stated, so I informed him/her about my findings. That it wasn't full and was not about to burst as he had stated. He started to shout at me that I should empty the bag. I got very nervous, my body felt numb. I told him/her that I needed to get a pair of gloves to empty the bag. I got a pair of gloves and put on same. The bag was held up to my eye level (1,300 milliters) was noted in bag. I tried to show Resident R1 the bag which I had in both of my hands and also tried to tell him/her that the bag had a maximum capacity of 2,000 milliliters. I wasn't given the change to talk to Resident R1. Each time I tried to speak, he/she got louder and louder as if he was preventing me from voicing my findings. I tried to calm him and told him I just wanted him/her to see that I was telling the truth and the bag wasn't full and about to burst. While I was about to empty the urine bag he told me I was a witch and I should leave his room. The fact that he/she lied about the urine bag, shouted at me, and called me a witch and stated that he was going to file a lawsuit pertaining a full bag of urine. I saw all of his actions towards me as his caregiver as very humiliating, it also caused me a painful loss of pride, dignity, as well as deep embarrassment and shame. My humanly defense mechanism chipped in and my response to him calling me a witch was the same like your mother. He shouted loudly for the nurse. Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 on April 30, 2026 at 1:20 p.m. [NAME] Employee E1 and Employee E2 confirmed the above findings. The Director of Nursing Employee E2 stated that on March 21, 2026 when the incident occurred, nurse aide Employee E3 was immediately suspended and called over the phone. Employee E3 gave a statement over the phone and was asked to come in and write a statement in person. Employee E2 stated that nurse aide Employee E3 came in and gave her written statement on March 26, 2026. Employee E2 stated that at that time the investigation was completed and substantiated for verbal abuse and Employee E3 was terminated. 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 PA. Code 211.12(c) Nursing services

Based on review of clinical records, facility documents, and interview with staff and residents, it was determined the facility failed to ensure Resident R1 was free from physical abuse. This failure resulted in actual harm to Resident R1 who was grabbed by a facility's employee by the collar, held in a choking position and placed (his/her) hand on the resident's face. The employee's hands had to be pried away from Resident R1's. A reasonable person would determine that a staff member holding a resident with a diagnosis of major depression and heart failure in a chocking hold caused actual harm, placing Resident R1 at risk for psychological trauma or one of five residents reviewed. Findings include: Review of facility policy titled Abuse Policy-Prevention and Management with review date of August 2025 revealed, The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Continued review of the same facility abuse policy revealed under section title Staff to Resident Abuse revealed:When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. The facility is responsible to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behavior. All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population. Facility cannot disown the acts of staff, since the facility relies on them to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to heart failure, muscle weakness, Major Depressive Disorder (loss of interest in pleasurable activities) and absence of left leg below knee. Review of Resident R1's Minimum Data Set (MDS- federally required resident assessment completed at a specific interval) section C0500 BIMS (Brief Interview of Mental Status) revealed Resident R1 had a BIMS score of 15 indicating Resident R1 was cognitively intact. Review of documentation submitted to the State Survey Agency on February 24, 2026, revealed on February 23, 2026, at 2:45 PM, Resident R1 reported a nurse aide verbally, physically, and mentally abused (him/her). The facility description of the incident revealed, The Resident who speaks Spanish and English asked the aid to repeat what (he/she) said to (him/her). The aide repeated it and the resident became very upset and grabbed the CNA (nurse aide) sweater by the neck. The Aide in response, grabbed the resident and place his arm around the resident's neck and told the resident he cannot do anything to him because the resident only have one leg. The ADON (Assistant Director of Nursing) had to separate the two parties. Nurse aide, Employee E4 was identified as the perpetrator and was suspended on February 23, 2024, immediately after the incident. The facility concluded that nurse aide, Employee E4 fought back and grabbed Resident R1. It became a Physical Altercation between resident and staff. Both parties had to be separated. The facility terminated Nurse aide, Employee E4 on March 12, 2026. Review of undated facility investigation report completed by Director of Nursing (DON), Employee E2 related to the abuse incident revealed Staff to resident abuse [Nurse aide, Employee E4] said something in Spanish to [Resident R1]. Resident R1 responded stating, repeat what you just said. [Nurse aide, Employee E4] repeated it and [Resident R1] grabbed [Nurse aide, Employee E4's] sweater. [Nurse aide, Employee E4] in return placed [Resident R1] in a choke holding position while putting [Nurse aide, Employee E4's] hand on the [Resident R1's] face. This incident was witnessed by [Assistant Director of Nursing, Employee E3] who had to separate [Nurse aide Employee E4] and [Resident R1]. Further review of the investigation report revealed during the investigation, there was a verbal abuse incident that occurred on February 21, 2026, between Nurse aide, Employee E4 and Resident R1. Review of documentation submitted to the State Survey Agency on March 30, 2025, revealed the facility initiated an investigation of an allegation of verbal abuse involving Nurse aide, Employee E4. The facility documented During investigating another abuse investigation, A staff member reported a witnessed abuse event. as per staff she was new and did not know what she witnessed was abuse. she became aware that the event she witnessed was abuse during in-service and an example of abuse was presented. The facility substantiated the allegation of verbal abuse. The conclusion of both reported abuse incidents for February 21, 2026, and February 23, 2026, was Based on the nature of witnessed abuse- 2 incidents- recommended termination. This is not the first time this employee was suspended/suspected for abuse. Review of written statement by Nurse aide, Employee E4's dated February 23, 2026, revealed on February 23, 2026, Employee 4 was leaving the 6th floor unit when Resident R1 yelled for Employee E4 to hold the door (without Resident R1 signing out). Further, the statement revealed, Employee E4 previously told Resident R1 on February 21, 2026, that Resident R1 needs to sign out, so Employee 4 did not hold the door and left the unit. While Employee E4 was going back to the building Resident R1 saw Employee E4 in the lobby and Resident R1 proceeded to curse at Employee E4 and asks why Employee E4 did not hold the door. Employee E4 did not respond. Once Employee E4 got back to the 6th floor unit Employee E4 had a general conversation with Assistant Director of Nursing (ADON), Employee E3, after a few minutes Resident R1 came over and told ADON, Employee E3 that Employee E4 had a problem with (him/her) by not opening the door for (him/her). Further Nurse aide, Employee E4's statement revealed Resident R1 started cursing and making threats. Employee E3 (ADON) asked Resident R1 to sign out and Resident R1 refused and continued yelling. Resident R1 started to move towards Employee E4 and backed Employee E4 against the wall. Employee E3 (ADON) told Resident R1 to stop and to go the other way but resident refused and grabbed Employee E4 and pulling Employee E4 towards (him/her). Employee E3 (ADON) started yelling for help. Employee E4 extended his arms to stop Resident R1 from hitting (him/her). Observation conducted on March 19, 2026, at 10:00 AM of the 6th floor nursing unit revealed the door to the unit is locked. A sign out book was located at the nurse station for residents to sign out before exiting the unit. Telephone interview with Director of Nursing (DON), Employee E2 conducted on March 19, 2026, at 12:03 PM revealed Employee E2 was not aware of the first incident which occurred on February 21, 2026, between Nurse aide, Employee E4 and Resident R1. Continued interview with Employee E2 (DON) revealed she became aware of the February 21, 2026, incident as she was investigating the incident that occurred on February 23, 2026. Employee E2 (DON), confirmed the February 21, 2026, incident was not reported in a timely manner due to the incident not being reported to her at the time of the incident. Employee E2 confirmed both incidents of resident abuse were reported on February 24, 2026, due to the Director of Nursing not being in the facility on February 23, 2026. Interview with Nurse aide, Employee E6 conducted on March 19, 2026, at 12:10 PM revealed on February 21, 2026, after lunch, Nurse aide, Employee E6 who was coming out of a resident room, observed Nurse aide, Employee E4 and Charge nurse, Employee E7 sitting behind the nurse's station. Nurse aide, Employee E6 revealed observation of Nurse aide, Employee E4, having a loud back and forth argument with Resident R1 who was in a wheelchair stationed in front of the nurse's station. Nurse aide, Employee E4 repeatedly speaking to Resident R1 in Spanish with each time Employee E4 said something Resident R1 became increasingly agitated. Nurse aide, Employee E6 revealed she did not understand what was being said as she did not understand Spanish. Nurse aide, Employee 6 also revealed the only thing she understood was Employee E4 saying I won't open the door! which was said in English. Employee E6 (nurse aide) revealed both Resident R1 and Employee E4 (N.A) were speaking in loud voices. Employee E6 further indicated in order to calm Resident R1 down Nurse aide, Employee E6, assisted Resident R1 in signing the logbook to leave the unit. Nurse aide, Employee E6 proceed to open the door for Resident R1. Further interview with Nurse aide, Employee E6 revealed Employee E6 then went to the Nursing Supervisor, Employee E8's office to report the incident. Additionally, Employee E6 revealed when she got to Nursing Supervisor's office, Employee E8 asked her what the noise was all about because Nursing supervisor, could hear raised voices from the office. Nurse aide, Employee E6 reported the incident to Employee E8, the Nursing Supervisor. Surveyor attempted phone interview with Nurse aide, Employee E4 which was unsuccessful. Telephone interview was attempted with Nursing Supervisor, Employee E8 and it was unsuccessful. Interview conducted with Assistant Director of Nursing (ADON), Employee E3 on March 19, 2026, at 3:25 PM, revealed on February 23, 2026, approximately 2:00 PM, Employee E3 was administering medications on the 6th floor unit. Employee E3 revealed Nurse aide, Employee E4 was working on the 6th floor and was in the hallway close to Employee E3. Resident R1 approached ADON, Employee E3 and told Employee E3 (he/she) wanted to report Nurse aide, Employee E4. Resident R1 told Employee E3 that Employee E4 doesn't want to open the door for him and Employee E4 doesn't want to do anything for (him/her). Employee E3 told Resident R1 she will take care of it. Resident R1 turned to wheel (himself/herself) away when Employee E4 said something in Spanish which made Resident R1 become suddenly very agitated. Resident R1 started to propel (himself/herself) towards Employee E4. Employee E3 instructed Employee E4 to move away but Employee E4 said I will not move! When Resident R1 was in front of Employee E4, Employee E4 bent forward and Resident R1 grabbed Employee E4's sweater collar. Employee E3 then removed Resident R1's hands from Employee E4's collar. When Resident R1 let go of Employee E4's collar, Employee E4 then put his hand around Resident R1's neck. Employee E3 initiated a call for help while attempting to pry Employee E4's hand from Resident R1's neck. When Employee E3 was able to remove Employee E4's hand from Resident R1's neck, Employee E4 then put his other hand on Resident R1's face and pushed it. Employee E3 removed Employee E4's hand from Resident R1's face and redirected Resident R1's wheelchair away from Employee E4. Additional interview with ADON, Employee E3 revealed she immediately reported the incident to Nursing Home Administrator, Employee E1. Nurse aide, Employee E4 was immediately suspended the same day. Interview conducted with Social Worker, Employee E9 on March 19, 2026, at 11:29 AM revealed Employee E9 learned of the incident on February 24, 2026. Further Employee E9 revealed Resident R1 did not want to discuss the incident. Interview conducted with Resident R1 on March 19, 2026, at 9:25 AM reveal Resident R1 stated It's all good now. I'm over it. Resident R1 refused to provide further information. Follow up interview conducted with Resident R1 on March 19, 2026, at 1:47 PM revealed the incident had caused (him/her) some distress but did not want to talk any further about it. Interview conducted with facility Nursing Home Administrator, Employee E1 on March 19, 2026, at 1:30 PM confirmed the incident on February 21, 2026, was not reported to her or to the Director of Nursing, Employee E2. The Nursing Home Administrator, Employee E1 found out about the incident of February 21, 2026, during the investigation into the incident that occurred on February 23, 2026. The facility failed to ensure Resident R1 was free from physical abuse. This failure resulted in actual harm to Resident R1 who was grabbed by a facility's employee by the collar, held in a choking position and placed (his/her) hand on the resident's face. The employee's hands had to be pried away from Resident R1's. A reasonable person would determine that a staff member holding a resident with a diagnosis of major depression in a chocking hold caused actual harm, placing Resident R1 at risk for psychological trauma. 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 202.29(a) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 PA. Code 211.12(c) Nursing services

Based on review of clinical records, facility documents, and interview with staff and residents, it was determined that the facility failed to ensure to immediately protect a resident involved in a staff to resident abuse for one of five residents reviewed. (Resident R1) Findings include:Review of facility policy title Abuse Policy-Prevention and Management review date 8/2025 revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Continued review of the facility abuse policy under section title Staff to Resident Abuse revealed: When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. The Shift Supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager, if applicable are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation/exploitation of policy standards and procedures: Implementation, On-going monitoring, Reporting, Investigation, Tracking and trending.Further, a NOTE indicating that When a facility has identified abuse, the facility must take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. Facilities that take immediate action to correct any issues can reduce the risk of further harm continuing or occurring to other residentsUnder section Protection: Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property: Immediate suspension of suspected employee(s), pending outcome of the investigation.Under section Investigation, The Facility will begin the investigation process immediately upon notification of the incident and will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. The Shift Supervisor/Charge Nurse is identified as responsible for immediate Initiation of the reporting process.Upon receiving reports of physical or sexual abuse the DON/designee shall immediately examine the resident. Findings of the examination must be recorded in the Resident's record: The nurse shall immediately notify the physician, and the resident/resident's representative, The Administrator, Director of Nursing or designee shall notify the appropriate Agency/State office according to State specific guidelines for timeliness of reporting as applicable. Applicable reports will be completed per State, requirements or as designated by reporting agencies. Under section Reporting The Facility will report abuse, neglect, misappropriation, and/or exploitation incidents timely and within the Federal/State requirements. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder (major loss of interest in pleasurable activities). Review of Resident R1's Minimum Data Set (MDS- a federally required resident assessment completed at a specific interval) completed January 5, 2026, section C0500 BIMS (Brief Interview of Mental Status) revealed that Resident R1 had a BIMS score of 15 suggesting that Resident R1 was cognitively intact. Review of documentation submitted to the State Survey Agency on February 24, 2026, related to an incident that occurred on February 23, 2026, revealed that on February 23, 2026, at 2:45PM, Resident R1 reported that a nurse aide verbally, physically and mentally abused (him/her). Nurse aide, Employee E4 was identified as the perpetrator and was suspended on February 23, 2024, immediately after the incident. The facility completed the investigation and terminated Nurse aide, Employee E4 on March 12, 2026. Further facility investigation revealed that Resident R1 also reported that [Nurse aide, Employee E4] always argue with (him/her). Review of undated facility investigation report completed by Director of Nursing (DON), Employee E2 related to the abuse incident reported by Resident R1 revealed Staff to resident abuse [Nurse aide, Employee E4] said something in spanish to [Resident R1]. Resident R1 responded stating, repeat what you just said. [Nurse aide, Employee E4] repeated it and [Resident R1] grabbed [Nurse aide, Employee E4's] sweater. [Nurse aide, Employee E4] in return placed [Resident R1] in a choke holding position while putting [Nurse aide, Employee E4's] hand on the [Resident R1's] face. This incident was witnessed by [Assistant Director of Nursing, Employee E3] who had to separate [Nurse aide Employee E4] and [Resident R1]. Further review of the investigation report revealed that during the investigation, it was determined that there was another abuse incident that occurred on February 21, 2026, between Nurse aide, Employee E4 and Resident R1. The incident was substantiated. The facility was not able to provide a written investigation related to the abuse incident of February 21, 2026. Telephone interview with Director of Nursing (DON), Employee E2 conducted on March 19, 2026, at 12:03PM revealed that there was a verbal abuse incident that occurred between Nurse's Aide Employee E4 and Resident R1 on March 21, 2026, and that a physical abuse incident also occurred between Employee E4 and Resident R1 on February 23, 2026. Further Employee E2 revealed that Employee E2 was not made aware of the first incident that occurred on February 21, 2026, between Nurse aide, Employee E4 and Resident R1. Further DON, Employee E2 revealed that she became aware of the February 21, 2026, incident as she was investigating the incident that occurred on February 23, 2026. Further Employee E2 also confirmed that the February 21, 2026, incident was not reported in a timely manner because the incident was not reported to her at the time of the incident. Further DON, Employee E2 also confirmed that both incidents of resident abuse were reported on February 24, 2026, because she was not in the facility on February 23, 2026. Further interview with DON Employee E2 revealed that she was not aware of the February 21, 2026, verbal abuse incident between Nurse's Aide Employee E4 and Resident R1. Further Employee E2 confirmed that Employee E4 continued to work after the incident on February 21, 2026 until Employee E4's suspension on February 23, 2026, when an incident of a physical abuse incident between Employee E4 and Resident R1 that occurred on February 24, 2026, was reported to the Nursing Home Administrator. Interview with facility Nursing Home Administrator, Employee E1 conducted on March 19, 2026, at 1:30 PM confirmed that the incident on February 21, 2026, was not reported to her and to the Director of Nursing, Employee E2. Further, Employee E1 revealed that Employee E1 found out about the verbal abuse incident between Employee E4 and Resident R1 on February 21, 2026, while investigating the physical abuse incident between Employee E4 and Resident R1 that occurred on February 23, 2026. Further interview with Nursing Home Administrator Employee E1 confirmed that Employee E4 continued to work after the incident on February 21, 2026, until Employee E4's suspension on February 23, 2026, when an incident of a physical abuse incident between Employee E4 and Resident R1 that occurred on February 24, 2026, was reported to Employee E1. 28 Pa. Code 201.18(b)(3)(e)(1) Management28 Pa. Code 202.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 PA. Code 211.12(c) Nursing services

Based on review of facility documents, review of clinical record, review of facility policies, interview with staff and residents, it was determined that the facility failed to ensure that all alleged violations involving abuse is reported immediately, but not later than 2 hours after the allegation is made for one of five residents reviewed. (Resident R1) Findings include:Review of facility policy title Abuse Policy-Prevention and Management review date 8/2025 revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Continued review of the facility abuse policy under section title Staff to Resident Abuse revealed: When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. The Shift Supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager, if applicable, are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation/exploitation of policy standards and procedures: Implementation, On-going monitoring, Reporting, Investigation, Tracking and trending. The Shift Supervisor/Charge Nurse is identified as responsible for immediate Initiation of the reporting process.Further review of the facility policy revealed that The Administrator, Director of Nursing or designee shall notify the appropriate Agency/State office according to State specific guidelines for timeliness of reporting as applicable. Applicable reports will be completed per State, requirements or as designated by reporting agencies.Under section Reporting The Facility will report abuse, neglect, misappropriation, and/or exploitation incidents timely and within the Federal/State requirements. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder (major loss of interest in pleasurable activities). Review of Resident R1's Minimum Data Set (MDS- a federally required resident assessment completed at a specific interval) completed January 5, 2026 section C0500 BIMS (Brief Interview of Mental Status) revealed that Resident R1 had a BIMS score of 15 suggesting that Resident R1 was cognitively intact. Review of documentation submitted to the State Survey Agency on February 24, 2026, related to an incident that occurred on February 23, 2026, revealed that on February 23, 2026, at 2:45PM, Resident R1 reported that a nurse aide verbally, physically and mentally abused (him/her). Nurse aide, Employee E4 was identified as the perpetrator and was suspended on February 23, 2024, immediately after the incident. The facility completed the investigation and terminated Nurse aide, Employee E4 on March 12, 2026. Further facility investigation revealed that Resident R1 also reported that [Nurse aide, Employee E4] always argue with (him/her). Review of undated facility investigation report completed by Director of Nursing (DON), Employee E2 related to the abuse incident reported by Resident R1 revealed Staff to resident abuse [Nurse aide, Employee E4] said something in spanish to [Resident R1]. Resident R1 responded stating, repeat what you just said. [Nurse aide, Employee E4] repeated it and [Resident R1] grabbed [Nurse aide, Employee E4's] sweater. [Nurse aide, Employee E4] in return placed [Resident R1] in a choke holding position while putting [Nurse aide, Employee E4's] hand on the [Resident R1's] face. This incident was witnessed by [Assistant Director of Nursing, Employee E3] who had to separate [Nurse aide Employee E4] and [Resident R1]. Further review of the investigation report revealed that during the investigation, it was determined that there was a verbal abuse incident that occurred on February 21, 2026, between Nurse Aide, Employee E4 and Resident R1. The incident of verbal abuse was substantiated. Telephone interview with Director of Nursing (DON), Employee E2 conducted on March 19, 2026, at 12:03PM revealed that Employee E2 was not made aware of the verbal abuse incident that occurred on February 21, 2026, between Nurse Aide, Employee E4 and Resident R1. Further DON, Employee E2 revealed that she became aware of the February 21, 2026, verbal abuse incident while she was investigating the incident that occurred on February 23, 2026. Further interview with DON Employee E2 confirmed that the February 21, 2026, verbal abuse incident was not reported in a timely manner because the incident was not reported to her at the time of the incident. Further DON, Employee E2 also confirmed that both incidents of resident abuse were reported on February 24, 2026, because she was not in the facility on February 23, 2026. Interview with facility Nursing Home Administrator, Employee E1 conducted on March 19, 2026, at 1:30 PM confirmed that the verbal abuse incident on February 21, 2026, was not reported to her and to the Director of Nursing, Employee E2. Further the Nursing Home Administrator, Employee E1 found out about the verbal abuse incident of February 21, 2026, during the investigation of the incident that occurred on February 23, 2026. Further interview with Employee E1 confirmed that both incidents were reported on February 24, 2026. The facility was not able to provide a written investigation related to the abuse incident of February 21, 2026. 28 Pa. Code 201.18(b)(3)(e)(1) Management28 Pa. Code 202.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 PA. Code 211.12(c) Nursing services

Based on review of clinical record, review of facility documents and review of facility policy, it was determined that the facility failed to assess/evaluate a resident after an incident of physical abuse for one of five residents reviewed. (Resident R1) Findings include:Review of facility policy title Abuse Policy-Prevention and Management review date 8/2025 revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. Continued review of the facility abuse policy revealed that upon receiving reports of physical or sexual abuse the DON/designee shall immediately examine the resident. Findings of the examination must be recorded in the Resident's record: The nurse shall immediately notify the physician, and the resident/resident's representative. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder (major loss of interest in pleasurable activities). Review of Resident R1's Minimum Data Set (MDS- a federally required resident assessment completed at a specific interval) completed January 5, 2026 section C0500 BIMS (Brief Interview of Mental Status) revealed that Resident R1 had a BIMS score of 15 suggesting that Resident R1 was cognitively intact. Review of documentation submitted to the State Survey Agency on February 24, 2026, related to an incident that occurred on February 23, 2026, revealed that on February 23, 2026, at 2:45PM, Resident R1 reported that a nurse aide verbally, physically and mentally abused (him/her). Nurse aide, Employee E4 was identified as the perpetrator and was suspended on February 23, 2024, immediately after the incident. The facility completed the investigation and terminated Nurse aide, Employee E4 on March 12, 2026. Further facility investigation revealed that Resident R1 also reported that [Nurse aide, Employee E4] always argue with (him/her). Review of undated facility investigation report completed by Director of Nursing (DON), Employee E2 related to the abuse incident reported by Resident R1 revealed Staff to resident abuse [Nurse aide, Employee E4] said something in spanish to [Resident R1]. Resident R1 responded stating, repeat what you just said. [Nurse aide, Employee E4] repeated it and [Resident R1] grabbed [Nurse aide, Employee E4's] sweater. [Nurse aide, Employee E4] in return placed [Resident R1] in a choke holding position while putting [Nurse aide, Employee E4's] hand on the [Resident R1's] face. This incident was witnessed by [Assistant Director of Nursing, Employee E3] who had to separate [Nurse aide Employee E4] and [Resident R1]. Interview with ADON, Employee E3 conducted on March 19, 2026, at 3:25PM, revealed that on February 23, 2026, at around a little past 2:00PM, Employee E3 was giving out meds on the 6th floor unit. Further, ADON, Employee E3 revealed that Nurse aide, Employee E4 was working on the 6th floor and was in the hallway close to ADON, Employee E3. Resident R1 then approached ADON, Employee E3 and told ADON, Employee E3 that he wanted to report Nurse aide, Employee E4. Resident R1 told ADON, Employee E3 that Employee E4 doesn't want to open the door for him and that Employee E4 doesn't want to do anything for him. Employee E3 told Resident R1 that she will take care of it. Resident R1 then started to wheel himself away when Employee E4 said something in Spanish which made Resident R1 become suddenly very upset. Resident R1 then started to propel (himself/herself) towards Employee E4. Employee E3 then told Employee E4 to move away but Employee E4 said I will not move! When Resident R1 was in front of Employee E4, Employee E4 bent forward and Resident R1 grabbed Employee E4's sweater collar. Employee E3 then removed Resident R1's hands from Employee E4's collar. When Resident R1 let go of Employee E4's collar, Employee E4 then put his hand around Resident R1'd neck. Employee E3 started to call for help while attempting to pry Employee E4's hand from Resident R1's neck. When Employee E3 was able to remove Employee E4's hand from Resident R1's neck, Employee E4 then put his other hand on Resident R1's face and pushed it. Employee E3 then removed Employee E4's hand from Resident R1's face and pushed Resident R1's wheelchair away from Employee E4. Further review of Resident R1's clinical record revealed no documented evidence that the resident was assessed by a licensed nurse after an incident of verbal abuse by Nurse's Aide Employee E4 on February 21, 2026, no documented evidence that Resident R 1 was evaluated, by a psychologist or was provided with emotional or psychological support after the verbal abuse incident. Further review of Resident 1's clinical record revealed no documented evidence that Resident R1 was assessed by a licensed nurse and an incident of physical abuse by Nurse's Aide Employee E4 on February 23, 2026. Further there was documented evidence that a physician was made aware or the incident. Further, there was no documented evidence that Resident R1 was examined by the physician after the incident of physical abuse by Employee E4 on February 23, 2026. Interview with facility Nursing Home Administrator, Employee E1 conducted on March 19, 2026, at 1:30 PM confirmed that an incident of staff to resident verbal abuse between Employee E1 and Resident R1 had occurred on February 21, 2026 and a staff to resident physical abuse occurred between Employee E4 and Resident R1 occurred on February 23, 2026, where Employee E4 put resident R1 on a choke hold. 28 Pa. Code 201.18(b)(3)(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 PA. Code 211.12(c) Nursing services

Based on review of clinical record, facility policy, and staff interview it was determined that the facility failed to ensure that a resident was informed of and allowed to exercise their right to leave the facility Against Medical Advise (AMA) for one out of 5 residents reviewed. (Resident CL1). Findings Include:A review of the facility policy titled Discharge Against Medical Advice (AMA), last revised 6/2025, stated: A Discharge Against Medical Advice form must be completed when a cognitively intact resident/patient or the legally responsible party for a non-cognitively intact resident/patient insists on leaving the facility Against Medical Advice (AMA). The attending physician, CEO, and Director of Nursing must be notified immediately following each AMA.Review of Resident CL1's nursing notes indicated that the resident was admitted to the facility on [DATE], at approximately 6:30 p.m. with a diagnosis of anoxic brain damage. A nursing note dated the same day at 7:19 p.m. stated, [Resident CL1] is Alert and Oriented to 1. person, 2. place and 3. Time (AAOX2-3) with confusion. [Resident CL1] is a high elopement risk, voicing concerns about leaving the facility and returning to the streets. [Resident CL1] was observed crying in the hallway and yelling, demanding to leave. The nursing supervisor and MD (physician) were made aware. New orders were received to place the patient on 1:1 rotation for further assessment.A review of the physician discharge completed on September 27, 2025, at 10:24 a.m. indicated [Resident CL1] was admitted for short rehab. Resident admitted but refuses to stay in the facility. Very aggressive behavior, she left AMA (against medical advice). Under condition upon discharge, it indicated [Resident CL1] stable/alert and oriented.On October 3, 2025, at 12:57 p.m. an telephone interview with the license nurse, Employee E3 who was assigned to Resident CL1 reported that Resident CL1 was alert and oriented and wanted to leave against medical advice (AMA), Resident CL1 was screaming and yelling wanting to leave, I verbalized to my supervisor, Employee E4 and briefly mentioned the AMA process by stating you could leave against medical advice.On October 3, 2025, at 1:22 p.m., a telephone interview was conducted with the registered nurse, Employee E4, who was acting as the supervisor for the evening shift. Employee E4 reported, Resident CL1 was admitted and was pacing, going into residents' rooms, which made people nervous. I learned she was experiencing withdrawal symptoms and completed the initial assessment after reviewing documents. A 1:1 was recommended to ensure safety. Resident CL1 was fully continuous and left the facility without signing AMA documents. Resident CL1 left Against Medical Advice (AMA). I did not personally review the AMA documents with her.On October 6, 2025, at 10:50 a.m., an interview was conducted with the Director of Nursing (DON), Employee E2, who reported that when Resident CL1 arrived at the facility, she/he wanted to leave because she/he is a young person and, upon seeing the elderly population, stated, I do not belong here. DON, Employee E2 confirmed that the facility failed to inform Resident CL1 of her right to leave Against Medical Advice (AMA). DON, Employee E2 interviewed licensed nurse, Employee E3 and supervisor nurse, Employee E4, who were responsible for educating Resident CL1 about her AMA rights. DON Employee E2 reported that Licensed nurse, Employee E3 stated he was an agency nurse and relied on the supervisor to conduct the AMA education and have Resident CL1 sign the AMA documentation.On October 6, 2025, at 11:30 a.m., the Administrator, Employee E1, and the Director of Nursing confirmed that Resident CL1 was not informed of her right to leave Against Medical Advice (AMA) and did not receive the required education about AMA policy.28 Pa. Code 201.29 (a) Resident Rights

Based on clinical record reviews, interviews with staff, reviews of hospital records and policies and procedures, it was determined that the facility failed to provide the behavioral health care and services to meet the needs of one of sixteen residents reviewed to ensure that each resident attained or maintained the highest practicable physical, mental and psychosocial well-being. (Resident CL1) Findings include:A review of the facility policy titled behavioral mental health care substance use services dated March 19, 2025, revealed that it was the policy of the facility to provide an interdisciplinary approach to substance use disorder, trauma, withdrawal, anger or behavioral symptoms which lead to negative consequences for themselves or other residents. The policies said that the facility would have sufficient staff who have the skill sets to meet the behavioral needs of the residents who have a diagnosis of mental health disorder, substance abuse disorder, trauma, increased withdrawal, anger or behavioral symptoms which lead to negative consequences for themselves or other residents. The policy indicated that resident's demonstrating changes in behavior were to be evaluated to ensure that appropriate interventions both non-pharmacological and pharmacological measures were instituted timely.A review of the policy titled behaviors-continuous one to one supervision dated May 7, 2025, revealed that the whereabouts and well-being of residents was the responsibility of the nursing staff. Enhanced supervision or one to one supervision of each resident was also the responsibility of the nursing staff. A designated staff member would be assigned to be responsible for the one-to-one supervision of each resident. The policy indicated that the staff member assigned to one-to-one supervision of a resident shall be aware of the resident at all times and be within arm's length of the resident assigned. The policy said that the nursing staff member may be assigned to one-to-one close supervision of a resident. This would require the staff assigned to be aware of the resident, have eyes on the resident at all times and be at close distance to the resident at all times.Clinical record review revealed that Resident CL1 was admitted to the facility at 6:30 p.m., on September 26, 2025. The nursing admission assessment indicated that the resident was received from the hospital after being treated September 5 through September 26, 2025, for anoxic brain damage (the brain does not receive enough oxygen for an extended period of time usual causes poisoning from drug overdose). The assessment indicated that the resident was a smoker with a history of poly substance abuse methadone, heroin and cocaine. The nurse documented that the resident had adequate hearing, was alert and had adequate vision. The nurse documented that Resident CL1 was alert times 2 to 3 with confusion. The licensed practical nurse, Employee E3 indicated that the medication orders were confirmed with the physician.Hospital record review revealed that Resident CL1 had a history of polysubstance use disorder. The hospital indicated that Resident CL1 was to continue with buprenorphine-naloxone (suboxone) a medication used to manage opioid cravings and withdrawals. The physician ordered 8-2 mg. of suboxone one film under the tongue for seven days, twice a day, melatonin 5mg at bedtime and Narcan 4mg spray into nostril for opioid reversal may repeat every 2 to 3 minutes until medical assistance arrives.Clinical record review revealed that the licensed practical nurse confirmed medication orders upon admission for Resident CL1 as follows buprenorphine-naloxone (suboxone) 8-2 mg. twice a day, one film under the tongue for seven days, twice a day and Narcan 4mg spray into nostril for opioid reversal may repeat every 2 to 3 minutes until medical assistance arrives.Interview with the licensed practical nurse, Employee E3 at 1:00 p.m., on October 3, 2025, revealed that upon admission to the facility Resident CL1 was requesting and demanding suboxone medication. The licensed practical nurse said that the registered nurse on duty was notified that Resident CL1 needed the suboxone medication immediately. There was no evidence the licensed nurse, Employee E3 notified the physician of the residents request for the medication (suboxone). The licensed practical nurse indicated that Resident CL1 was crying in the hallway and stating that she wanted to leave the facility to get back to the streets. There was no documentation to indicate that the licensed practical nurse counselled and educated the resident about leaving the facility.Interview with the registered nurse, Employee E4, at 1:30 p.m., on October 3, 2025, revealed that the nurse assessed the resident upon admission and noted that Resident CL1 was pacing, anxious and exhibiting withdrawal symptoms. The registered nurse reported that the medication (suboxone) was supposed to be delivered STAT (immediately) to the facility. The registered nurse said that STAT means within an hour. The medication that was being requested was not delivered within an hour of the resident's admission to the facility. The registered, Employee E4 reported that Resident CL1 was placed on one-to-one observation upon admission to the facility.Interview with nursing assistant, Employee E5, at 2:30 p.m., on October 3, 2025, revealed that this nursing staff member was assigned to provide one-to one supervision for safety with Resident CL1 on September 26, 2025. The nursing assistant reported that the resident was anxious and running in the hallways banging on other resident 's bedroom doors on the third-floor nursing unit. Resident CL1 was banging on the hallway door trying to leave the building. The resident was hitting on the stair well door, it opened and alarmed at 8:30 p.m. on September 26, 2025. The resident walked down the stairwell steps. The nursing assistant said she followed Resident CL1 down the steps and out the entrance of the facility, which was located on the first floor. The nursing assistant said that she was trying to calm Resident CL1 by sitting with her on the bench outside. She was offering to get the resident a cigarette. The nursing assistant said she left the resident seated on the bench and began to walk back into the facility to get the security guard. The nursing assistant reported that she saw Resident CL1 run toward the parking lot. The nursing assistant said that she was not in the physical condition to run after Resident R1 in the darkness.Interview with the administrator, Employee E1, at 3:00 p.m., on October 3, 2025 revealed that the Philadelphia police department was notified and the registered nurse supervisor for the three to eleven shift filed a missing person (Resident R1) report with the police officer on September 26, 2025.Interview with the director of nursing at 10:30 a.m., on October 6, 2025, confirmed that the suboxone was not administered to Resident CL1 during her stay at the facility on September 26, 2025. The director of nursing said that the hospital usually discharges the resident with the suboxone medication that would be delivered to the facility, by the ambulance transferring staff. Further interview with the director of nursing revealed that the facility had no suboxone in the emergency supplies for use for Resident Cl1, despite a diagnosis of substance abuse disorder. 28 PA. Code 211.10(c)(d) Resident care policies28 PA. Code 211.12(d)(1) Nursing services

Based on the review of clinical records, job descriptions, facility policy, facility documentation, and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not investigate alleged violations or incidents related to a resident not being informed of and allowed to exercise their right to leave the facility Against Medical Advice (AMA) for one out of five residents reviewed (Resident CL1). Findings Include:Review of the facility policy titled Incident Reporting and Investigation of Accident Hazards, and Supervision, Assistive Devices, last revised October 2024, revealed the following:It is the policy of the Facility to monitor and evaluate any adverse occurrence that is not consistent with the routine operation of the Facility or the care of a resident(s). All accidents/incidents involving mistreatment, neglect, abuse, or injuries of unknown origin will be reported immediately to the Director of Nursing (DON) and Administrator (NHA) for further review and reporting based on State and Federal regulations.The policy further states under Data Collection:Complete the incident report:a. Collect information related to the facts and circumstances of the incident being investigated: Witness statements should include only factual information. Employees should be educated to include only firsthand information and not secondhand information in their statements. Witness statements must be completed at the facility; they should not be written from home or emailed to the facility. Witness statements should be reviewed by the Unit Manager, Supervisor, Assistant Director of Nursing (ADON), DON, or NHA prior to the employee leaving the facility to ensure the information is pertinent to the incident, includes applicable details, and is legible, signed, and dated.Review of Resident CL1's clinical progress notes indicated that the resident was admitted to the facility on [DATE], at approximately 6:30 p.m. with a diagnosis of anoxic brain damage. A progress note dated the same day at 7:19 p.m. stated, CL1 is Alert and Oriented to 1. person, 2. place and 3. Time (AAOX2-3) with confusion. CL1 is a high elopement risk, voicing concerns about leaving the facility and returning to the streets. CL1 was observed crying in the hallway and yelling, demanding to leave. The nursing supervisor and MD were made aware. New orders were received to place the patient on 1:1 rotation for further assessment.A review of the physician discharge completed on September 27, 2025, at 10:24 a.m. indicated CL1 was admitted for short rehab. Resident admitted but refuses to stay in the facility. Very aggressive behavior, she left AMA. Under condition upon discharge, it indicated CL1 stable/alert and oriented.On October 3, 2025, at 12:57 p.m. an telephone interview with the license nurse, Employee E3 who was assigned to CL1 reported that CL1 was alert and oriented and wanted to leave against medical advice (AMA), CL1 was screaming and yelling wanting to leave, I verbalized to my supervisor, Employee E4 further reported that CL1 disappeared at approximately 08:05 p.m. off the unit.On October 3, 2025, at 1:22 p.m., a telephone interview was conducted with the registered nurse, Employee E4, who was acting as the supervisor for the evening shift. E4 reported, CL1 was admitted and was pacing, going into residents' rooms, which made people nervous. I learned she was experiencing withdrawal symptoms and completed the initial assessment after reviewing documents. A 1:1 was recommended to ensure safety. CL1 was fully continuous and left the facility.On October 6, 2025, at 10:50 a.m., an interview was conducted with Nursing Aide (NA), Employee E5, who was assigned to provide 1:1 supervision for Resident CL1 from 7:00 p.m. to 8:00 p.m. on September 26, 2025. Employee E5 reported that she was informed she needed to supervise Resident CL1 on a 1:1 basis. According to NA, Employee E5, the 1:1 supervision appeared to frustrate Resident CL1, and her behaviors escalatedshe began banging on the entry door, pacing in the hallways, cursing, screaming, and yelling that she wanted to leave the facility.All facility doors were coded, so Resident CL1 was initially unable to exit. However, she then attempted to open a fire exit door. After pushing on it for approximately 15 seconds, the fire door opened, triggering the alarm. Resident CL1 proceeded down the stairs from the third floor to the first floor, with NA, Employee E5 following her. Both Resident CL1 and NA, Employee E5 exited the building onto the front porch, where NA, Employee E5 was able to temporarily calm Resident CL1 down.Resident CL1 repeatedly stated, I'm not staying here. I'm going to leave. [NA, Employee E5] asked [Resident CL1] to sit on a bench and wait while she contacted security at the front desk. Although [Resident CL1] was still within [NA, Employee E5's] line of sight, she got up and eloped from the area before security arrived.On October 6, 2025, at 11:30 a.m., the Administrator, Employee E1, and the Director of Nursing confirmed that Resident CL1 left the facility without authorization and was not given the opportunity to sign the required Against Medical Advice (AMA) documentation. Additionally, the facility failed to investigate the incident by not collecting statements from the staff involved. The incident was treated solely as an AMA discharge rather than as an elopement, despite the resident exiting the facility without formal discharge procedures.28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policy, staff interviews and review of clinical records, it was determined that the facility failed to ensure that weights, nutritional assessments, notifications to the physician of a significant weight loss were completed in a timely manner, and that nutritional interventions were implemented for 1 out of 2 residents reviewed (Resident R1). Findings include:Review of the facility policy, Weight and Height Assessment and Interventions, with a review date of May 2025 indicated that any weight changes of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with a licensed nurse confirming the reweigh. The policy stated that if the weight is verified, nursing will immediately notify the dietician in writing, and the attending physician/resident/resident representative will be notified of unplanned significant weight change .Continued review of the policy indicated that the dietician would respond within 72 hours or written notificationReview of the November 2025 physician orders included the following diagnosis: left wrist fracture; left ankle fracture; hypertension (high blood pressure), and unspecified protein-calorie malnutrition (protein calorie malnutrition happens an individual is not consuming enough protein and calories and can lead to muscle loss, fat loss, and can cause the body to not work as it usually would).Review of the resident's weight records indicated that that resident was weighed by nursing staff on September 3, 2025, the date of her admission into the facility and her weight was recorded as 110 pounds (lbs.) Continued review of the resident's weight records indicated that on October 4, 2005, the resident's weight was recorded as being 103.5 lbs. which indicated a 6% significant weight loss in 30 days. Review of the resident's clinical record revealed no documented evidence related to the significant weight loss from the dietician, and no documentation that the physician was made aware of the weight loss. Continued review of the resident's weight record did not show evidence that a re-weight was taken in a timely manner.During an interview with the Regional Dietician (Employee E3) on November 21, 2025, at 12:14 p.m., the resident's significant weight loss was confirmed by the Regional Dietician. During the above-referenced interview, the resident's clinical record was reviewed, and it was discussed with the Regional Dietician that there was no documentation in the clinical record that the weight loss was addressed and/or acknowledged by the dietician, and no indication that the physician was notified.Review of the resident's Comprehensive Nutritional Assessment, dated September 6, 2025, indicated that the resident weight was 110, and that she was at high malnutrition risk. September 6, 2025, above referenced nutritional assessment included adding two snacks a day as an intervention.Review of the residents person-centered plan of care dated September 4, 2025, indicated that the resident was at risk for alteration in nutrition/hydration. Interventions that included nutritional supplements, in addition to afternoon and evening snacks. Review of the resident's clinical record revealed no evidence that Resident R1 was provided with two snacks twice a day.During an interview with the Director of Nursing (DON) on November 21, 2025, it was confirmed by the DON that there was no documentation that could be produced to show evidence that the resident received two snacks twice a day.28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. Resident R1 was unable to be located for over six hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)Findings Include:Review of facility policy, titled, Prevention and Management of Accident, Hazards Adequate Supervision, and Assistive Devices with a revision date of July 24, 2025, revealed, the facility will ensure that the resident environment remains as free of accident hazards as is possible, and that the residents will receive adequate supervision and assistive devices to prevent hazards. Continued review of the policy revealed, iii. Wandering/Elopement Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge or supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Facility policies define the mechanisms and procedures for assessing and identifying, monitoring and managing residents at risk for elopement to minimize the risk of a resident leaving a safe area without the facility's awareness and/or appropriate supervision. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with the following diagnoses; Unspecified Dementia (cognitive decline is evident, but the specific type of dementia cannot be determined), Adjustment Disorder with Depressed Mood (symptoms of depression or loss of interest, that arise in response to a specific stressful event), Depression (feelings of overwhelming sadness), Hyperlipidemia (elevated levels of lipids (fats and fat-like substances) in the blood, including cholesterol and triglycerides), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). Review of Resident R1's Elopement Risk Evaluation completed on admission dated July 24, 2025, revealed the resident was ambulatory, with a history of elopement and exit seeking. The resident utilizes an electronic monitoring device, care plan for risk for elopement and place on secured unit. Review of Resident R1's admission MDS (Minimum Data Set- periodic assessment of resident's care needs) was not completed until July 28, 2025, and it revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 indicates severe cognitive impairment. Review of Resident R1's admission progress notes completed by the physician on July 25, 2025 revealed, .had some agitation at the hospital [he/she] wanders. Also noted in his progress notes, Psychiatry- no anxiety noted. Resident R1 has a history of wandering. Review of facility investigation provided by the facility revealed a timeline dated July 26, 2025. The following is the summary of the timeline:At 6:00 p.m. The resident was standing behind the unit door on or around 6:00 p.m. A staff member from housekeeping opened the door and the resident came out. The staff member asked the resident where [he/she] was going, and the resident responded outside. The staff member tried talking to the resident, but the resident headed straight to the elevator. The staff and resident rode down on the elevator together. As per housekeeping staff, the resident was unsure of where to exit the building, and security showed [him/her] the front door. As per security, he was unsure of the time this occurred but stated it was still light outside.At 7:45 p.m. staff noticed resident was missing at or around 7:45 p.m.At 8:00 p.m. a full search of the unit was performed, and the supervisor was notified around 8:00 p.m. The supervisor and facility staff conducted a full house check and check of the outside the perimeter of the facility for the resident. The Physician, Director of Nursing, and Responsible Party were notified at 8:45 p.m. A call was placed to the police, university security notified, and the elopement protocol initiated. 9:00 p.m.- 11:20 p.m. Continued perimeter and expanded perimeter search. Vicinity patrol over three local streets.July 27, 2025- 12:00 a.m. Approximately 12:00 a.m. phone call was placed to Resident R1's daughter to find out where resident would possibly go. Resident's last known address checked- no one was home. Daughter also provided alternative address.1:22 a.m. Resident was found at the alternative location at 1:22 a.m. The police were called several times while a staff member kept Resident R1 in sight until the police arrived to provide to transport the resident back to the facility at 2:00 a.m.2:00 a.m. Upon arrival to the facility the Director of Nursing received the resident, the resident was assessed no injury. Resident R1 was confused and unable to give an account of where [he/she] went. Resident was placed on one to one and labs were drawn. Interview held with the Regional Nurse, Employee E3 on August 7, 2025, at 10:00 a.m. revealed the incident that occurred with Resident R1 was an accident. The housekeeping staff openly admitted it in their statement that they let the resident go off of the unit onto the elevator. We tried to call the security staff twice and he did not return our phone calls. When asked if the resident was wearing a wander guard at the time of elopement Employee E3 stated, no. Review of facility investigation file revealed a statement from housekeeping staff Employee E18, indicating, I went on the fifth floor to look for a coworker and as I was leaving the floor the resident was standing by the door. I initially thought Resident R1 was a visitor but once Resident R1 left the floor and got on the elevator, I asked [him/her] did [he/she] stay here [he/she] said yes and that [he/she] was trying to get outside. I got off on the sixth floor to continue to look for my coworker after looking for him I got back on the elevator and Resident R1 was still on. Once we got on the first floor the Resident R1 started going in a different direction than outside. That's when the front desk security guard directed Resident R1 in the right director to get outside. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was assessed an elopement risk on July 24, 2025. The resident went missing on July 26, 2025, and was not returned to the facility until six hours later in the early morning hours of July 27, 2025. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Regional Nurse on August 8, 2025 at 11:50 a.m. The facility provided a Plan of Correction on August 7, 2025, for submission and it was approved at 2:31 p.m. The plan of correction was as follows: July 26, 2025, a unit search was done, and the resident was not located July 26, 2025, the police were notified. July 26, 2025, the resident's daughter was notified and asked about familiar places the resident would go to. July 26, 2025, the resident was located at the address given by then family. July 26, 2025, a skin assessment was completed on the resident. No new skin alterations or signs of physical injury were noted. July 26, 2025, the resident was placed on one to one supervision and laboratory tests were ordered by the physician. July 26, 2025, elopement reassessments were completed for all residents and care plans were reviewed and updated if necessary. July 27, 2025, elopement books were reviewed and updated. All staff were educated on elopement prevention and not allowing residents off the unit when entering/exiting units as well as communicating with a supervisor if a resident is exhibiting exit seeking behaviors. A whole house education started on July 26, 2025, and was completed on July 28, 2025. Any new staff as well as new agency staff will receive elopement education prior to starting a shift. The security desk was moved by the elevators so that security will be able to verify residents that are allowed to leave the unit and have the resident sign out on the logbook. Security staff were educated on verification of residents leaving and returning to the facility by signing out and back in on the resident logbook on July 27, 2025. A resident council meeting was held on July 28, 2025, to re-educate residents on signing out and in procedures when leaving and returning to the units. Random observation audits will be done on units daily to observe staff entering and leaving units to ensure residents remain secure on the unit. Audits will be done daily for two weeks then weekly for four weeks, then monthly for two months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed. A QAPI (Quality Assurance Performance Improvement) meeting was held on July 28, 2025, and the facility reviewed the elopement plan of correction related to the elopement that occurred on July 26, 2025. The Medical Director was in attendance as well as the Regional Nurse and the Regional Director of Operations. Elopement drills were completed on July 28, 2025, and August 1, 2025, with good response by the staff. Drills will be done monthly for three months the quarterly. Drills will be reviewed at QAPI (Quality Assurance Performance Improvement). On August 7, 2025, the implementation of the action plan was verified. Twelve facility staff were interviewed from various units, and departments. Facility staff were able to answer how you know if a resident is at risk for elopement, what you would do if an elderly person looked confused about where they were going while here, and what the code is for when someone has eloped from the facility. The new security desk set up was visualized in the main lobby and new signage was visualized on the locked doors of the nursing units. Review was made of documents including staff educations, elopement assessments, and elopement audits. Following the verification of the completion of the immediate action plan the Immediate Jeopardy was lifted on August 7, 2025, at 2:31 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services28 Pa. Code 211.12(d)(2) Nursing services

Based on the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility. This failure resulted in an Immediate Jeopardy situation for Resident R1 who was missing from the facility overnight for approximately six hours. (Resident R1) Findings Include: Review of the job description for the Nursing Home Administrator (NHA) with a revision date of June 15, 2023 states, Position Summary-this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state and local regulations. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Further review of the NHA job description revealed, Essential Duties and Responsibilities-. Develop, maintain and implement operational policies and procedures to meet residents' need in compliance with federal, state and local requirements. Determine the personnel requirements of the facility in collaboration with Department Managers and hire or arrange for sufficient staff to provide for sound resident care and implement the facility policies and procedures. Review of the job description for the Director of Nursing (DON) with a revision date on October 10, 2023 states, Position Summary- The Director of Nursing functions as the administrative authority for the Department of Nursing. This Director will be responsible for the organization and oversight of all nursing operations and for the supervision of care for all residents at the facility. Further review of the DON job essential requirements revealed, Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care. Review of facility policy abuse Abuse Policy- Prevention and Management last revised April 14, 2022 states, Policy-the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Further review of the policy revealed, .Neglect-Failure of the Facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of Unspecified Dementia (cognitive decline is evident, but the specific type of dementia cannot be determined), Adjustment Disorder with Depressed Mood (symptoms of depression or loss of interest, that arise in response to a specific stressful event), Depression (feelings of overwhelming sadness), Hyperlipidemia (elevated levels of lipids (fats and fat-like substances) in the blood, including cholesterol and triglycerides), and Hypertension (condition where the force of blood pushing against the artery walls is consistently too high). Review of Resident R1's Elopement Risk Evaluation completed upon admission dated July 24, 2025, revealed the resident was ambulatory, with a history of elopement and exit seeking. The resident utilizes an electronic monitoring device, care plan for risk for elopement and place on secured unit. Review of Resident R1's admission MDS (Minimum Data Set- periodic assessment of resident's care needs) completed on July 28, 2025, revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 indicates severe cognitive impairment. Review of facility investigation dated July 26, 2025, revealed the following timeline: At 6:00 p.m. The resident was standing behind the unit door on or around 6:00 p.m. A staff member from housekeeping opened the door and the resident came out. The staff member asked the resident where he was going, and the resident responded outside. Staff member tried talking to the resident, but the resident headed straight to the elevator. Staff and resident rode down on the elevator together. As per housekeeping, the resident was unsure of where to exit the building, and security showed him the front door. As per security, he was unsure of the time this occurred but stated it was still light outside. At 7:45 p.m. staff noticed resident was missing at or around 7:45 p.m. the resident was brought back to the facility on July 27, 2025, at 2:00 a.m. Interview with the Regional Nurse, Employee E3 on August 7, 2025, at 10:00 a.m. revealed the incident that occurred with Resident R1 was an accident. The housekeeping staff openly admitted it their statement that they let the resident go off of the unit onto the elevator. We tried to call the security staff twice and he did not return our phone calls'. When asked if the resident was wearing a wander guard at the time of elopement Employee E3 stated, no. The Regional Nurse confirmed the facility did not ensure the safety of one resident. (Resident R1) Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position contributing to the Immediate Jeopardy situation for Resident R1. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility records, interviews with resident and staff, it was determined that the facility failed to ensure comfortable and safe temperature levels. Facilities failed to maintain a temperature range of 71 to 81 F for four of four resident rooms. (301, 302, 311, 328) Findings Include: Interview with Resident R169 on January 28, 2025, at 11:00 a.m. with Maintenance Director, Employee E9 stated the room temperature was too high, and she was suffocating in the room. She stated she had COPD and would like the room temperature at 72-degree Fahrenheit. Interview with Resident R134 on January 28, 2025, at 11:35 a.m. it was too hot for her, and she needed fan to make her comfortable. Resident stated it's been a month since the facility had the temperature issue. Interview with Resident R151 on January 28, 2025, at 11:34 a.m. stated it was very hot in the facility. He stated it was very hard for him to sleep at night due to the heat. Interview with Resident R169 on January 28, 2025, at 11:39 a.m. stated it was always hot in the facility. She showed the heater and there was a towel placed over the vent to prevent heat from getting in the room. Interview with Resident R14 on January 28, 2025, at 11:54 a.m. stated it was too hot in the facility. Interview with Resident R156 on January 28, 2025, at 11:57 a.m. stated it was too hot in the facility. Resident R156's family member stated its always hot in the facility whenever he visited. Interview with Resident R108 on January 28, 2025, at 12:30 p.m. stated it was always hot in the facility and she would like to be little cooler. Temperature check of resident rooms with the maintenance director using facility thermometer was performed on January 28, 2025, at 11:11 a.m. the following temperatures were recorded, 302-82.8-degree Fahrenheit. 301 82.2-degree Fahrenheit. 311 83.3-degree Fahrenheit. 328-83 -degree Fahrenheit. A follow up room temperature was performed at 12:44 p.m. which revealed the following; 301-84-degree Fahrenheit. 311-82.9-degree Fahrenheit. Interview with the Maintenance Director, Employee E9 on January 28, 2025, at 1:00 p.m. confirmed that the temperatures recorded above 81 degrees Fahreheit 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for three of four residents reviewed for psychotropic medications (Residents R142, R139 and R158). Findings include: Review of Resident R142's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 14, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cerebrovascular accident (damage to the brain from interruption of its blood supply), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things) and psychotic disorder (loss of contact with reality). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of three, which indicated that the resident was severely cognitively impaired. Review of progress notes for Resident R142 revealed a nurses note, dated December 23, 2024, at 4:47 p.m. which indicated that the resident had an appointment with neurology (branch of medicine that specializes in disorders of the brain, spinal cord and nerves) and returned with a new order for risperidone (antipsychotic medication used to treat mood disorders) 1 m.g (milligram) twice per day. Review of Resident R142's neurology consultant note, dated December 23, 2024, revealed that the consultant recommended for the resident to receive risperidone 1 m.g twice per day. Review of Medication Administration Records (MARs) for Resident R142 revealed that the resident received risperidone on December 24, 25, and 26, 2024, for a total of four doses. Continued review of progress notes for Resident R142 revealed a nurses note, dated December 26, 2024, at 3:03 p.m. which indicated that the resident was seen by psychiatry (mental health) and discontinued the risperidone. Review of Resident R142's psychiatry note, dated December 26, 2024, noted that the resident was started on risperidone by neurology. The psychiatrist recommended to discontinue the risperidone because the resident was already on aripiprazole (antipsychotic medication) and that the resident should not be on two antipsychotic medications. The risperidone was subsequently discontinued on December 26, 2024. Further review of Resident R142's progress notes revealed no indication that the resident or her responsible party were notified of the medication recommendation, that the risks and benefits were explained or that the resident was offered alternative treatment options. Review of Resident R139's Annual MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including severe depression with psychotic symptoms (a mental disorder characterized low mood and disconnection from reality). Continued review revealed that the resident had a BIMS score of 9, which indicated that the resident was moderately cognitively impaired. Review of Resident R139's progress notes revealed a nurses note, dated September 5, 2024, at 9:47 a.m. which indicated that the resident was seen by psychiatry and recommended to discontinue risperidone and start aripiprazole solution. Review of Resident R139's psychiatry note, dated September 4, 2024, revealed that the resident had paranoid delusions (false beliefs in something that is untrue) and auditory hallucinations (hearing things that are not there). The psychiatrist noted to add paranoid schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations) to the resident's diagnosis list, discontinue risperidone and start aripiprazole solution added to orange juice or apple sauce. Review of MARs for Resident R139 revealed that the resident was started on aripiprazole on September 6, 2024, and that the medication was discontinued on September 27, 2024. Continued review revealed that the resident received a total of 10 doses and refused the medication for a total of 12 doses. Continued review of Resident R139's progress notes revealed a nurses note, dated September 27, 2024, at 2:02 p.m. which indicated that the resident was seen by psychiatry and recommended to discontinue aripiprazole due to patient refusal. Review of Resident R139's psychiatry note, dated September 25, 2034, revealed that the psychiatrist recommended to discontinue aripiprazole due to patient refusal. Further review of Resident R139's progress notes revealed no indication that the resident or her responsible party were notified of the medication recommendation, that the risks and benefits were explained or that the resident was offered alternative treatment options. Review of Resident R158's Admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including non-traumatic brain dysfunction, delirium (confusion) and encephalopathy (brain damage). Continued review revealed that the resident had a BIMS score of 6, which indicated that the resident was severely cognitively impaired. Review of medication administration records revealed physician's orders for olanzapine (antipsychotic medication used to treat certain mental health disorders, such as schizophrenia [loss of reality with delusions and hallucinations] and bipolar [severe high and low mood changes]) 7.5 m.g (milligrams) once per day at bedtime for delirium. The medication was administered November 15, 2024, through January 8, 2025. Review of Resident R158's progress notes revealed a nurses note, dated January 8, 2025, which indicated that the resident was seen by psychiatry, recommended to discontinue olanzapine and start Depakote 125 m.g every 12 hours (medication used to treat seizures and certain mental health disorders such as bipolar). Review of Resident R158's psychiatry note, dated January 8, 2025, revealed that the psychiatrist recommended to discontinue olanzapine and start Depakote. Continued review of the consultation note revealed that there was no documented clinical indication or rationale for why the consultant recommended the medication change. Continued review of medication administration records revealed that Resident R158 began receiving Depakote on January 9, 2025, as recommended by the psychiatry consultant. Further review of Resident R158's progress notes revealed no indication that the resident or her responsible party were notified of the medication recommendation, that the risks and benefits were explained or that the resident was offered alternative treatment options. Interview on January 30, 2025, at 1:21 p.m. Employee E4, Assistant Director of Nursing (ADON) confirmed that there was no documentation available for review at the time of the survey to indicate that Residents R142, R139 and R158 or their responsible parties were informed of their psychotropic medication changes, that the risks and benefits were explained or that they were offered alternative treatment options. 28 Pa Code 201.29(a) Resident rights 28 Pa code 211.2(d)(6) Medical Director

Based on the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a resident/resident representative grievance was promptly documented and resolved for one of 32 resident records reviewed. (Resident R110) Findings Include: Review of facility policy Grievance/Concern Form; Grievance/Concern Log revised October 28, 2021 revealed Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form or completing a review on the customer service kiosk when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. Any resident, his/her representative, family member or advocate may file a Grievance/Concern. Form or complete a review on the Customer service kiosk regarding treatment, facility services, Medical care, behavior of other residents or staff members, theft of property, missing items, Discrimination, etc. without fear of threat or reprisal in any form. Upon request, the facility will provide a copy of the grievance policy to the resident or resident/Representative. The facility will practice immediate reporting standards as required by state law of all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider. The resident and/or Resident Representative or person who presented the grievance will be Informed of the findings of the investigation and the actions that will be taken to resolve the issue or problem orally in person or phone and or in writing if requested. Interview with Resident R110 on January 28, 2025, at 11:42 a.m. stated a week ago a man came into my room and opened his pants and started masturbating right next to my bed. Resident stated she got terrified and screamed. Resident stated that was the man living across from her room. Resident pointed out Resident R34's room. Resident stated she reported this to a staff and completed a grievance form which was given by the staff. Resident stated she did not hear or see anything from the staff about the grievance or did not receive a copy of the grievance Resident stated she felt like she was harassed and would like to press charges against the resident. Review of facility investigation for Resident R110 dated January 24, 2025, revealed that the resident reported to the staff that another resident was showing his private parts in her room. Resident reported the incident to the staff. Staff provided a grievance form for the resident to fill out. Further review of the facility investigation revealed no evidence that the facility staff followed up with the resident or no information was available grievance. A copy of the grievance was requested to the Director of Nursing on January 29 and January 30, 2024. Interview with the Director of Nursing on January 31, 2025, at 11:00 a.m. stated there was no grievance available from the resident which the resident stated she filed on January 24, 2025. Interview with Social Worker on January 31, 2025, at 11:30 a.m. confirmed that the resident filed the grievance, gave it to the staff but the facility was unable to locate the grievance. Facility also did not know the content of the grievance filed by the resident on January 24, 2025. 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged sexual abuse to the State Agency and the Administrator as required for one of 32 residents reviewed (Resident R110). Findings include: Review of facility policy titled Abuse Investigation and Reporting dated September 8, 2022, indicated that The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. The Administrator, Director of Nursing, and Risk Manager, if applicable are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation/exploitation of policy standards and procedures: -Implementation -On-going monitoring -Reporting -Investigation -Tracking and trending When a facility has identified abuse, the facility must take all appropriate steps to remediate the Noncompliance and protect residents from additional abuse immediately. Facilities that take immediate Action to correct any issues can reduce the risk of further harm continuing or occurring to other Sexual abuse includes, but is not limited to: o Unwanted intimate touching of any kind especially of breasts or perineal area; o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; o Forced observation of masturbation and/or pornography; and o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g., posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Residents, The Facility will report abuse, neglect, misappropriation, and/or exploitation incidents timely and within The Federal/State requirements. o Notify the Shift Supervisor/Charge Nurse/Manager immediately if an allegation or suspected abuse, Neglect, mistreatment, misappropriation of property occurs, or injury of unknown source. This responsible Manager will then notify the Administer and Director of nursing immediately. o Report the incident to the Administrator, Director of Nursing, and the Risk Manager, if applicable. The Administrator and Director of Nursing or designee will report to the Regional Clinical Manager and RDO and immediately assist with the direct of the investigation. o Notify the designated State agency(s) within 2 hours after identification of the alleged/suspected abuse, neglect and/or misappropriation incident by electronic reporting system/fax/ and or telephone based on Agency specific requirement for reporting. Initiate process according to the Federal/State regulations for abuse investigation and reporting and the Elder Justice Act for any incidents involving suspicion of a Crime. Review of Resident R110's Minimum Data Set (MDS- assessment of resident care needs) dated January 1, 2025 identified the resident with a BIMS (Brief Interview of Mental Status) score of 15 out of 15 which place the resident as cognitively intact. Review of Resident R34's Minimum Data Set (MDS- assessment of resident care needs) dated December 7, 2024 identified the resident with a BIMS (Brief Interview of Mental Status) score of 15 out of 15 which place the resident as cognitively intact. Review of MDS dated [DATE] revealed that the resident had a BIMS score of 11 which indicated that the resident's cognitive status was moderately impaired. Interview with Resident R110 on January 28, 2025, at 11:42 a.m. stated a week ago a man came into my room and opened his pants and started masturbating right next to my bed. Resident stated she got terrified and screamed. Resident stated that was the man living across from her room. Resident pointed out Resident R34's room. Resident stated she reported this to a staff and completed a grievance form which was given by the staff. Resident stated she did not hear or see anything from the staff about the grievance or did not receive a copy of the grievance Resident stated she felt like she was harassed and would like to press charges against the resident. Review of clinical record for Resident R34 dated January 24, 2025, which was entered late on January 26, 2024 revealed that This nurse was made aware from the Nurse Aide that resident was displaying sexual behaviors to himself in front of the other resident. The other resident was interviewed and explained that he entered her room while she was sleeping and stood at the edge of her bed and began to pleasure himself. Review of facility investigation for Resident R110 dated January 24, 2025, revealed that the resident reported to the staff that another resident was showing his private parts in her room and was masturbating. Resident reported the incident to the staff. Staff provided a grievance form for the resident to fill out. Interview with the Director of Nursing on January 31, 2025, at 11:00 a.m. stated that their staff did report that Resident R34 was in Resident R110's room however she was not aware of the details such as showing private parts or masturbating. Director of Nursing confirmed that the Administrator was not notified of the incident immediately as required. Director of Nursing also confirmed that the facility did not report the incident to state survey Agency as required, she stated after the allegation was reported by the surveyor the facility did report the allegation to appropriate agencies as required. 28 Pa Code 201.14. (c) Responsibility of licensee. 28 Pa. Code 211.12(d) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that psychotropic medication changes met professional standards of practice for one of four residents reviewed for psychotropic medications (Resident R158). Findings include: Review of Resident R158's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including non-traumatic brain dysfunction, delirium (confusion) and encephalopathy (brain damage). Review of medication administration records revealed physician's orders for olanzapine (antipsychotic medication used to treat certain mental health disorders, such as schizophrenia [loss of reality with delusions and hallucinations] and bipolar [severe high and low mood changes]) 7.5 m.g (milligrams) once per day at bedtime for delirium. The medication was administered November 15, 2024, through January 8, 2025. Clinical record review for Resident R158 revealed a psychiatric (mental health) evaluation, dated January 8, 2025. The evaluation noted that the resident was confused, not oriented and had poor memory with impaired judgment and insight. The consultant noted that the resident had a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with behavioral disturbances and impulse control disorder. The consultant recommended to discontinue olanzapine and start Depakote (medication used to treat seizures and certain mental health disorders such as bipolar) 125 m.g every 12 hours. Further review of the consultation note revealed that there was no documented clinical indication or rationale for why the consultant recommended the medication change. Review of progress notes for Resident R158 revealed that there were no documented changes in behavior for the resident prior to evaluation by psychiatry on January 8, 2025. Continued review of medication administration records revealed that Resident R158 began receiving Depakote on January 9, 2025, as recommended by the psychiatry consultant. The medication records indicated that the resident needed the medication for cognitive communication deficit. Interview on January 30, 2025, at 1:21 p.m. Employee E4, Assistant Director of Nursing (ADON) confirmed that there was no documented rationale or clinical indication for why the psychiatry consultant recommended Resident R158's psychotropic medications. 28 Pa code 211.2(d)(3) Medical Director

Based on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R151). Findings include: Review of Resident R151's clinical record revealed that the resident was readmitted to the facility on [DATE]. Clinical record review for Resident R151 revealed a wound consultant report, dated January 22, 2025. The report indicated that the resident had a left shin wound with arterial etiology and a right distal shin wound with arterial etiology both wound was documented as full thickness wound. that was present on his readmission to the facility. The wound consultant recommended that the left shin wound be cleansed with 0.125% Dakin's solution (used to prevent and treat wound infections), treated with betadine (antimicrobial wound treatment) and leave it open to air. Further review of the wound consultant report recommended that the right distal shin wound be cleansed with wound cleanser, apply medical grade honey and cover with boarder gauze. Clinical record review for Resident R151 revealed a wound consultant report, dated January 29, 2025. The wound consultant recommended that the left shin wound be cleansed with 0.125% Dakin's, apply with betadine (antimicrobial wound treatment) as primary treatment and leave it open to air. Further review of the wound consultant report recommended that the right distal shin wound be cleansed with wound cleanser, apply medical grade honey and cover with boarder gauze. Review of clinical record for Resident R151 revealed no documented evidence that the wound care physician report was communicated to the attending physician. There was no documented evidence that the physician approved or disapproved the recommendation. Review of active physician's orders for Resident R151 revealed an order, dated January 9, 2025, to cleanse bilateral shin wound with Dakin's solution and apply betadine and leave it open to air. There was no evidence that the right shin wound treatment recommended by the wound care practitioner was followed or the resident received the recommended treatment. Review of Medication Administration Record for Resident R151 for the month of January 2025 revealed that the resident received the same treatment to right and left shin from January 10, 2025. The wound care practitioner recommendation for January 22, 2025, and January 29, 2025 was not followed by the staff. Interview on January 30, 2025, at 1:00 p.m. Employee E2, Director of Nursing (ADON) confirmed that Resident R151 wound care was consistent with the wound consultant's recommendations. 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on observations of care and services, clinical record review, interviews with staff and residents and reviews of facility policies, it was determined that facility failed to ensure that each resident received proper treatment and assistive devices to maintain vision for one of two residents reviewed for communication needs. (Resident R138) Findings include: Review of the facility policy titled Clinical Manual, dated March 5, 2024 revealed that it was the responsiblility of the facility to make arrangements for each resident for needed vision services. The facility was also responsible to notify the resident's responsible party about the vision care and services that were needed. The policy also said that if the resident was in need of a vision consult that it would arrange for the consultation in a timely manner. Clinical record review for Resident R138 revealed a quarterly assessment dated [DATE] that indicated this resident's preferred language was Creole. The assessment also indicated that this resident needs an interpreter to communicate with the doctor or health care staff. The assessment indicated that Resident R138 had difficulty communication his needs. Observations of Resident R138 with Employee E17 at 9:30 a.m., on Janaury 29, 2025 revealed that the activities staff member provided Resident R138 with a news letter written in Creole on a weekly basis. The activities staff member confirmed she did not know if Resident R138 read the newspaper because she did not speak Creole and cannot ask the resident. Observations of the interactions with the Licensed nurse, Employee E15, who was also the interpreter for Resident R138 at 10:00 a.m., on January 31, 2025 revealed that Resident R138 was reporting that he cannot see to read the newspaper that the activities staff member was giving to him. The licensed nurse, Employee E15 reported that Resident R138 was able to read Creole and if he had glasses he could read and enjoy the newspaper. The licensed nurse reported that Resident R138 was not confused and that he has a language barrier with staff because he reads speaks and understands Creole.Llicensed nurse, Employee E15 reported that he does need an interpretor to facilitate his understanding with a doctor or healthcare staff member. Observations at 10:00 a.m., on January 31, 2025 with Licensed nurse, Employee E15 revealed that Resident R15 has a small printed picture board that he could not read; because his vision was impaired he seeing only large print not regular print in newspapers. Interview with Resident R138 at 10:15 a.m., on January 31, 2025 confirmed that the resident needs corrective lenses. The interpreter, Employee E15 reported that the resident was not sure if he had the money to pay for corrective lenses. Clinical record review for Resident R138 revealed an eye examination dated July 24, 2024 that indicated that the physician had requested the vision examination for the resident's impaired vision. The specialist examining the resident said that the resident would not confirm yes or no answers during the examination. The vision specialist determined that the resident had vision impairment on July 24, 2024. 28 PA Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R271). Findings include: Review of Resident R271's Entry MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 25, 2025, revealed that the resident was readmitted to the facility on [DATE]. Clinical record review for Resident R271 revealed a wound consultant report, dated January 27, 2025. The report indicated that the resident had a sacral pressure ulcer that was present on his readmission to the facility. The wound consultant recommended that the wound be cleansed with 0.125% Dakin's solution (used to prevent and treat wound infections), treated with medical grade honey (antimicrobial wound treatment) and calcium alginate (absorbent wound dressing that promotes healing), then covered with a bordered foam dressing. Review of progress notes for Resident R271 revealed a wound consultant note, dated January 27, 2025, at 2:39 p.m. which indicated that the resident had new treatments listed in his wound plan and to reference the recommended orders for updated treatments. Continued review of progress notes for Resident R271 revealed an attending physician note, dated January 27, 2025, at 11:17 p.m. which indicated to provide wound care to the resident's sacrum as reported. Review of physician's orders for Resident R271 revealed an order, dated January 27, 2025, to cleanse sacral ulcer with Dakin's 0.125% daily, apply skin prep to wound perimeter, follow by medihoney and cover with border foam. Continued review of physician's orders for Resident R271 revealed another order, dated January 27, 2025, to clean the sacrum with Dakin's 0.125%, apply medihoney and cover with bordered gauze daily. Observation on January 29, 2025, at 11:31 a.m. revealed Employee E10, licensed nurse, perform wound care to Resident R271's sacrum. Employee E10, licensed nurse, removed the old dressing, cleansed the wound with Dakin's solution, applied medihoney and applied a clean bordered foam dressing. Interview on January 30, 2025, at 1:21 p.m. Employee E4, Assistant Director of Nursing (ADON) confirmed that Resident R271 had two active wound care orders for his sacrum that specified different treatments and confirmed that neither order was consistent with the wound consultant's recommendations. Employee E4, ADON, confirmed that the facility follows recommendations made by the wound consultant unless the attending physician specifies an alternative treatment. Employee E4, ADON, stated that she would need to clarify the treatment orders for Resident R271's sacral wound. 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed conduct smoking assessment to ensure the safety of a resident who smokes for one of 32 residents reviewed. (Resident R14) Findings include: Review of facility documentation revealed that the Resident R14 was a smoker, and the resident was included in the smoking list provided by the facility. Resident was added to smoking list with smoking privileges. Review of facility investigation for Resident R14 dated January 10, 2025, revealed that During this shift resident was observed on the floor sitting upright on his buttocks in front of the bathroom without his back brace or wheelchair in place. Resident was asked why he was on the floor at which the resident stated, I fell on the way back from the bathroom. Resident was then asked why he did not call for assistance to go to the bathroom at which he got out of bed to secretly smoked in the bathroom. Review of clinical records for Resident R14 did not reveal any evidence that facility conducted an evaluation to determine the ability of the resident to smoke safely with or without supervision at the time when resident admitted smoking in the room. Review of smoking assessment completed part of admission assessment dated [DATE] which was the only smoking assessment revealed that the resident was a non-smoker and no smoking care plan was created. Interview with the Activities Director, Employee E17 on January 31, 2025, at 1.00 p.m., confirmed that Resident R14 was a smoker, and he had the smoking privilege. She stated he smoked when he was first admitted , and the facility had his smoking supplies. Employee E17 also confirmed that the resident smoked in his room, and he was educated not to smoke in his room. Interview with the Director of Nursing, Employee E2 on January 31, 2025, at 12.30 p.m., confirmed that the facility should conduct a smoking safety assessment for all resident who wishes to smoke and should develop and smoking safety care plan with interventions. Employee E2 also confirmed that there was no smoking safety assessment available for Resident R14. 28 Pa Code 201.14(a) responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from abuse, which resulted in actual harm to Resident R2 who was pushed by a nursing staff, fell to the floor and sustained an acute fracture of the distal radial metaphysis for one of eight residents reviewed. (Resident R2) Findings include: Review of facility policy, 'Abuse policy- Prevention and Management', dated September 8, 2022, reviewed on august 2024, revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion . Continued review revealed, abuse was defined as the willful infliction of injury. Examples of injuries that could indicate abuse include, but are not limited to injuries that are non-accidental or unexplained; fractures, sprains, or dislocations. Further review of the Abuse Policy indicated; When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. The facility is responsible to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behavior. All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population. Facility cannot disown the acts of staff since the facility relies on them to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. Striking a combative resident is not an appropriate response in any situation. Not acceptable for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Retaliation by staff is abuse, regardless of whether harm was intended, and must be reported. Review of Resident R2's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 6, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age),Thyroid Disorder (Thyroid disease is a general term for a medical condition that keeps your thyroid from making the right amount of hormones), Diabetes Mellitus (DM) (Diabetes Mellitus is a disease of inadequate control of blood levels of glucose), and Cirrhosis (Cirrhosis is severe scarring of the liver). Further review revealed that the Resident R2 had a Summary Score of 6 in Brief Interview for Mental Status (BIMS). (The patient can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Review of Resident R2's care plan, dated May 2, 2024, revealed that the resident was at risk for falls; was dependent on activities or staff to remind, invite, escort him to a variety of programs that meet his emotional, intellectual, physical, social needs; had non-compliant behaviors, potential to be physically aggressive behavior related to anger; and had impaired thought processes due to Dementia. Interventions included for staff to maintain a safe environment free of clutter and wet floors; ensure adequate lighting; when Resident R2 becomes agitated, intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of facility documentation submitted to the Department of Health on August 17, 2024, revealed that on August 17, 2024, at 1:42 p.m., Resident R2 was in the 5th floor dining room. At that time, Employee E3, Director of Rehab, was walking into the 5th floor dining area. Employee E3 saw, Resident R2 yelling and cursing and walking towards a staff member, Nurse aide, Employee E4. The Nurse aide, Employee E4, approached Resident R2; then Resident R2 grabbed onto Nurse aide, Employee E4's hands. Director of Rehab, Employee E3, observed that the Nurse aide Employee E4 was pushing Resident R2 to get him off her. When Nurse aide, Employee E4 pushed Resident R2, the resident landed against the wall and then slid to the floor. Director of Rehab, Employee E3 immediately went to the Resident R2 to assist him. Resident R2 wanted to get up on his own, so Director of Rehab, Employee E3 stood by Resident R2 until he got up and then assisted him to his room. Director of Rehab, Employee E3 called the Nursing Supervisor, Registered Nurse, Employee E6, to explain what had occurred. The Nursing Supervisor, Employee E6, came to the unit and assessed Resident R2. The resident was noted to have two abrasions on his back and swelling was noted to his left wrist. The physician was called, and orders were received. The supervisor requested a statement from the nurse aide, Employee E4, and sent her home. Supervisor contacted the Nursing Home Administrator (NHA) to inform her of what occurred. Resident R2 received Tylenol for pain and orders to cleanse the abrasions to his back with normal saline and leave open to air. X-rays were ordered to the left hand and wrist as well as ice pack to be applied every 15 minutes for swelling. X-ray results were received and indicated a fracture of the left distal radial metaphysis (wrist). Review of facility investigation related to the incident revealed a written statement from Employee E3, Director of Rehab, dated August 17, 2024, which stated that he was in the fifth-floor dining room, where Resident R2 was observed yelling and cursing. Nurse Aide, Employee E4, approached Resident R2, when Resident R2 grabbed on to the Nurse aide, Employee E4. The Nurse Aide, Employee E4, was observed by the Director of Rehab, Employee E3, pushed Resident R2 to the ground, where Resident R2 landed on his side, with Resident R2's back against the wall. Director of Rehab, Employee E3 assisted Resident R2 off the ground and helped him to the room, where the Nurse Supervisor was contacted to assess the resident. Director of Rehab, Employee E3 contacted police and reported the incident. On August 29, 2024, at 12:30 p.m., interview with Director of Rehab, Employee E3 repeated the information given in his written statement as mentioned above. Review of facility investigation related to the incident revealed a written statement from the Nurse aide, Employee E4, dated August 17, 2024, which stated that: [Resident R2] walked up to me, grabbed my neck, I snatched away real quick and he fell on the floor. Phone interview conducted with Nurse aide, Employee E4 on August 29, 2024, at 12:15 p.m., revealed that on August 17, 2024, Resident R2 was there in the dining room of fifth floor for lunch. Resident R2 wanted to sit with a group of four residents, along with a female resident, but there was no space. Nurse aide, Employee E4 pulled the chair. Then Resident R2 spit on nurse aide, Employee E4's face. Resident R2 was not steady on his feet. Resident R2 fell backward. Nurse aide, Employee E4 stated that she did not touch Resident R2, as she was carrying the food tray in her left hand, and was using the right hand to prevent the spit falling on her face. Review of clinical nurses note, dated August 17, 2024, by Nursing Supervisor, Registered nurse, Employee E6, revealed as follows: This nurse was made aware by physical therapy (PT) staff that resident sustained physical injury from a care nurse while in the dining room. PT staff states that he witnessed resident behaving aggressively in the dining room and the resident hit a care nurse, and then the care nurse grabbed the resident by his neck and forcefully pushed him against the wall. The resident fell to the floor. The PT staff quickly intervene, and safely removed the resident from the dining area and took him to his room. Resident is not a good historian of the event. Resident assessed; injuries noted, two abrasions to his upper back, #1 measured 12 x 2.5 cm, #2 measured 5 x 1 cm. Upon further assessment swelling noted to (L) hand and wrist, facial grimacing, and guarding of the arm noted. Resident was able to wiggles fingers. Acetaminophen administered for pain. Call place to Physician, new order to X-ray the (L) arm. Ice pack x 3 days for swollen. Q (every) Shift pain assessment in place. New order to clean upper back daily with NSS ( Normal Saline Solution), Leave Open To Air. Staff was immediately removed from premises. Department head notified. On August 29, 2024, at 3:00 p.m., interviewed Nursing Supervisor, Registered nurse, Employee E6 restated the above information, and added that she did not witness the incident. Review of Imaging Narrative Note for Resident R2, dated August 18, 2024, for the X- ray service performed on August 17, 2024, indicated as follows: There is an acute fracture of the distal radial metaphysis. (Distal radial fractures are fractures that occur at the wrist). Review of Employee E4's personnel file revealed that she was hired by the facility on January 26, 2022, as a nurse aide. Continued review revealed that Employee E4, nurse aide, received training on the prevention of elder abuse on January 26, 2022. Further review revealed that Employee E4, nurse aide, received training on facility policy, De-escalation on May 9, 2022 and continued in-service on December 14, 2023. Interview on August 29, 2024, at 12:54 p.m., the Nursing Home Administrator, while reviewing the video footage of the incident, dated August 17, 2024, confirmed that Resident R2 fell , whereas Nurse aide, Employee E4, pushed the resident. The NHA confirmed that the resident sustained acute fracture of the distal radial metaphysis. The NHA confirmed that the facility substantiated the allegation of physical abuse against Employee E4, nurse aide, and subsequently terminated her from employment. The facility failed to ensure that Resident R2 remained free from abuse, resulting in actual harm to Resident R2 who was pushed by a nursing staff, fell to the floor and sustained an acute fracture of the distal radial metaphysis. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on review of clinical records, facility documentation, and other documentation and interviews with staff, it was determined that the facility failed to notify the physician of a change in nutritional status for a resident on a blood-glucose-lowering medication causing actual harm to one resident who experienced a critically low blood glucose level that had to be emergently treated. The facility failed to timely evaluate and treat one resident exhibiting signs and symptoms of an acute infection, which resulted in actual harm to the resident who required a surgical amputation of a finger. Aditiaonally the facility failed to ensure that physican's orders were followed for a skin protective device for three of five residents reviewed (Residents CL1, Resident CL2, and Resident R1). Findings included: Review of the Food and Drug Administration (FDA) guidelines for [MEDICATION NAME] (an oral blood-glucose-lowering sulfonylurea class of drug) 5 mg (milligram) revealed under precautions and the manufacturer states, all sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED] (low blood glucose level) likely to occur when caloric intake is deficient. Under the subheading Loss of Control of Blood Glucose the manufacturer stated, when a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, a loss of control may occur. Under the heading Information for Patients the manufacturer stated, They should be informed about the importance of adhering to dietary instructions, of a regular exercise program and of regular testing of urine and/or blood glucose. Review of The Journal of Biosciences and Medicines, (YEAR), Volume 3, pages 68-70 revealed an article Sulfonylurea Induced Severe [DIAGNOSES REDACTED] in a Diabetic with [MEDICAL CONDITION]. The introduction states, acute or chronic [MEDICAL CONDITION] can potentiate (sulfonylurea) effects and may result in life threatening [DIAGNOSES REDACTED] even with therapeutic doses . Sulfonylureas reduce blood glucose concentrations by stimulating the release of insulin from the pancreatic beta-cells . Severe [DIAGNOSES REDACTED] can be observed when blood glucose concentrations fall and supply of glucose to the brain becomes diminished . The duration of [DIAGNOSES REDACTED] may also be prolonged due to the presence of active metabolites of sulfonylurea in the setting of [MEDICAL CONDITION]. Review of Resident CL1's medical record revealed that the resident was admitted to the facility on (MONTH) 19, 2019, with diagnoses, including but not limited to, traumatic amputation (surgical removal) of left great toe Additionally, the resident had [DIAGNOSES REDACTED]. Review of hospital records for Resident CL1 revealed that prior to her admission to the nursing home she was admitted as an inpatient to a hospital on (MONTH) 11, 2019. Upon discharge from the hospital, the physician recommended the resident start taking her previously prescribed [MEDICATION NAME]. Review of physician's orders [REDACTED]. mg, give 1 tablet by mouth at bedtime for wound infection for 32 days. Continued review of physicians orders for Resident CL1 revealed no order to monitor the resident's blood glucose levels with at the restarted of the blood glucose lowing medication. Review of the (MONTH) 2019 Medication Administration Record [REDACTED] Review of food and drink intake documentation for Resident CL1 for (MONTH) 30, 2019, revealed as follows: - Breakfast - resident refused fluid and food intake - Lunch - resident refused fluid and food intake - Dinner - no documentation for fluid and food intake - Bedtime - no documentation for bedtime snack. Review of nursing progress notes for Resident CL1 dated (MONTH) 30, 2019, revealed no documentation that the physician was notified that the resident was not eating or drinking. Review of Resident CL1's progress notes dated (MONTH) 31, 2019, at 4:13 a.m. revealed that the resident was found unresponsive to verbal and tactile stimuli on (MONTH) 31, 2019, at 3:50 a.m. A blood sugar level was obtained with a value of 37 mg / dL (milligrams per deciliter; the normal fasting blood glucose range is between 70 and 100 mg / dL). Facility staff administered 1 mg of [MEDICATION NAME] (a hormone used to raise the blood glucose level). The resident remained lethargic (difficult to arouse) and attempts to arouse the resident were unsuccessful, prompting the staff to call 9-1-1. Upon arrival of the emergency services, a repeat blood sugar revealed the resident had a blood glucose level of 45 mg / dL, lower than the normal fasting blood glucose range. Review of hospital records for Resident CL1 dated (MONTH) 31, 2019, at 3:40 p.m. revealed the resident was admitted to the hospital after the hypoglycemic incident at the facility. Interview with the Nursing Home Administrator (NHA) on (MONTH) 12, 2019, 5:05 p.m. revealed the facility did not have a [DIAGNOSES REDACTED] policy. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on (MONTH) 12, 2019, at 2:30 p.m. regarding Resident CL1's emergency [DIAGNOSES REDACTED] from (MONTH) 31, 2019, revealed that the facility nurses do not follow manufacturer guidelines for medications, they only follow what the physician's orders [REDACTED]. Interview with the Medical Director on (MONTH) 12, 2019, at 4:21 p.m. revealed that nursing staff should have notified him that Resident CL1 was not eating properly, considering the resident was on [MEDICATION NAME], a blood-glucose-lowering medication. Review of Resident CL1's progress notes revealed the resident was discharged from the facility on (MONTH) 31, 2019, at 4:25 a.m. when she was emergently transferred to the hospital due to a critically low blood glucose level. The facility failed to notify the physician of a change in nutritional status for a resident on a blood-glucose-lowering medication and this situation resulted in actual harm to the resident who had a critically low blood glucose that required emergency treatment and hospitalization . Review of clincial record for Resident CL2 revealed the resident was admitted to the facility on (MONTH) 24, (YEAR), with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS- periodic review of resident care needs) dated (MONTH) 2, 2019, revealed that the resident was moderately impaired in decision making skills. The MDS further indicated that the resident needed extensive assistance with dressing, toileting, hygiene and bathing. Review of care plan for Resident CL2 revealed an undated care plan titled the resident has the potential/actual impairment to skin integrity of the left middle finger skin tear with infection related to biting of fingers. The goals listed on the care plan were as follows: The resident will maintain or develop clean and intact skin by the review date ; The resident will have no complications related to wound on left middle finger caused by continuous biting of the finger through the next review. Further review of the skin impairment care plan for Resident CL2 revealed the interventions listed on the care plan were as follows to follow facility protocols for treatment of [REDACTED].D. and mitts to be placed on hands due to biting. Review of progress notes for Resident CL2 dated (MONTH) 27, 2019, revealed that an open area was noted on the resident's left middle finger. First aid applied, will continue to monitor. Review of wound care sheets for Resident CL2 dated (MONTH) 28, 2019, revealed a new area to the left middle finger. Mechanical injury -ulceration of left middle finger .resident bit his hand. The wound was described with full thickness ulceration of the left middle finger 1.0 centimeters (cm) by 0.5 cm by 0.1 cm, wound base 80% slough, 20 % granular with scant non-odorous serous drainage, edges adherent to the wound base. Periwound without [DIAGNOSES REDACTED], crepitus, [MEDICAL CONDITION] or induration. Patient does not demonstrate evidence of pain when effected area palpated. The plan included to cleanse site with normal saline or wound cleanser, apply [MEDICATION NAME], and a clean dry dressing to open area change two times a day and PRN (as needed) for soiling/dislodgement. Review of physician's orders [REDACTED]. Review of Resident CL2's (MONTH) 2019 Treatment Administration Record (TAR - documentation that nursing staff sign to acknowledge that a treatment has been done) , revealed no documented evidence that that the physician ordered a daily treatment to the left middle finger were completed for nine of 31 scheduled treatments on (MONTH) 2, 6, 7, 26, 27, 28, 29, 30 and 31, 2019. Review of wound care sheets dated (MONTH) 3, 2019, revealed that the left middle finger had full thickness ulceration. 1.0 cm by 0.5 cm by 0.1 cm wound base 100 % pale yellow, with scant non-odorous serous drainage, edges adherent to the wound base. Periwound without [DIAGNOSES REDACTED] (redness), crepitus (cracking), [MEDICAL CONDITION] (swelling) or induration. Patient does not demonstrate evidence of pain when area palpated. Review of progress notes for Resident CL2 dated (MONTH) 4, 2019, revealed that the left middle finger on side of finger small circular wound with yellow tissue present in the wound bed . treatment done as ordered. Further review of the progress note indicated that a sock was applied to hand for protection. Review of progress notes for Resident CL2 dated (MONTH) 5, 2019, revealed that resident removes sock and bites at dressing, and the area was redressed. Review of wound care sheets for Resident CL2 dated (MONTH) 12, 2019, revealed that the left middle finger had full thickness ulceration 0.6 cm by 1.0 cm by 0.1 cm wound base 100 % pale yellow, with scant non-odorous serous drainage, the edges adherent to the wound base. periwound without [DIAGNOSES REDACTED], crepitus, [MEDICAL CONDITION] or induration. Patient does not demonstrate evidence of pain when area palpated. Discontinue present order and start to cleanse area with normal saline or wound cleanser, pat dry, apply Xeroform with self-adhesive coban dressing, change every day and as needed. Review of the wound care sheets for Resident CL2 dated (MONTH) 17, 2019, revealed that the left middle finger was 0.8 cm by 0.5 cm by 0.1 cm wound base 100 % pale yellow slough, with scant non-odorous serous drainage, edges adherent to the wound base. Periwound macerated without [DIAGNOSES REDACTED], crepitus, [MEDICAL CONDITION] or induration. Patient does not demostrate evidence of pain. The resident continued to bite his hand and treatment was to continue. Review of progress notes dated (MONTH) 18, 2019, revealed that resident observed with sock off and chewing left middle finger while in bed. Dressing replace, sock replace, behavior redirected at this time. Left middle finger with ongoing swelling, discoloration, open area with minimal amount of slough noted, foul odor present .PRN Tylenol (pain medication) administered. Review of progress notes dated (MONTH) 23, 2019, revealed treatment to left middle finger, left middle finger present with foul odor with purulent drainage due to be seen by wound care team on (MONTH) 24, 2019. Further review of nursing notes dated (MONTH) 24, 2019, revealed that the left middle finger had a foul odor with purulent drainage . Sock applied .The resident is due to be seen by wound care on (MONTH) 25, 2019, previously consulted for (MONTH) 24, 2019. Review of progress notes dated (MONTH) 25, 2019, revealed that the there was a foul odor to the left middle finger, resident to be seen on wound rounds tommorow. Review of a change in condition form for Resident CL2, dated (MONTH) 26, 2019, at 10:38 a.m. (8 days since the foul odor to the left mindle finger was identified) revealed that the resident was seen on wound rounds. The Nurse Practitioner (NP) had ordered the resident transferred to the hospital for further evaluation and treatment to the left middle finger and to rule out osteo[DIAGNOSES REDACTED] (inflammation of bone caused by infection). Left middle finger noted with extreme odor, excessive swelling and drainage. The resident was also noted with grimacing indicating possible pain . Physician and responsible party notified. Further review of progress notes for Resident CL2 dated (MONTH) 26, 2019, at 11:46 a.m. revealed an instruction to cancel the resident's transfer to the emergency room per the Director of Nursing (DON). Continued review of progress notes for Resident CL2 dated (MONTH) 26, at 2:33 p.m. revealed that the resident's left middle finger was noted with foul odor, excessive swelling noted to finger and displaying signs and symptoms of pain. Resident noted with the grimacing during dressing changes. PRN Tylenol 650mg give. Review of physician's orders [REDACTED]. Review of nurse's notes dated (MONTH) 26, 2019, at 2:50 p.m. revealed the physician ordered a stat (meaning to perform immediately) x-ray to the left middle finger to rule out osteo[DIAGNOSES REDACTED] (infection of the bone), left middle finger with swelling, excessive amount of drainage and odor. Review of the x-ray results for Resident CL2 for the left middle finger, dated (MONTH) 26, 2019, at 6:40 p.m. revealed the following results: There is destruction of the distal aspect of the middle phalanx (finger) as well as the proximal distal phalanx of the third finger which may be secondary to fracture or osteo[DIAGNOSES REDACTED]. There is diffuse osteopenia. Conclusion: There is destruction of the distal aspect of the middle phalanx as well as the proximal distal phalanx of the third finger which may be secondary to fracture or osteo[DIAGNOSES REDACTED]. This is new from the prior and is therefore most likely due to intervening trauma. Review of physician;s orders for Resident CL2 dated (MONTH) 26, 2019, at 8:00 p.m. revealed an order for [REDACTED]. Review of physician's orders [REDACTED]. Review of progress notes for Resident CL2 dated (MONTH) 27, 2019, at 7:36 a.m. revealed a dressing change to the left middle finger and it was noted with foul smell and the finger was swollen, the wound bed was dark color skin around the bed, the area was boggy and macerated with bloody drainage. Review of progress notes for Resident CL2 dated (MONTH) 28, 2019, at 1:55 p.m. revealed that the left middle finger presents edemetous with purulent slimy foul-smelling drainage . Mitts applied B/L (bilateral) Further review of progress notes dated (MONTH) 29, 2019, at 10:54 a.m. revealed that the left middle finger was noted with a foul odor and excessive swelling noted. Review of progress notes for Resident CL2 dated (MONTH) 29, 2019, at 3:22 p.m. revealed that the family came in to see the resident and insisted that the resident be sent to the emergency room for evaluation and treatment to his left middle finger infection. Review of progress notes for Resident CL2 dated (MONTH) 29, 2019, revealed that the resident was admitted to the hospital with [REDACTED]. Review of the hospital's emergency department physician notes for Resident CL2, dated (MONTH) 29, 2019, revealed that the left hand had diffuse swelling, tenderness and [DIAGNOSES REDACTED] (redness of the skin). The left third digit with diffuse swelling, discoloration and malodorous drainage open wound. The plan was to evaluate for serious infection of the resident's hand and digit and to hospitalize. Review of hospital records for Resident CL2 revealed that the resident was admitted to the hospital on (MONTH) 29, 2019, with a human bite wound to the left third digit (finger) with necrosis (death of cells or tissue through disease or injury) and discharge (discharge can be bloody, serous, purulent etc.). An x-ray of the left middle finger on (MONTH) 29, 2019, revealed the findings: that there is extensive soft tissue swelling of the third finger with bony destruction of the distal aspect of the middle phalanx and proximal aspect of the distal phalanx. The remainder of the fingers are held in fixed flexion. Impression: Finding consistent with osteo[DIAGNOSES REDACTED] /septic arthritis of the middle finger involving the distal inter phalangeal joint, middle and distal phalanges. Review of the hospital form for a surgical procedure for Resident CL2, dated (MONTH) 31, 2019, revealed the indication for surgery: the patient is a demented nursing home resident who presents with pain, swelling, and purulent drainage from his left long finger. X-ray confirmed chronic osteo[DIAGNOSES REDACTED]. Family aware and counseled regarding his condition. After risks and benefits explained, the family consented to amputation. Continued review of hospital documentation for Resident CL2 dated (MONTH) 31, 2019, revealed that the resident had a left long finger amputation on (MONTH) 31, 2019. Documentation of the procedure revealed that amputation through the middle phalanx was then performed. The middle phalanx was noted to be grossly necrotic with copious purulence emanating from the bone which was soft and necrotic. Strength soft tissue were also noted to be necrotic and infected. Further review of hospital records for Resident CL2 dated (MONTH) 2, 2019, revealed that the resident under went a second procedure. to the left long finger Interview with the Medical Director on (MONTH) 12, 2019, at 3:00 p.m. confirmed that he cancelled Resident CL2's transfer to the emergency room and ordered the oral antibiotics, he stated that he did not believe that there was an emergent need for the resident to go to the emergency room even when the x-ray results stated osteo[DIAGNOSES REDACTED] and all the nursing progress notes stated foul smelling, swelling, macerated, bloody drainage and purulent drainage. The facility failed to timely evaluate and to provide timely treatment to Resident Cl2's left middle finger after showing signs and symtoms of foul odor, excessive swelling and prudulent drainage, which resulted in actual harm to Resident R1 requiring transfer to the hospital, [DIAGNOSES REDACTED]. Review of a facility policy titled Oxygen Administration Policy and Procedure dated as created in (MONTH) (YEAR) revealed no provisions for the prevention of skin damage related to the use of a nasal cannula for oxygen administration. Review of Resident R1's (MONTH) 2019 physician's orders [REDACTED]. Further review of (MONTH) 2019 physician's orders [REDACTED]. Observation of Resident R1 on (MONTH) 12, 2019, at 8:56 a.m. revealed the resident was lying in bed wearing an oxygen administration nasal cannula. The tubes of the nasal cannula were observed tight into the resident's cheeks. Interview with Resident R1 on (MONTH) 12, 2019, at 8:57 a.m. revealed the nasal cannula was causing pain to the right ear because the tubing was on too tight. When asked if the resident had any other problems with the oxygen therapy, the resident stated, the only other problem with oxygen is sores on my ear (pointed to her right ear). Review of progress notes for Resident R1 dated (MONTH) 30, 2019, at 5:48 p.m. revealed that under the nasal cannula on the right ear she has an opening 0.5 centimeters (cm) x 1.0 cm. Review of a nutrition progress note for Resident R1 dated (MONTH) 13, 2019, at 2:08 p.m. revealed the resident had a Stage II (partial-thickness skin loss into but no deeper than the dermis) pressure ulcer behind her right ear at that time. Review of Resident R1's plan of care revealed that the Stage 2 pressure ulcer to the resident's right ear under nasal cannula was resolved on (MONTH) 21, 2019. Review of Resident R1 (MONTH) 2019 Treatment Administration Record revealed that on Sunday, (MONTH) 8, 2019, there was no documented evidence that the treatment order for foam padding to O2 tubing to be change on Sunday during the 11-7 shift was completed. Observation and interview with Employee E19, Licensed Practical Nurse (LPN) on (MONTH) 12, 2019, at 10:26 a.m. revealed confirmation that the resident's oxygen cannula tubing had been applied too tightly to the resident's face. Additionally, Employee E19 stated that Resident R1 had tight pressure around the back of her right ear where the oxygen tubing dug into her skin. Employee E19 stated that the pressure of the tubing had damaged the resident's skin. Employee E19 described the wound bed as open skin with a white moist substance. Employee E19 described the wound as a Stage 2 pressure ulcer. Review of nursing documentation dated (MONTH) 12, 2019 at 3:36 p.m. revealed that the resident had facial grimacing while she was applying ear protectors to nasal canula, on assessment maceration noted behind R (right ear), no open areas noted. Site cleansed and foam applied. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on (MONTH) 12, 2019, at 5:05 p.m. revealed, as stated by the NHA, LPNs can't diagnose pressure ulcers and the DON stated, the resident has macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) skin behind her ear. The facility failed to ensure that the skin protective device to be applied to R1's oxygen tubing was in place as order by the physician resulting in the resident developing a macerated area behind the right ear. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/19/19 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 08/12/19, 06/19/19 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/19/19 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 08/12/19, 06/19/19

0414Based on review of facility policy and procedure, clinical record, facility documentation and interviews with staff, it was determined, the facility failed to provide proper supervision for one of one resident identified as an elopement risk, resulting in harm to Resident R260 eloping from the facility, sustaining a fall, transfer and admission to the hospital and failed to ensure an environment free of accident hazards for two of 42 residents reviewed (Resident R126). Findings include: Review of the facility policy and procedure titled, Clinical Operations, updated, March, (YEAR), indicated the purpose of the policy and procedure was To monitor and evaluate occurrence which is not consistent with the routine operation of the facility or care of a particular resident. Documentation submitted by the facility to the State agency, on (MONTH) 5, 2019, at 5:00 p.m. indicated Resident R260, eloped from the third floor nursing unit on (MONTH) 5, 2019, at approximinatley 4:20 a.m. and was not located till 6:45 a.m., two hours and 15 minutes after last being seen by a staff person on the third floor nursing unit. Review of Resident 260's clinical record revealed Resident R260, was initially admitted to the facility on (MONTH) 29, 2019, for rehabilitation services. Review of admission physician order's dated (MONTH) 29, 2019, revealed the [DIAGNOSES REDACTED]. Continued review of R260's clinical record revealed admission care plan's, initiated on (MONTH) 29, 2019, which identified the resident as an elopement risk, decreased independence with ambulation, balance, cognitive decline and risk of falling. The elopement care plan revealed that the resident was at risk of elopement related to cognitive impairment. The goal of the elopement care plan was for the resdient to remain safe inside the facility. Continued review of the resident's care plan revealed, that Resident R260, had a decrease in lower extremity muscle strength, related to ambulation and balance. Review of the cognitive care plan indicated that Resident R260, was identified as being moderately impaired cognitively, related to short term memory loss, demonstrated specific functional decline and decreased problem solving. The fall care plan indicated that Resident R260, was at risk of falls related to new and unfamiliar environment. Review of nursing progress note, dated, (MONTH) 4, 2019, at 2:30 p.m. revealed Resident R260, was observed ambulating around the third floor nursing unit, required frequent redirection from nursing staff, for wandering into other resident's rooms and was observed urinating on floor and filling urinal with water. Staff spoke with Resident R260, which he indicated, I need to know when I go home. Review of a second progress note on (MONTH) 4, 2019, at 2:50 p.m. revealed, Resident R260 remained ambulating indepently around third floor nursing unit, continued to need frequent redirection to stop wandering into other resident rooms and urinating on the floor. The nursing note also indicated, that the resident's, cognition was impaired but the resident was physically capable of ambulating around the unit. Additional review of nursing progress notes for Resident R260, revealed a nursing note dated (MONTH) 4, 2019 at 10:00 p.m. indicated that the resident was awake and alert with confusion, (resident), has been ambulatory around unit, (resident), expressed desire to leave and go to group . (Resident) redirected frequently throughout the shift by nursing staff Resident has had a recent acute onset of confusion with ambulation and exit seeking behaviors . (resident) was provided with a entertainment in activity area, however he continues to ambulate and wander into other's rooms. The nursing note lastly indicated, R260, Was placed on every 15 minute checks for safety/elopement and is started on neuro checks. Nursing note reviewed dated (MONTH) 5, 2019, at 8:20 a.m. indicated, (Resident), being monitored every 15 minutes for previous behaviors earlier in the day, resident was restless and pacing up and down the hallway. He would go into his room and nap for an hour or so then he will be back pacing up and down hallway. Nursing supervisor assisted in collecting an urine sample from (resident), around 4:00 a.m. on (MONTH) 5, 2019. (Resident), returned to pacing around 4:20 a.m. on the third floor nursing unit She was meet by Employee E8, certified nurse aide, to do a 15 minute check on (resident), to be told, Resident), was not in his room. On (MONTH) 18, 2019, at 9:00 a.m. surveyor, Director of Nursing and Employee E9, Director of Environmental Services, followed the path, Resident R260, took on (MONTH) 5, 2019, at approximinatley 4:20 a.m. from the third floor secure nursing unit. During the walk, it was revealed by Employee's E2 and E9, that Resident R260, took the service elevator from the secure third floor nursing unit, which was around the corner and down the hall and can not been seen from the third floor nursing station. Resident R260, made a left off the service elevator, walked down the service hall way, to the entry/exit door, (door numbered 0043). Employee E9, indicated, that door 0043, opened from the inside to go outside, 24 hours a day, but you can not enter through the door till 6 a.m., the door locks at 6 p.m. going from outside to inside for the service hall way. Upon going through door 0043, Employee's E2 and E9, continued to show the surveyor the path Resident R260, walked till he was found, 75 feet, from the loading dock entry/exit door. It was revealed that Resident R260, walked down the hill in the area of the loading dock, around two corners, it was indicated that R260, fell by an air conditioning unit, on the far back side of the facility property, which was not in site from any area from the inside of the facility. Employee E9, indicated, that when he reported to work on (MONTH) 5, 2019, for his 7 a.m. shift, he was the person that found R260, sitting on the ground, with both knee's bleeding as a result of having a fall and had a bump on the back of his head. Employee E9, indicated he helped R260, to stand up and took him to the third floor nursing unit, at approximinatley 6:45 a.m. on (MONTH) 5, 2019. Continued review of nursing notes for Resdient R260, revealed a note written on (MONTH) 5, 2019, at 11:30 a.m. Resident R260 is post elopement and is in lounge with close supervision. Review of the facility investigation, related to Resident R260, elopement from the third floor nursing unit, indicated, Resident R260, was found to have a bump to the back of his head, discoloration to both knee's and a scratch on the back of his left elbow. The report indicated that Resident R260, remained very confused. Nursing note dated, (MONTH) 5, 2019 at 11:30 p.m. indicated, Resident R260 was transferred to the local hospital emergency room for evaluation and treatment and was found to have a change in mental status, for which he was admitted to the hospital for to have continued evaluation and treatment as needed. An interview with the Director of Nursing on (MONTH) 18, 2019, at 9:45 a.m. after following the path Resdient R260, took from the secure third floor nursing unit till he was found, more than two hours from when he was last seen, confirmed the facility failed to adequately monitor the safety of one resident who was identified as an elopement risk, resulting in harm to one resident. The facility failed to provide proper supervision for Resident R260 who was assessed at risk for elopment resulting in actual harm to Resident R260 eloping from the facility's secured unit, sustaining a fall, hitting the back of his head and requiring transfer and admission to the hospital. Review of Resident R126's comprehensive assessment MDS (an assessment of care needs) dated (MONTH) 14, 2019 indicated that Resident R126 was cognitively intact. The assessment also indicated that this resident required one person assist with transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). The assessment indicated that Resident R126 required one person physical assist for walking in the bed room and that the resident was using a wheelchair as a mobility device. During an interview with Resident R126 at 11:15 a.m., on (MONTH) 14, 2019 it was reported that the resident had a fall in the bed room. The resident explained that the wardrobe inside the bedroom fell over, and on top of him. An injury was sustained by the resident as the unsecured wardrobe knocked the resident to the floor. Resident R126 reported during this interview that he used the wardrobe/cabinet to hold as he was trying to stand to reach the inside of the cabinet. Clinical record review confirmed that Resident R126 was found on the floor inside the bedroom at 7:15 p.m., on (MONTH) 6, 2019. The clinical record also indicated that Resident R126 reported that the cabinet fell over on him, as he was trying to get a sweater out of it. The resident described to the staff that he was holding onto the cabinet door, when it fell over with the resident. The clinical record indicated that the nursing staff found the resident's cabinet on top of the resident's bed and chair. The nursing staff assessed Resident R126 and found the resident to have a 4 centimeter abrasion on the right ankle and a 2.5 centimeter abrasion on the right chin. Interview with the maintenance department staff, Employee E17 revealed that the wardrobes/cabinets are free standing and with weight as exerted by Resident R126, it was confirmed that it would fall over. On (MONTH) 18, 2019 the maintenance staff reported that they drilled into the wall inside Resident R126's bed room (528) fifth floor, to secure the wardrobe/cabinet to the wall. On (MONTH) 19, 2019, Resident R126 had a room change to room [ROOM NUMBER] on the fourth floor. There was no indication that the maintenance staff was aware of Resdient R126's room change to fourth floor. The maintenance staff were informed by the survey team that Resident R126 had a free standing wardrobe/cabinet in room [ROOM NUMBER]. Interview with the nursing home administrator at 4:00 p.m., on (MONTH) 19, 2019, revealed that the facility failed to assess the safety of the free standing wardrobes and cabinets for Resdient R126 and other residents throughout the facility. The facility failed to ensure the monitoring of one resident who was identified as an elopement risk and failed to ensure an environment free of accident hazards for residents. F689 Previously cited (MONTH) 12, (YEAR). 42 CFR 483.(h) Free of Accident Hazards/Supervision/Devices 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 5/2/18 28 Pa. Code: 201.18(b)(1)(3) Management Previously cited 5/2/18 28 Pa. Code: 211.10(d) Resident care policies Previously cited 5/2/18 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services Previously cited 5/2/18

Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure that hot food, served to all of the residents that eat independently or with assistance, was at a safe temperature. This failure placed all residents in the facility who are served hot food and beverages at risk of being burned and resulted in an Immediate Jeopardy situation. Findings include: Observation of Fourth Floor Dining Room on January 29, 2019, at 12:30 p.m. revealed staff asking residents if they would like soup. Residents were observed lifting spoons to their mouths and blowing onto it. Two residents placed their soup filled spoons back into the bowls. Interview with Employee E4, Acting Food services Director, revealed that the soup temperature was 167 degrees Fahrenheit. Employee E4, Acting Food services Director, confirmed that the soup temperature had been recorded prior to being placed in the steam table. Further observation of the fourth floor dining room revealed that steam was visible from the steam table. Interviews at the time of the meal observation on January 29, 2019, confirmed that residents indicated the soup was hot. Resident R3 stated, The soup was good. Too hot at first. I blew on it. Resident R4 stated, Yes. The soup was good and hot. Resident R5 stated, Soup was good but hot. Interview with the Nursing Home Administrator (NHA), revealed The food is prepared by our dietary staff offsite at our sister facility. Twice each day, we send a refrigerated van over to the other facility to bring over the meals. Food arrives on trays and is delivered to our dinettes on each floor. Trays of food are placed in the refrigerator until just before meal time when food is removed from the refrigerator and is placed in the ovens for heating. Temperatures of food are recorded as food is taken out of the oven. If temperature is acceptable (no less than 160 degrees), it is placed on the steam table. If temperature is less than 160 degrees Fahrenheit, it is placed back in the oven. An interview on January 28, 2019, at 2:30 p.m. with the Nursing Home Administrator, confirmed that the food temperatures are not rechecked at the steam table. A review of the facility policy, D-270, Equipment Temperature Log, dated last revised July 2018, indicated that Food temperatures will be taken prior to the start of each meal to ensure that hot foods are hot and cold foods are cold. Procedure Guidelines indicated that the temperature of hot foods should be no less than 160 degrees Fahrenheit. The policy did not indicate a safe maximum temperature and did not address re-taking temperatures at the steam table (point of service). A review of the food temperature logs for January 2019, revealed temperatures of hot food documented, as high as 200 degrees Fahrenheit. Interview with the NHA, at the time of the observation, revealed that the Dietary Manager is responsible for reviewing the temperature logs. Interview with the NHA on January 29, 2019, at 4:15 p.m. confirmed that the temperatures of hot foods and hot beverages are not rechecked at point of service. An Immediate Jeopardy situation was identified to the NHA and Employee E3, Corporate Consultant, on January 29, 2019, at 6:00 p.m. related to the findings of documented hot food temperatures of 170- 200 degrees Fahrenheit and the potential [MEDICAL CONDITION] residents at meal service. It was also determined that the facility had no process in place to monitor the temperatures of hot foods, at the point of service, to ensure that hot food and beverages are served at safe temperatures. A corrective action plan to address the Immediate Jeopardy was developed and included the following interventions: 1. The facility will immediately begin monitoring food temperatures two times at each meal beginning with breakfast on January 30, 2019. Food temperatures will be taken and recorded when removed from re-therming units. Food temperatures will again be taken and recorded at point of service prior to plating for distribution to residents. 2. Food temperature records will be revised immediately to reflect recording of both temperatures. New temperature sheets will include acceptable serving temperature ranges. Test trays will continue to be completed daily, including temperatures on each unit prior to distribution of the tray to the resident. If temperatures are not within acceptable ranges, food will either be reheated or allowed to cool for fifteen minutes. Temperatures will again be taken to ensure they are within acceptable ranges. (Hot beverage 130-150 degrees) (Cold beverages <41.) Dietary staff as well as Activity Department staff will be re-educated by the Dietician/Food Service Director on the above process beginning January 30, 2019, prior to the breakfast meal. Anticipated date of completion for education will be Friday, February 1, 2019. Dietary and activity staff not scheduled January 30 or January 31st will have education on the new process prior to their next scheduled shift. 3. Administrator will review all temperature logs and test tray audits during the week. The manager on duty will monitor temperature logs on weekends. Temperature logs and revised process will be reviewed at each monthly quality Assurance meeting. The Immediate Jeopardy was removed on January 31, 2019, at, 2:00 p.m. after it was verified that the corrective action plan was implemented. During onsite visits on January 30 and 31, 2019, reviews of temperature logs and staffing inservices were conducted. A review of temperature log sheets indicated that the temperatures of the food were checked twice prior to serving to residents. A review of inservice logs revealed that staff did receive inservice training regarding acceptable temperature ranges for serving hot foods and/or hot liquids to residents. Interviews with dietary staff indicated that they were aware of the acceptable food temperatures. A test tray was conducted on the sixth floor dining room on January 31, 2019, during the lunch meal which revealed that the temperatures of the food items were as follows: coffee-135 degrees Fahrenheit (F), Chicken tacos-135 degrees Fahrenheit, ground meat was- 119 degrees Fahrenheit, Rice-140 degrees Fahrenheit, chicken noodle soup-178 degrees Fahrenheit, pureed vegetables-115 degrees Fahrenheit, pureed chicken-115 degrees Fahrenheit and ground vegetables were- 132 degrees Fahrenheit. All food items that were below established serving temperatures (ground meat, pureed vegetables and pureed chicken) were reheated, re-tempted and all were served within the range the facility had declared (130-150 °F). The chicken noodle soup was allowed to cool for 15 minutes, and served to residents when the temperature dropped to 149 degrees Fahrenheit. Interviews with dietary staff indicated that they had received in-service training and were aware of the acceptable food temperatures. Interviews with seven residents during the lunch meal revealed that the residents were satisfied with the temperatures of their lunch meal. The facility failed to ensure that hot foods and liquids were served to residents at safe temperatures. This failure presented potential harm to residents [MEDICAL CONDITION] scalding and resulted in an Immediate Jeopardy situation on January 29, 2019. Nutritive Value/Appearance, Palatable/Preferred Temperature CFR(s): 483.60(d)(1)(2) - Previously cited 05/02/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/25/18, 07/17/18, 07/05/18, 05/02/18, 01/19/18, 08/11/17, 03/01/17 28 Pa. Code 201.18(a) Management Previously cited 01/10/19, 05/02/18 28 Pa. Code 201.18(b)(1) Management Previously cited 01/10/19, 10/31/18, 07/17/18, 07/05/18, 05/02/18, 01/19/18, 08/11/17, 06/22/17, 03/01/17 28 Pa. Code 201.18(b)(3) Management Previously cited 01/10/19, 07/17/18, 07/05/18, 05/02/18, 08/11/17, 03/01/17 28 Pa. Code 201.18(e)(1) Management Previously cited 05/02/18, 01/19/18, 08/11/17, 03/01/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/31/18, 05/02/18, 02/22/18

Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure that hot food, served to all of the residents that eat independently or with assistance, was at a safe temperature. This failure placed all residents in the facility who are served hot food and beverages at risk of being burned and resulted in an Immediate Jeopardy situation. Findings include: Observation of Fourth Floor Dining Room on (MONTH) 29, 2019, at 12:30 p.m. revealed staff asking residents if they would like soup. Residents were observed lifting spoons to their mouths and blowing onto it. Two residents placed their soup filled spoons back into the bowls. Interview with Employee E4, Acting Food services Director, revealed that the soup temperature was 167 degrees Fahrenheit. Employee E4, Acting Food services Director, confirmed that the soup temperature had been recorded prior to being placed in the steam table. Further observation of the fourth floor dining room revealed that steam was visible from the steam table. Interviews at the time of the meal observation on (MONTH) 29, 2019, confirmed that residents indicated the soup was hot. Resident R3 stated, The soup was good. Too hot at first. I blew on it. Resident R4 stated, Yes. The soup was good and hot. Resident R5 stated, Soup was good but hot. Interview with the Nursing Home Administrator (NHA), revealed The food is prepared by our dietary staff offsite at our sister facility. Twice each day, we send a refrigerated van over to the other facility to bring over the meals. Food arrives on trays and is delivered to our dinettes on each floor. Trays of food are placed in the refrigerator until just before meal time when food is removed from the refrigerator and is placed in the ovens for heating. Temperatures of food are recorded as food is taken out of the oven. If temperature is acceptable (no less than 160 degrees), it is placed on the steam table. If temperature is less than 160 degrees Fahrenheit, it is placed back in the oven. An interview on (MONTH) 28, 2019, at 2:30 p.m. with the Nursing Home Administrator, confirmed that the food temperatures are not rechecked at the steam table. A review of the facility policy, D-270, Equipment Temperature Log, dated last revised (MONTH) (YEAR), indicated that Food temperatures will be taken prior to the start of each meal to ensure that hot foods are hot and cold foods are cold. Procedure Guidelines indicated that the temperature of hot foods should be no less than 160 degrees Fahrenheit. The policy did not indicate a safe maximum temperature and did not address re-taking temperatures at the steam table (point of service). A review of the food temperature logs for (MONTH) 2019, revealed temperatures of hot food documented, as high as 200 degrees Fahrenheit. Interview with the NHA, at the time of the observation, revealed that the Dietary Manager is responsible for reviewing the temperature logs. Interview with the NHA on (MONTH) 29, 2019, at 4:15 p.m. confirmed that the temperatures of hot foods and hot beverages are not rechecked at point of service. An Immediate Jeopardy situation was identified to the NHA and Employee E3, Corporate Consultant, on (MONTH) 29, 2019, at 6:00 p.m. related to the findings of documented hot food temperatures of 170- 200 degrees Fahrenheit and the potential [MEDICAL CONDITION] residents at meal service. It was also determined that the facility had no process in place to monitor the temperatures of hot foods, at the point of service, to ensure that hot food and beverages are served at safe temperatures. A corrective action plan to address the Immediate Jeopardy was developed and included the following interventions: 1. The facility will immediately begin monitoring food temperatures two times at each meal beginning with breakfast on (MONTH) 30, 2019. Food temperatures will be taken and recorded when removed from re-therming units. Food temperatures will again be taken and recorded at point of service prior to plating for distribution to residents. 2. Food temperature records will be revised immediately to reflect recording of both temperatures. New temperature sheets will include acceptable serving temperature ranges. Test trays will continue to be completed daily, including temperatures on each unit prior to distribution of the tray to the resident. If temperatures are not within acceptable ranges, food will either be reheated or allowed to cool for fifteen minutes. Temperatures will again be taken to ensure they are within acceptable ranges. (Hot beverage 130-150 degrees) (Cold beverages <41.) Dietary staff as well as Activity Department staff will be re-educated by the Dietician/Food Service Director on the above process beginning (MONTH) 30, 2019, prior to the breakfast meal. Anticipated date of completion for education will be Friday, (MONTH) 1, 2019. Dietary and activity staff not scheduled (MONTH) 30 or (MONTH) 31st will have education on the new process prior to their next scheduled shift. 3. Administrator will review all temperature logs and test tray audits during the week. The manager on duty will monitor temperature logs on weekends. Temperature logs and revised process will be reviewed at each monthly quality Assurance meeting. The Immediate Jeopardy was removed on (MONTH) 31, 2019, at, 2:00 p.m. after it was verified that the corrective action plan was implemented. During onsite visits on (MONTH) 30 and 31, 2019, reviews of temperature logs and staffing inservices were conducted. A review of temperature log sheets indicated that the temperatures of the food were checked twice prior to serving to residents. A review of inservice logs revealed that staff did receive inservice training regarding acceptable temperature ranges for serving hot foods and/or hot liquids to residents. Interviews with dietary staff indicated that they were aware of the acceptable food temperatures. A test tray was conducted on the sixth floor dining room on (MONTH) 31, 2019, during the lunch meal which revealed that the temperatures of the food items were as follows: coffee-135 degrees Fahrenheit (F), Chicken tacos-135 degrees Fahrenheit, ground meat was- 119 degrees Fahrenheit, Rice-140 degrees Fahrenheit, chicken noodle soup-178 degrees Fahrenheit, pureed vegetables-115 degrees Fahrenheit, pureed chicken-115 degrees Fahrenheit and ground vegetables were- 132 degrees Fahrenheit. All food items that were below established serving temperatures (ground meat, pureed vegetables and pureed chicken) were reheated, re-tempted and all were served within the range the facility had declared (130-150 °F). The chicken noodle soup was allowed to cool for 15 minutes, and served to residents when the temperature dropped to 149 degrees Fahrenheit. Interviews with dietary staff indicated that they had received in-service training and were aware of the acceptable food temperatures. Interviews with seven residents during the lunch meal revealed that the residents were satisfied with the temperatures of their lunch meal. The facility failed to ensure that hot foods and liquids were served to residents at safe temperatures. This failure presented potential harm to residents [MEDICAL CONDITION] scalding and resulted in an Immediate Jeopardy situation on (MONTH) 29, 2019. Nutritive Value/Appearance, Palatable/Preferred Temperature CFR(s): 483.60(d)(1)(2) - Previously cited 05/02/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/25/18, 07/17/18, 07/05/18, 05/02/18, 01/19/18, 08/11/17, 03/01/17 28 Pa. Code 201.18(a) Management Previously cited 01/10/19, 05/02/18 28 Pa. Code 201.18(b)(1) Management Previously cited 01/10/19, 10/31/18, 07/17/18, 07/05/18, 05/02/18, 01/19/18, 08/11/17, 06/22/17, 03/01/17 28 Pa. Code 201.18(b)(3) Management Previously cited 01/10/19, 07/17/18, 07/05/18, 05/02/18, 08/11/17, 03/01/17 28 Pa. Code 201.18(e)(1) Management Previously cited 05/02/18, 01/19/18, 08/11/17, 03/01/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/31/18, 05/02/18, 02/22/18

Based on observation, review of clinical records, facility policies and procedures, and facility documentation, and interviews with staff, it was determined that the facility failed to obtain and follow physician's orders related to the care and maintenance of intravenous (IV) catheters for two residents reviewed (Residents R151 and R315); failed to assess, monitor, identify and promptly intervene in response to an acute change in one resident's condition (Resident R107); and failed to assess and monitor 10 of 12 residents receiving blood thinning medication (Residents R22, R51, R92, R99, R117, R137, R150, R156, R214 and R413), causing actual harm to four residents who required hospitalization or prompted a delay in treatment related to abnormally elevated blood clotting levels (Residents R92, R51, R117 and R413). This failure placed residents receiving blood thinning medication at a high risk for injury, and resulted in an Immediate Jeopardy situation. Findings include: Review of an undated and untitled facility document, located along with the Medication Administration Record [REDACTED]. The protocol instructed that for OTH1's residents, staff were to ensure that a PT ([MEDICATION NAME] time-blood test that determines the amount of time in seconds it takes for blood to clot) and INR (International Normalized Ratio-blood test that determines the thinness of the blood. The average normal range of INR for a person taking [MEDICATION NAME] is 2.00-3.00) level was to be drawn twice weekly (each Monday and Thursday or each Tuesday and Friday). The protocol further stated that based on the results of the INR blood test, staff were to use the following instructions as orders given by OTH1: for INR of 0-1.49, Increase [MEDICATION NAME] by 1 milligram (mg); for INR of 1.50-1.99, Increase [MEDICATION NAME] by 0.5 mg; for INR of 2.00 -3.00, No Change; for INR of 3.01-4.99, HOLD [MEDICATION NAME] dosage, check levels daily, until level is less than 3, then restart [MEDICATION NAME], minus 0.5 mg of current dosage; and for INR of greater than 5, HOLD [MEDICATION NAME] dosage, call physician, check levels daily until level is less than 3, then restart [MEDICATION NAME] at the current dosage minus 1 mg. Further review of the protocol revealed no documentation indicating what was the facility's safe maximum [MEDICATION NAME] dose (how high a nurse could increase the dosage of [MEDICATION NAME] based on the protocol), or that staff were not to exceed a specific [MEDICATION NAME] dose. Review of Davis's Drug Guide for Nurses, Twelfth Edition, dated 2011, revealed that some medications, such as anticoagulants ([MEDICATION NAME] & [MEDICATION NAME]), .have a greater potential for harm than others. These medications have been identified by the Institute for Safe Medication Practices as high alert drugs. Davis's Drug Guide for Nurses additionally stated that residents over [AGE] years old .exhibit greater than expected PT/INR response. Monitor for side effects at lower therapeutic ranges and that taking [MEDICATION NAME]/[MEDICATION NAME] along with aspirin (over the counter blood thinning medication) may increase the response to [MEDICATION NAME]/[MEDICATION NAME] and increase the risk of bleeding. Further review of Davis's Drug Guide for Nurses revealed Medication errors involving anticoagulants have resulted in serious harm or death from internal or intracranial (within the skull) bleeding. Review of the clinical record for Resident R92 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) 2013 with [DIAGNOSES REDACTED]. Review of a Certified Registered Nurse Practitioner (CRNP) progress note dated (MONTH) 26, (YEAR), revealed that Resident R92 was on anticoagulation therapy (blood thinning medication) for Afib, that the resident's current PT was 10.6 and INR was 1.01, that the resident was currently on [MEDICATION NAME] 15.5 mg orally every day, and that the resident's PT/INR lab draw dates were Mondays and Thursdays. The CRNP progress note additionally indicated that Resident R92 was on aspirin 81 mg Delayed Release (DR-medication dissolved in stomach and releases into the bloodstream over 24 hours), one tablet orally every day, that staff were to monitor the resident for any bleeding or bruising (assessment to indicate the blood may be too thin), and to change the [MEDICATION NAME] dosing as needed. Review of the physician's orders for (MONTH) and (MONTH) (YEAR) revealed [MEDICATION NAME] protocol see binder with the following sequence of Resident R92's [MEDICATION NAME] orders: (MONTH) 26, (YEAR), through (MONTH) 4, (YEAR), 16.5 mg daily; (MONTH) 5-8, (YEAR), 17 mg daily; (MONTH) 9-11, (YEAR), 18 mg daily; and (MONTH) 12, (YEAR), 19 mg daily. Review of a nursing progress note dated (MONTH) 13, (YEAR), at 3:00 p.m. revealed that blood was noted in Resident R92's incontinence brief and added that the blood appeared to come from the resident's penis. The nursing progress note additionally stated that the nurse notified the CRNP of the bleeding. Review of a CRNP progress note dated (MONTH) 13, (YEAR), revealed that the CRNP examined the resident per nursing request related to bleeding from Resident R92's urethra (the tube from the penis that drains urine from the bladder), that the resident was currently receiving [MEDICATION NAME] 19 mg at bedtime for a [DIAGNOSES REDACTED]. Review of the [MEDICATION NAME] ([MEDICATION NAME]) Therapy Flow Sheet for Resident R92 revealed documentation that the resident was administered [MEDICATION NAME] 19 mg on (MONTH) 13, (YEAR), the same day the resident was noted with bleeding from the urethra. Review of a nursing progress note dated (MONTH) 14, (YEAR), at 3:38 p.m. revealed Resident R92 was noted as having some blood in urine and that the resident's labs were pending. Review of a lab report, dated (MONTH) 14, (YEAR), revealed Resident R92's PT was greater than 102.0 (would take more than 102 seconds or approximately one and one-half minutes for the blood to clot), and INR was greater than 10.17. Review of a nursing progress note dated (MONTH) 14, (YEAR), at 8:56 p.m. revealed Resident R92 was sent to an acute care hospital at 7:20 p.m. for the elevated PT/INR results. Review of a hospital Clinical Summary/Transition of Care report, dated (MONTH) 15, (YEAR), revealed Resident R92 was evaluated at the hospital emergency department (ED) for supratherapeutic (very high level) INR level of more than 10, and while in the ED, the resident, was found to have mild urethral bleeding and blood in his gums. The Clinical Summary/Transition of Care report added that the resident was treated in the ED with Vitamin K (antidote to reverse thinned blood caused by the supratherapeutic INR) 10 mg IV, and required a CT (computed tomography-type of radiology imaging) of the head to rule out acute bleeding in the brain or stroke (caused from bleeding in the brain). The Clinical Summary/Transition of Care report indicated that Resident R92's INR was normalized to 2.1 while in the hospital and the resident's [MEDICATION NAME] was restarted at a dose of 5 mg daily. Review of a nursing progress note, dated (MONTH) 15, (YEAR), at 10:23 p.m. revealed that the resident returned from the acute care hospital that evening and that the resident's current [MEDICATION NAME] dose was 5 mg (versus the 19 mg the resident received prior to transfer to the hospital on (MONTH) 14, (YEAR)). Interview with Employee E17, Licensed Practical Nurse (LPN), on (MONTH) 26, (YEAR), at approximately 11:50 a.m. revealed this LPN routinely worked both day (7:00 a.m. - 3:00 p.m.) and evening (3:00 p.m. - 11:00 p.m.) shifts, was familiar with the facility's [MEDICATION NAME] Protocol, and confirmed that nursing staff were using the protocol as physician's orders for any of OTH1's residents. Further interview with Employee E17 revealed in that nurse's professional opinion, less experienced Licensed Nurses in the facility did not have a full understanding of the protocol, including specifically when a physician needed to be notified of an INR level that was out of range, and confirmed there was no established limit in the protocol for how high a [MEDICATION NAME] dose could be administered. Employee E17 additionally stated that nurses follow the protocol as an order from the physician and if the dose is 20 mg for example, most nurses wouldn't even question that. Per the protocol, if the INR comes back within the parameters set in the protocol, a nurse could increase the dose even higher than that. Upon request of the last few months of drug regimen review reports by the facility's licensed/consultant pharmacist, the only report that could be produced by the facility staff was the, Executive Summary of Consultant Pharmacist's Medication Regimen Review report dated (MONTH) 31, (YEAR). Review of the report revealed the following recommendations: for Resident R92, You may want to consider replacing [MEDICATION NAME] with Eliquis (prescription blood thinning medication that does not require PT/INR monitoring). For Resident R156, Increased risk for a bleed with [MEDICATION NAME] + Aspirin. For Resident R99, Do we still need [MEDICATION NAME] protocol orders - i (sic) do not see an order for [REDACTED]. doses of [MEDICATION NAME]: (MONTH) 26, (YEAR), through (MONTH) 4, (YEAR), 16.5 mg daily; (MONTH) 5-8, (YEAR), 17 mg daily; (MONTH) 9-11, (YEAR), 18 mg daily; and (MONTH) 12, (YEAR), 19 mg daily. Further review of Resident R92's lab reports revealed on (MONTH) 12, (YEAR), (two days prior to the supratherapeutic value obtained on (MONTH) 14, (YEAR),) the resident's PT was 9.8 seconds and INR was 0.93 (below the established range of 2-3 for Resident R92). Upon request from the facility staff regarding if there was any telephone or written correspondence from the facility's contracted laboratory regarding evaluation of Resident R92's sudden sharp and marked increase in the INR from 0.93 on (MONTH) 12, (YEAR), to greater than 10.17 on (MONTH) 14, (YEAR), an interview with the Acting Director of Nursing and Regional Director of Operations on (MONTH) 26, (YEAR), at approximately 3:45 p.m. confirmed there was no evidence the facility's lab reviewed or evaluated this sudden spike in INR. Further interview with the Regional Director of Operations and Acting Director of Nursing on (MONTH) 26, (YEAR), at approximately 3:45 p.m. confirmed the facility did not have a written policy or procedure for the [MEDICATION NAME] Protocol used for OTH1's residents; that there was no current facility process, or designated staff member, to monitor the PT/INR values for any abnormal trends that could be reported to the facility's Quality Assurance Committee for review and evaluation; that there was no documented evidence available for review that the facility's pharmacy was reviewing any resident's medication regimen, including high alert medication usage, since (MONTH) (YEAR); and there was no documentation that the facility's contracted laboratory was reviewing residents on the [MEDICATION NAME] Protocol for any unsafe range/swing in values. Based on these findings, Immediate Jeopardy to the health and safety of the residents on the [MEDICATION NAME] Protocol was identified to the Regional Director of Operations at 4:15 p.m. on (MONTH) 26, (YEAR). The facility's immediate action plan, dated (MONTH) 26, (YEAR), at 7:50 p.m. included: 1) On Thursday, (MONTH) 26, (YEAR), 11 patients have been identified on [MEDICATION NAME] therapy. Lab results for ten of the 11 have been received and evaluated by the facility's Medical Director with no supratherapeutic results. The 11th patient will have their level re-drawn this evening and will have their PT/INR result called to the Attending Physician for further medical management. 2) Medical Director placed call to the owner of the contracted laboratory provider on (MONTH) 26, (YEAR), at 6:20 p.m. for confirmation of quality control measures. Medical Director was reassured that they follow proper protocols as calibration controls are run every day. 3) Medical Director has reviewed the current [MEDICATION NAME] protocol in place and has discontinued this current protocol. 4) New policy will be implemented (MONTH) 26, (YEAR), stating that all patients receiving [MEDICATION NAME] will have the results called to the Attending Physician for further medical management. 5) All 3:00 p.m. to 11:00 p.m. Licensed Nurses have already been in-serviced today on the above. The facility administration will ensure that all Licensed Nurses on all shifts will be in-serviced as well. * Pharmacy consultant will review all resident's doses of [MEDICATION NAME] and document the results of their review. Medical Director will review their findings. 6) Administration will do daily audits times 4 weeks of all patients receiving [MEDICATION NAME] to ensure the ordered labs were obtained, results were received, and the results were reviewed with the Attending Physician for appropriate medical management. 7) After the 4 week audit and competency is established, the facility will audit weekly times 4 weeks then monthly thereafter. 8) The results of all audits will be presented and reviewed at the monthly QAPI (Quality Assessment and Performance Improvement program-focuses on indicators of the outcomes of care and quality of care). Review of the clinical record for Resident R51 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) (YEAR) revealed that the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R51 revealed the following PT/INR values: (MONTH) 9, (YEAR), PT 11.4, INR 1.09; (MONTH) 11, (YEAR), PT greater than 102.0, INR greater than 10.17. Review of the nursing progress notes revealed the following: on (MONTH) 9, (YEAR), Resident R51's [MEDICATION NAME] dose was increased to 15 mg based on the INR level of 1.09 and the [MEDICATION NAME] Protocol. Review of a nursing progress note dated (MONTH) 11, (YEAR), at 5:02 a.m. revealed that the nurse was called to Resident R51's room by a nursing assistant and upon the nurse's entrance to the resident's room, Resident R51 was noted with blood of the side of her face, both hands and nails. The nursing progress note stated, Resident (sic) mouth rinsed out several times, gauze applied to inner left posterior teeth and resident instructed to bite down on (gauze) . Bleeding decreased a lot (sic), however there is still some bleeding remaining. Nursing supervisor made aware, call left on MD answering service. Review of a nursing progress note, dated (MONTH) 11, (YEAR), at 7:24 a.m. revealed Resident R51 was not actively bleeding and that the staff were still waiting a call from MD. Review of a nursing progress note dated (MONTH) 11, (YEAR), at 5:24 p.m. revealed that due to the resident's PT of greater than 102.0 and INR greater than 10.17, the resident's physician was notified and ordered for the resident to be sent to the hospital for evaluation. Review of a nursing progress note, dated (MONTH) 11, (YEAR), at 11:28 p.m. indicated the nurse called the acute care hospital that evening around 6:00 p.m. and confirmed that Resident R51 was being admitted to the hospital for coagulation disorder (blood clotting problem related to supratherapeutic INR). Review of a nursing progress note dated (MONTH) 16, (YEAR), revealed the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Review of the clinical record for Resident R117 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) and (MONTH) (YEAR) revealed the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R117 revealed the following PT/INR values: (MONTH) 19, (YEAR), PT 23.7, INR 2.29; (MONTH) 22, (YEAR), PT 51.2, INR 5.03; (MONTH) 23, (YEAR), PT 47.9, INR 4.70; (MONTH) 25, (YEAR), PT 37.2, INR 3.63; (MONTH) 26, (YEAR), PT 10.1, INR 0.96 and (MONTH) 29, (YEAR), PT 27.2, INR 2.64. Review of the nursing progress notes revealed the following: on (MONTH) 19, (YEAR), Resident R117's [MEDICATION NAME] dose was 6 mg; on (MONTH) 22, (YEAR), due to the INR of 5.03, the resident's [MEDICATION NAME] was on hold; [MEDICATION NAME] remained on hold until (MONTH) 26, (YEAR), where the [MEDICATION NAME] dose was restarted at 6.0 mg; and on (MONTH) 29, (YEAR), the [MEDICATION NAME] dose was reduced to 5.5 mg. Review of a nursing progress note, dated (MONTH) 2, (YEAR), revealed that Resident R117 returned to the facility from overnight observation at an acute care hospital for replacement of the resident's suprapubic catheter (tube inserted through the lower abdomen directly into the bladder to drain urine) and while in the ED blood work was completed that revealed the resident's PT was 43.5 and INR 4.6. The nursing progress note further indicated that due to the elevated INR, the resident was kept overnight for observation and that urology (a physician who specializes in treatment of [REDACTED]. Review of the clinical record for Resident R413 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) (YEAR) revealed that the resident was on the facility's [MEDICATION NAME] Protocol, and the ordered dose of [MEDICATION NAME] as of (MONTH) 5, (YEAR), was 13.5 mg. Review of lab reports for Resident R413 revealed the following PT/INR values: (MONTH) 5, (YEAR), PT 21.1, INR 2.04. Review of a nursing progress note dated (MONTH) 5, (YEAR), at 6:39 a.m. revealed that the nurse received a call from Resident R413's son that the resident was on the floor and upon entering the room, Resident R413 was found on the floor between the bed and the wall in a seated position. The nursing progress note added that an open area on top of the resident's inside lip was bleeding but has no active bleeding at this time. Review of a nursing progress note dated (MONTH) 5, (YEAR), at 3:30 p.m. revealed the resident's PT was 21.1 and INR was 2.04, and per the facility's [MEDICATION NAME] Protocol, staff were to continue with the resident's current dosage of 13.5 mg daily. Review of a nursing progress note, dated (MONTH) 7, (YEAR), at 1:57 p.m. stated that Resident R413 complained of not feeling well with the resident stating that he was coughing up blood on previous shift. The nursing progress note additionally indicated Resident R413's physician was notified and ordered the staff to send the resident to an acute care hospital for evaluation. Review of a nursing progress note, dated (MONTH) 18, (YEAR), at 1:14 a.m. revealed Resident R413 was readmitted to the facility from the hospital during the previous 3:00 p.m. - 11:00 p.m. shift (April 17, (YEAR)). Review of a readmission physician's order, dated (MONTH) 17, (YEAR), revealed the resident's readmission dose of [MEDICATION NAME] was 4 mg daily, versus the 13.5 mg the resident received prior to a transfer to the hospital on (MONTH) 7, (YEAR). Review of the clinical record for Resident R150 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) (YEAR) revealed the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R150 revealed the following PT/INR values: (MONTH) 2, (YEAR), PT 10.0, INR 0.95; (MONTH) 5, (YEAR), PT 11.0, INR 1.05; (MONTH) 9, (YEAR), PT 10.9, INR 1.04; (MONTH) 16, (YEAR), PT greater than 102.0, INR greater than 10.17; (MONTH) 17, (YEAR), PT 10.6, INR 1.01; (MONTH) 18, (YEAR), PT 12.3, INR 1.18 and (MONTH) 20, (YEAR), PT 68.1, INR 6.73. Review of the [MEDICATION NAME] ([MEDICATION NAME]) Therapy Flowsheet for Resident R150 revealed documentation that the resident received [MEDICATION NAME] 19 mg on (MONTH) 12, 13, and 14, (YEAR). Review of nursing progress notes revealed the following: on (MONTH) 16, (YEAR), at 9:25 p.m. Resident R150's PT/INR results were not available from the facility's lab and that no result available and computer said 'RESULT TO FOLLOW, SPECIMEN REDRAW WAS NECESSARY. The nursing progress note went on to state, [MEDICATION NAME] will be drawn tomorrow. Further review of the nursing progress notes or the [MEDICATION NAME] ([MEDICATION NAME]) Therapy Flowsheet revealed no documentation that the nursing staff were aware of the lab results dated (MONTH) 16, (YEAR), which indicated supratherapeutic ranges of PT greater than 102.0, INR greater than 10.17, or that the physician was made aware of these results. Review of a nursing progress note, dated (MONTH) 17, (YEAR), at 10:30 p.m. revealed the resident's PT was 10.6 and INR was 1.01 that shift and Per [MEDICATION NAME] protocol [MEDICATION NAME] is to be increased by 1 mg. Resident is currently on dosage 19 mg. Per md (sic) protocol the dosage is to be increased to 20 mg po (by mouth-orally) (every) evening. Charge nurse didn't feel comfortable giving resident that amount of [MEDICATION NAME]. Placed call out to md (sic) per OTH2 (physician) hold [MEDICATION NAME] dosage due to 20 mg is 'a lot of [MEDICATION NAME]' and recheck PT/INR in am. Review of a nursing progress note dated (MONTH) 18, (YEAR), at 8:36 p.m. revealed the nurse placed a call to Resident R150's physician related to the PT of 12.3 and INR of 1.18 and that per the [MEDICATION NAME] Protocol, the resident's current dosage of [MEDICATION NAME] would be increased by 1 mg, which would be 20 mg of [MEDICATION NAME]. Review of another nursing progress note dated (MONTH) 18, (YEAR), at 9:17 p.m. revealed Resident R150's physician returned the call and ordered for the resident to receive 15 mg of [MEDICATION NAME] daily, and recheck PT/INR on (MONTH) 20, (YEAR). Review of a nursing progress note dated (MONTH) 20, (YEAR), due to Resident's R150's supratherapeutic PT of 68.1 and INR of 6.73, the resident's physician was notified and ordered for the staff to give Vitamin K 5 mg orally. Review of the clinical record for Resident R137 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) 2012 with [DIAGNOSES REDACTED]. Review of physician's orders for (MONTH) and (MONTH) (YEAR) revealed that the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R137 revealed the following PT/INR values: (MONTH) 5, (YEAR), PT 10.4, INR 0.99; (MONTH) 9, (YEAR), PT 36.6, INR 3.57; (MONTH) 10, (YEAR), PT greater than 102.0, INR greater than 10.17 and (MONTH) 15, (YEAR), PT 62.9, INR 6.21. Review of the nursing progress notes revealed the following: on (MONTH) 5, (YEAR), Resident R137's [MEDICATION NAME] dose was increased to 13.5 mg; on (MONTH) 9, (YEAR), the [MEDICATION NAME] was on hold due to INR of 3.37; on (MONTH) 10, (YEAR), due to the supratherapeutic INR value of greater than 10.17, the resident was sent to an acute care hospital for evaluation of the elevated INR; on (MONTH) 12, (YEAR), the resident was readmitted from the hospital with a [DIAGNOSES REDACTED]. On (MONTH) 16, (YEAR), at 8:01 p.m. the nursing progress note indicated the resident's abnormal PT of 62.9 and INR of 6.21 was received, the resident's physician was notified and ordered staff to administer Vitamin K 10 gm IM (intramuscular-injection through the skin into the muscle). Review of the clinical record for Resident R22 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of physician's orders for (MONTH) and (MONTH) (YEAR) revealed the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R22 revealed the following PT/INR values: (MONTH) 26, (YEAR), PT 13.5, INR 1.29; (MONTH) 29, (YEAR), PT 34.5, INR 3.36; (MONTH) 30, (YEAR), PT 45.3, INR 4.44 and (MONTH) 2, (YEAR), PT 18.8, INR 1.81. Review of the nursing progress notes revealed the following: on (MONTH) 22, (YEAR), Resident R22's [MEDICATION NAME] dose was 11.5 mg; on (MONTH) 29, (YEAR), due to the INR of 3.36, per the [MEDICATION NAME] Protocol, the resident's [MEDICATION NAME] was on hold until therapeutic (INR 2-3), with next INR drawn on (MONTH) 30, (YEAR); on (MONTH) 30, (YEAR), due to the INR of 4.44, the resident's [MEDICATION NAME] remained on hold as per protocol with INR to be redrawn in the a.m.; on (MONTH) 31, (YEAR), PT/INR to be drawn in the morning of (MONTH) 1, (YEAR); on (MONTH) 1, (YEAR), no documentation related to INR status; on (MONTH) 2, (YEAR), the INR was noted as 1.81; on (MONTH) 3, (YEAR), the resident was given [MEDICATION NAME] 7 mg. Further review of lab reports for Resident R22 revealed the following PT/INR values: (MONTH) 12, (YEAR), PT 24.0, INR 2.32 and (MONTH) 16, (YEAR), PT 63.9, INR 6.31. Further review of the nursing progress notes revealed the following: on (MONTH) 5, (YEAR), Resident R22's [MEDICATION NAME] dose was 7.5 mg; on (MONTH) 16, (YEAR), due to the INR of 6.31, the resident's [MEDICATION NAME] was held, with a new order to administer Vitamin K 10 mg IM for the supratherapeutic INR level. Review of the clinical record for Resident R214 (a [AGE] year old resident) revealed the resident was originally admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Review of admission physician's orders dated (MONTH) 17, (YEAR), instructed the staff to administer aspirin 81 mg daily for a [DIAGNOSES REDACTED]. The physician's order for [MEDICATION NAME] specifically stated that Resident R214 was on a [MEDICATION NAME]/[MEDICATION NAME] bridge (resident takes oral [MEDICATION NAME] in conjunction with [MEDICATION NAME] to enable the body to slowly and safely increase the resident's INR level), and that the staff were to discontinue [MEDICATION NAME] injections when the resident's INR reached therapeutic level. The admission physician's orders additionally indicated that the staff were to follow the facility's [MEDICATION NAME] Protocol for Resident R214. Review of the PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flowsheet for Resident R214 revealed the resident's therapeutic INR range goal was 2.0 - 3.0. Review of lab reports for Resident R214 revealed the following PT/INR values: (MONTH) 19, (YEAR), PT 11.3, INR 1.08 and (MONTH) 23, (YEAR), PT 43.1, INR 4.22. Review of the nursing progress notes revealed the following: on (MONTH) 17, (YEAR), Resident R214 was admitted to the facility from an acute care hospital after triple bypass heart surgery with the resident suffering [MEDICAL CONDITION](cerebro-vascular accident, stroke) during the surgery; that the resident was on a [MEDICATION NAME]/[MEDICATION NAME] bridge, that the resident's last INR on (MONTH) 17, (YEAR), was 1.3; and that [MEDICATION NAME] injections were to be discontinued when the INR came into therapeutic range. On (MONTH) 19, (YEAR), based on the INR result of 1.08, the resident's [MEDICATION NAME] was increased to 6 mg daily per the [MEDICATION NAME] Protocol. On (MONTH) 23, (YEAR), based on the resident's INR of 4.22, [MEDICATION NAME] was on hold and to follow the [MEDICATION NAME] Protocol. Review of the MAR indicated [REDACTED]. Review of the clinical record for Resident R156 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) (YEAR) revealed that the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R156 revealed the following PT/INR values: (MONTH) 19, (YEAR), PT 30.2, INR 2.94; (MONTH) 23, (YEAR), PT 88.2, INR 8.77 and (MONTH) 25, (YEAR), PT 15.2, INR 1.46. Review of the nursing progress notes revealed the following: on (MONTH) 19, (YEAR), Resident R156's [MEDICATION NAME] dose remained at 8.5 mg with the next routine INR to be drawn on (MONTH) 23, (YEAR). Review of a nursing progress note dated (MONTH) 23, (YEAR), at 10:05 p.m. revealed Resident's PT/INR today is 88.2/8.77. [MEDICATION NAME] therapy on Hold and start daily PT/INR until INR (becomes greater than) 3. When INR 3, (sic) restart [MEDICATION NAME] therapy follow [MEDICATION NAME] protocol order. Review of the facility's [MEDICATION NAME] Protocol instructed staff that for an INR result greater than 5, to follow the instructions including calling the physician. There was no documentation that Resident R156's physician was notified of Resident R156's supratherapeutic INR of 8.77 on (MONTH) 23, (YEAR). Review of the clinical record for Resident R99 (a resident over [AGE] years old) revealed the resident was originally admitted to the facility in (MONTH) 2014 with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) and (MONTH) (YEAR) revealed that the resident was on the facility's [MEDICATION NAME] Protocol. Review of lab reports for Resident R99 revealed the following PT/INR values: (MONTH) 29, (YEAR), PT 24.3, INR 2.35; (MONTH) 2, (YEAR), PT 41.9, INR 4.10; (MONTH) 3, (YEAR), PT 39.2, INR 3.83; (MONTH) 4, (YEAR), PT 16.8, INR 1.62; (MONTH) 5, (YEAR), PT 30.8, INR 3.00; (MONTH) 9, (YEAR), PT 36.9, INR 3.60; (MONTH) 10, (YEAR), PT 45.0, INR 4.41 and (MONTH) 12, (YEAR), PT 23.4, INR 2.26. Review of the nursing progress notes revealed the following: on (MONTH) 29, (YEAR), Resident R99's [MEDICATION NAME] dose was 11.5 mg; on (MONTH) 3, (YEAR), due to the INR of 3.83, the resident's [MEDICATION NAME] was on hold, with next INR drawn on (MONTH) 4, (YEAR); on (MONTH) 4, (YEAR), due to the INR of 1.62, the resident's [MEDICATION NAME] was restarted at 11 mg; on (MONTH) 10, (YEAR), due to the INR of 3.60, the resident's [MEDICATION NAME] was on hold; and on (MONTH) 12, (YEAR), the resident's [MEDICATION NAME] was restarted at 10.5 mg per the [MEDICATION NAME] Protocol. Following verification of the implementation of the immediate action plan, including onsite monitoring with review of daily facility audits of resident PT/INR levels and daily Licensed Nurse in-servicing on (MONTH) 27, 28, 29, 30, (YEAR), and (MONTH) 1, (YEAR), the Immediate Jeopardy was lifted at 2:00 p.m. on (MONTH) 2, (YEAR). Review of the facility policy, PICC (Peripherally Inserted Central Catheter-tube inserted into a vein used for long term infusion of fluids and medications) Line Care, dated last revised (MONTH) 1, (YEAR), revealed that catheter information must be included as part of the resident's clinical record (i.e. catheter insertion date and length of catheter), and that any symptoms of catheter movement, misposition or any obvious change in length requires the nurse to stop using the PICC line, and an X-ray should be obtained to verify the catheter placement and if it is still safe for use. Review of the clinical record for Resident R151 revealed that the resident was admitted to the facility from an acute care hospital on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set assessment (MDS-periodic assessment of needs) dated (MONTH) 2, (YEAR), revealed Resident R151 was identified as being cogniti

Based on clincal record review, facility documentation including policy and procedure, and interview with facility staff, it was determined that the facility failed to ensure care and services were consistently provided for two of 38 residents reviewed that had significant weight loss (Residents R87 and R89) and did not provide residents with physician ordered supplements and snacks as ordered by the physician. This failure placed residents identified at nutritional risk to have a significat weight loss which resulted in actual harm for two residents. Findings include: Review of the facility policy and procedure titled, Weight Monitoring, dated (MONTH) (YEAR), indicated, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. During the initial tour of the facility on (MONTH) 18, (YEAR), at 11:45 a.m. an observation was made of Resident R87 who appeared to be very thin, while in the dining room during a group activity. Clinical record review of Resident R87 revealed a physician's order dated (MONTH) 1, (YEAR), which indicated [DIAGNOSES REDACTED]. Continued review of the physician's orders did not indicate what type of diet order Resident R87 was receiving. Further review of Resident R87's physician's orders on (MONTH) 22, (YEAR), indicated that Resident R87 was to receive High Cal HN (a high calorie oral supplement fortified with vitamins and minerals) one time a day. Review of Resident R87's weights revealed the following recorded information: April 10, (YEAR) - 110 pounds March 5, (YEAR) - 128 pounds March 1, (YEAR) - 134 pounds February 5, (YEAR) - 136 pounds January 11, (YEAR) - 137 pounds January 2, (YEAR) - 143 pounds December 8, (YEAR) - 138 pounds November 21, (YEAR) - 150 pounds, Initial admission weight An interview with Employee E9, Registered Dietitian, on (MONTH) 23, (YEAR), at 10:25 a.m. confirmed since admission, over a span of 5 months, Resident R87 had a significant weight loss of 26%. Employee E9 further indicated that it was only a month ago that the High Cal HN supplement was added for Resident R87 when made aware of Resident R87's significant weight loss. Review of Resident R87's care plan's revealed a care plan related to nutrition/hydration, undated, which indicated that Resident R87 was to receive a regular, pureed consistency (pudding form) diet, and there was no indication of this diet on Resident R87's physician's orders. Continued review of the care plan indicated that Resident R87 was to maintain a +/- 5 pounds a month and required assistance of one person with eating. Continued review of Resident R87's physician's orders indicated on (MONTH) 21, (YEAR), and again on (MONTH) 5, (YEAR), an order was written for a three day calorie count be completed for Resident R87 due to identified weight loss during this time frame. Employee E9 confirmed on (MONTH) 23, (YEAR), again at 10:25 a.m. that both three day calorie counts were never completed as ordered. During the initial tour of the facility on (MONTH) 18, (YEAR), at 10:40 a.m. an observation of Resident R89, was made while she was in bed and the resident appeared very thin. An interview with Employee E5, Licensed Nurse, on (MONTH) 18, (YEAR), at 11:25 a.m. indicated that Resident R89 required physical assistance and verbal prompting with eating. Review of Resident R89's clinical record revealed physician's orders dated (MONTH) 1, (YEAR), which indicated [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] is usually caused by blood loss, insufficient dietary intake or poor absorption of iron from food, dementia with out behaviors, (such as agitation, wandering, and aggression)), and [MEDICAL CONDITION] (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability). Further review of Resident R89's physician's orders revealed an order dated (MONTH) 27, (YEAR), indicating that Resident R89 was on a general diet. A Glucerna shake (a nutritious drink to help manage weight loss) two times a day, for an appetite supplement, was ordered by the physician on (MONTH) 23, (YEAR), along with High Cal HN (a high calorie oral supplement fortified with vitamins and minerals) three times a day as a supplement was ordered on (MONTH) 22, (YEAR). Continued review of Resident R89's clinical record revealed a care plan, undated and titled, The Resident has an ADL Self Care Performance Deficit, which revealed that Resident R89 requires 1 staff participation to eat. Further review of Resident R89's care plans revealed another care plan, undated and related to nutrition/hydration, which indicated that Resident R89 will maintain present weight +/- 5 pounds/month and encourage greater than 75% consumption of all fluids provided. Observation of Resident R89 during the lunch meal on (MONTH) 18, (YEAR), at 12:30 p.m. revealed that Resident R89 was not able to feed himself and Employee E5, Licensed Nurse, was observed sitting across from Resident R89 (feeding) assisting another resident with their meal. Employee E5 was overheard saying to Resident R89, eat your meatball and spaghetti. During the observation, Employee E5 confirmed that Resident R89 needs physical assistance from staff with eating. Employee E5 was noted at the end of the observation as providing Resident R89 physical assistance with eating. Continued review of Resident R89's clinical record on (MONTH) 23, (YEAR), revealed the following recorded weights for Resident R89: March 5, (YEAR) - 139 lbs April 10, (YEAR) - 119 lbs An interview with Employee E9, Registered Dietitian, on (MONTH) 23, (YEAR), indicated that Resident R89 had a significant weight loss of 14.4% in five weeks. Employee E9 further indicated that no re-weights were obtained, after the recorded weight, on (MONTH) 10, (YEAR), that indicated a significant weight loss. During the same interview, the surveyor asked Employee E9 about interventions that were put in place after Resident R89 was identified with a significant weight loss, in which he replied, none were and he did not notify Resident R89's physician about the significant weight loss that had occurred. Also, Employee E9 indicated the information recorded on the Nutrition Therapy assessment dated (MONTH) 24, (YEAR), was not accurately recorded to reflect accurate weights. During the onsite visit on Sunday, (MONTH) 29, (YEAR), at 8:05 a.m. Employee E13, Dietary Supervisor, indicated during the initial tour of the dietary department that residents on Saturday, (MONTH) 29, (YEAR), did not receive physician ordered nutritious supplements, such as Ensure plus and snacks, or sandwiches, as also ordered by the resident's physician at 10:00 a.m. and 2:00 p.m. Employee E13 further indicated that resident's physicians ordered nutritious supplements and snacks were not going to be provided again today, Sunday, (MONTH) 29, (YEAR), for 10:00 a.m. and was not sure the 2:00 p.m. snacks would be provided. Employee E13 indicated during the interview that the facility computer system was down, that printed dietary slips indicated the residents that were to get physician ordered nutritious supplements and snacks, and what supplement or snack the resident was to receive. Also, Employee E13 indicated that she did not have any kind of paper system in place to refer to that would assist in providing physician ordered nutritious supplements and snacks to residents. During several observations of the dietary department on Sunday, (MONTH) 29, (YEAR), between 8:05 a.m. - 1:00 p.m. observations were made of many cases of nutritious supplements, such as Ensure plus, in the dry storage room that were readily available to be served to residents that had physician's orders for such a supplement. During a follow up interview with Employee E13, in the presence of Employee E14, Regional Director of Operations, on Sunday, (MONTH) 29, (YEAR), at 1:45 p.m. Employee E13 indicated that approximately 18 - 21 residents on the 6th floor nursing unit did not receive physician ordered nutritious supplements and/or snacks, and for the 5th, 4th and 3rd nursing floors approximately 13 - 18 residents on each nursing floor did not receive nutritious supplements and/or snacks as ordered by the residents physician, on Saturday, (MONTH) 28 and Sunday, (MONTH) 29, (YEAR). During the same interview, Employee E14, Regional Director of Operations, indicated that the Director of Dinning services was coming to the facility to assist with dietary operations related to residents not receiving nutritious supplements and/or snacks as physician ordered for Saturday, (MONTH) 28 and Sunday, (MONTH) 29, (YEAR). Review of Resident R89's clincal record revealed a physician order, dated (MONTH) 1, (YEAR), which indicated the following Diagnoses: [REDACTED]. intake or poor absorption of iron from food, dementia with out behaviors, (such as agitation, wandering, and aggression), and [MEDICAL CONDITION], (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability). Resident R89's care plan related to nutrition/hydration, indicated that Resident R89 was a risk for altered nutrition/hydration status. Review of Resident R89's nursing progress notes revealed a nursing progress note dated (MONTH) 24, (YEAR), written at 11:30 p.m. indicating, IV D5, 1/2 NSS, (an intravenous solution inserted into one vein to assist with hydration need, made up of, water, sugar and other additives), will start in the morning, after two tries not able to insert the line, supervisor made aware and stated keep her on the report. Nursing note dated (MONTH) 25, (YEAR), written at 12:30 p.m. indicated, Awaiting IV team to start IV fluids. Continued review of nursing progress notes dated (MONTH) 25, (YEAR), written at 11:00 p.m. indicated, medline IV site inserted at 6 p.m. waiting for pharmacy to deliver IV fluid. A (MONTH) 26, (YEAR), nursing note written at 8:00 a.m. indicated, Resident on [MEDICATION NAME] solution @ (at) 70 ml/hr (millileters per hour) intravenously for 24/hr. An additional nursing note on the same day, (MONTH) 26, (YEAR), written at 10:00 a.m. indicated, resident pulled IV out, 200 cc (cubic centimeters) of IV fluids inserted. Review of Resident R89's Medication Administration Record [REDACTED]. An interview with Employee E10, the Assistant Director on Nursing, on (MONTH) 24, (YEAR), at 5:15 p.m. confirmed that the physician order was never completed for Resident R89, related to IV D5, 1/2 NSS, as ordered by the physician for Resident R89, who needed additional hydration. Employee E10 further indicated that the IV D5, 1/2 NSS, is readily available and confirmed there was some IV D5, 1/2 NSS, currently available in the facility Emergency box (box where additional emergency related medications are kept) and indicated that it would have been available for administration to Resident R89 on (MONTH) 24, (YEAR), as ordered by the physician. The facility failed to properly monitor two residents with significant weight loss, notify the resident's physician of significant weight losses, ensure that recommendations to maintain resident body weight were completed in a timely fashion and did not ensure that physician order supplements and snacks were provided to residents as ordered, resulting in actual harm. 28 Pa. Code 211.5(f) Clinical records Previously cited 02/22/18, 03/01/17, 02/19/16 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/22/18 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 02/22/18, 08/11/17, 03/01/17, 02/19/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/22/18, 01/19/18, 08/11/17, 03/01/17, 02/19/16

Based on observations, interviews with residents and facility staff, and a review of facility documentation, it was determined that the facility failed to adequately monitor and maintain safe and comfortable air temperatures for all residents in the facility when outdoor temperatures exceeded 90 degrees Fahrenheit on July 23, 2016, and placed all of the residents in Immediate Jeopardy due to danger of significant adverse consequences. Findings include: An initial tour of the facility on July 23, 2016, at 10:00 a.m. revealed that the third, fourth, fifth and sixth floors in the facility were hot and humid. During the tour of the occupied living areas, such as resident rooms and the dining/activity areas, on all four floors, the room air felt extremely hot. Interview with Employee E1, Registered Nurse Supervisor, revealed that there was no maintenance staff in the facility at the time of the tour. Maintenance staff was requested to obtain the facility's thermometer to monitor room air temperatures. Personal small fans belonging to the residents were observed in various resident rooms. One box fan was observed on each nursing unit in the dining/activity room. The outside air temperature identified by the National Weather Service was 95 degrees Fahrenheit on July 23, 2016. Interview with Employee E4, Licensed Practical Nurse, on the 5th floor nursing unit, at 10:45 a.m. revealed that the temperature is usually fine and fans are available if needed and that the residents have not complained about the temperature. An interview with Employee E6, Licensed Practical Nurse, on the 4th floor nursing unit, at 10:50 a.m. revealed that the temperature on the unit is normally fine but if it is hot, hydration stations (areas where water is available to the residents) are available, residents are monitored every two hours to ensure that they have ice water and that no residents have complained about the temperature. An interview with Employee E7, Licensed Practical Nurse, on the 3rd floor nursing unit, at 11:00 a.m. revealed that Employee E7 had been working on the 3rd floor for three weeks and the temperature was fine until the temperature increased outside this week. The interview revealed that there are fans available, the residents are monitored every two hours for ice water and no residents have complained about the temperature. On July 23, 2016, at 11:15 a.m. observations and interview with Employee E2, a Cooler Operator (a person that works with cooling equipment such as air conditioners), revealed that one of the facility's two air compressor chillers (a portable system that acts as a water circulation system to an air conditioner system) was broken and that it was unknown how long the chiller had been down and when it would be replaced because the chillers are by two different owners. Employee E2 also stated that given the heat index outside this past week, it's hard to keep the building cool. Employee E2 did not have a facility thermometer. On July 23, 2016, at 11:30 a.m. a tour was conducted with Employee E3, Assistant Maintenance Director, on the third, fourth, fifth and sixth floors and room air temperatures were identified by the surveyor and Employee E3 using the facility's thermometer. The temperature identified by the surveyor and Employee E3 in resident room [ROOM NUMBER] was 85 degrees Fahrenheit and the resident was not present in the room. The temperature identified by the surveyor and Employee E3 in resident room [ROOM NUMBER] was 88 degrees Fahrenheit and the resident was not present in the room. Observation in resident room [ROOM NUMBER] revealed that the blinds were drawn to block the sun. The temperature identified by the surveyor and Employee E3 in room [ROOM NUMBER] was 83 degrees Fahrenheit. During an interview with Resident R20 at 11:50 a.m. while in this room, the resident stated, it is usually this temperature and I have asked for a fan. The temperature identified by the surveyor and Employee E3 in resident room [ROOM NUMBER] was 83 degrees Fahrenheit and the resident was not in the room. Interview with Employee E3 revealed that facility maintenance staff randomly checked temperatures in resident rooms during rounds or if there was a complaint. During this same interview, it was revealed that the facility was not aware of the current high temperatures in the resident rooms. On July 23, 2016, an interview with Employee E9, a HVAC 1 Specialist (a person with knowledge of air conditioning and heating systems), at 12:00 p.m. revealed that there were plans to replace the chiller. Employee E9 did not know when it would be replaced. At 12:20 p.m. Employee E9 left the facility to purchase 15 box fans to distribute on all four nursing units to decrease temperatures. Telephone interview on July 23, 2016, at 1:00 p.m. with the Nursing Home Administrator (NHA), revealed that the NHA knew the air compressor chiller was broken and did not know when the air compressor chiller would be replaced. Maintenance staff were instructed by the surveyor who was on-site to monitor the temperatures in every resident room, every two hours starting at 1:00 p.m. The temperatures on the sixth floor in resident rooms 609, 610, 611, 612, 613, 614, 615, 616, 617, 618, 619, 622, 629, 632, 635, 636, 638, and 639 were identified between 82 and 88 degrees Fahrenheit. The temperatures on the fifth floor in resident rooms 507, 510, 514, 515, 517, 518, 519, 520, 530, 531, 532, 533, 534, 535, 536, and 537 were identified between 82 and 85 degrees Fahrenheit. The temperatures on the fourth floor in resident rooms 406, 412, 413, 414, 415, 416, 417, 418, 419, 420, 428, 429, 430, 431, 432, 433, 434, 435 and 437 were identified between 82 and 86 degrees Fahrenheit. The temperatures on the third floor in resident rooms 313, 314, 315, 318 and 319 were identified between 82 and 84 degrees Fahrenheit. At 2:00 p.m. maintenance staff placed five box fans throughout each of the four nursing floors. The facility failed to monitor and maintain a temperature range of 71-81 degrees Fahrenheit during the current heat wave and failed to make timely interventions and increase monitoring of residents and the environment related to extreme temperatures. This failure placed the residents at risk for health consequences from extreme temperatures and caused an Immediate Jeopardy situation for all the residents. Immediate Jeopardy was identified on July 23, 2016, at 2:15 p.m. The facility's plan to correct the high temperatures throughout the facility included placing portable air conditioner units in the hallways; purchasing 15 box fans to place in resident rooms with high temperatures above 81 degrees Fahrenheit and 15 box fans to place in the hallways to circulate air until the replacement of the chiller; receiving 30 spot coolers from an outside contracting company to disperse on each nursing floor, the lobby and any other warmer areas; turning off hot water on all air conditioning units and activating cold water valves in all rooms with high temperatures; allowing the residents to relocate to cooler open rooms or to a sister facility with open beds; monitoring residents every two hours for comfort and providing hydration carts (area accessible to residents with cold water) in all patient areas; monitoring room temperatures every two hours until all temperatures are below 81 degrees Fahrenheit; and communication with the outside hospital to get an estimated time of arrival for any parts needed to repair the broken chiller. On July 23, 2016, at 2:45 p.m. surveyor on-site was notified by Employee E14, a hospital contract service employee, that 30 spot coolers (portable air conditioning unit) would be delivered to the facility to decrease the temperatures. At 5:00 p.m. the hospital contract service delivered the 30 spot coolers to the facility. Six spot coolers would be placed on each floor, two spot coolers would be placed in the facility lobby and two extra spot coolers would be placed in any other areas that were hot. At 5:30 p.m. a review of facility temperature logs revealed that air temperatures continued to range between 82 and 86 degrees Fahrenheit despite the use of the additional box fans on the four units. Maintenance staff were instructed surveyor on-site to monitor the temperatures in every resident room every hour. Observations on the third, fourth, fifth and sixth floors on July 24, 2016, at 9:30 a.m. revealed six spot coolers, three on each wing (north and south) of the unit delivering cool air. Observations of the resident rooms revealed that blinds were drawn for those residents with hot room temperatures. Interview with Employee E11, Maintenance Director, and Employee E16, Regional Environmental Service Director, revealed that air temperatures were decreased to 77-78 degrees Fahrenheit. On July 24, 2016, at 10:30 a.m. temperatures were obtained by the surveyor in random rooms during a tour. The temperature in room [ROOM NUMBER] was identified as 83 degrees Fahrenheit. Resident R12 stated the temperature was better and that the staff provided a box fan that was observed sitting next to Resident R12's bed. The temperature in room [ROOM NUMBER] was identified as 84 degrees Fahrenheit and the resident was not in the room. The temperatures in rooms 409, 418 and 415 were identified between 82 and 84 degrees Fahrenheit. Interview with Resident R20 in room [ROOM NUMBER] revealed that the staff provided the resident with a box fan to lower the temperature in the room. A box fan was observed in Resident R20's room and the blinds were drawn to prevent hot temperatures. Resident R21 was observed sitting in the hallway outside of room [ROOM NUMBER]. Interview with Resident R21 revealed that the staff provided a box fan for Resident R21 in room [ROOM NUMBER]. Resident R21 further stated that the temperature had gotten much better. An interview on July 24, 2016, at 11:35 a.m. with Employee E12, Clinical Services Director, revealed that Employee E12 and Employee E16, the Regional Environmental Services Director, were unaware that the air compressor chiller was broken. During this same interview, Employee E12 confirmed that maintenance staff would purchase ten oscillator (swings side to side) fans to help decrease the continued high temperatures on the sixth, fifth and fourth floors. On July 24, 2016, at 12:30 p.m., review of facility temperature logs revealed that air temperatures in resident rooms were between 71 and 80 degrees Fahrenheit. On July 24, 2016, at 1:18 p.m., the Immediate Jeopardy was removed due to corrective actions that were implemented by the facility. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 02/19/16 28 Pa Code 201.18(a)(e)(1) Management 28 Pa Code 201.18(b)(1)(3) Management Previously cited 02/19/16 28 Pa Code 207.2(a) Administrator's responsibility Previously cited 02/19/16

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to accurately assess, monitor, or complete timely treatments for two of nine residents with pressure ulcers reviewed (Residents R7 and R42), resulting in actual harm. Findings include: A review of Resident R7's MDS (Minimum Data Set - a periodic assessment of resident needs) dated 12/13/11, revealed [DIAGNOSES REDACTED]. A review of nursing progress notes, dated 2/21/12 at 2:35 pm, indicated that the resident was found with an open area on the sacrum. There was no documentation to indicate the size of the wound or a description of the wound's appearance. A nursing progress note, dated 3/3/12 at 3:40 PM, revealed that the resident complained that the buttocks area hurt. The nursing assessment identified 2 areas, a 5cm x 3cm and a 4cm x 3cm fluid filled blisters on the right buttock. A review of a wound consultants report, dated 3/5/12, indicated 2 wounds, a 2.5cm x 2.5cm pressure wound with depth on the sacrum and a 2.5cm x 2.3cm fluid filled blister on the right buttock. Nursing documentation, dated 3/8/12 at 11:30 PM, indicated that the 2 blisters on the right buttocks had opened. There again was no documentation as to the size or a description of the wounds. Review of a wound consultation completed 3/12/12, indicated that the resident had an unstageable necrotic (dead tissue) wound on the sacrum that measured 2.5cm x 3.0cm x an unspecified depth, that had deteriorated and one pressure wound on the right buttock, that measured 1.5cm x 1.0cm with a drainage. On 3/12/12 the wound consultant recommended changing the treatment to the unstageable pressure ulcer to Santyl (a [MEDICATION NAME] ointment to remove the dead tissue) and change the dressing every shift. A review of physician progress notes [REDACTED]. A review of the wound consultant's report, dated 3/19/12, indicated that the sacral wound now measured 2.5cm x 3.2cm x undetermined depth and had 85% thick adherent necrotic tissue, that required a surgical debridement of the wound. The consultant also identified a pressure ulcer on the right buttock that measured 1.1cm x 0.3cm x 0.2cm and was 50% slough (a separation of dead and live skin). The consultant recommended again changing the treatment, this time to calcium alginate ( a treatment for [REDACTED]. Observation of the wound treatments on 3/21/12, at 12:45 pm with employee E3 and E14, revealed a dressing on the wound that was dated 3/20/12 3-11 shift. The dressing that was removed was soaked with drainage and had not been completed on the previous 11-7 shift as ordered. When the dressing was removed there was a strong foul odor coming from the wound. The sacral wound appeared to be about 3.0cm x 3.0cm with a depth of 4.0cm in areas. This observation was confirmed by the employees performing the treatment. The nurse proceeded with the treatment and applied the Santyl in the sacrum wound and covered the wound with a dry dressing. There was no documentation that indicated that the physician had reviewed or initiated the wound consultants recommendation to change the treatment for [REDACTED]. There was no documentation to indicated that the treatments had been completed as ordered by the physician. There was no documentation to indicate that the physician had been notified of the wound consultant's recommendations regarding changing the treatment to the resident's wounds or that the physician had been notified of the deterioration on the wound. There was no nursing documentation that indicated that the staff was monitoring or assessing the size or description of the wound. An interview with Employee E2, on 3/22/12 at 11:00am confirmed that there was no additional documentation for review. Review of Resident R42's clinical record revealed nurse's documentation, dated February 6, 2012, which identified a 3 centimeter (cm) by 5 cm. Stage II pressure ulcer (partial thickness skin loss, superficial and presenting as a blister, abrasion, or shallow crater) on the resident's right buttock/hip. A March 19, 2012, review of Resident R42's current physician's treatment orders, updated March 7, 2012, found that Resident R42's right hip Stage IV (full thickness skin loss with extensive destruction, tissue necrosis/death, or damage to muscle, bone, or supporting structures)pressure ulcer was to be cleaned, then Santyl ([MEDICATION NAME], a sterile enzymatic [MEDICATION NAME] ointment, with the ability to digest collagen in necrotic tissue) applied and calcium alginate (an absorbent material made from seaweed, used with wounds with a large amount of drainage) twice daily (7am-3pm and 3pm-11pm). Observation of Resident R42 on March 21, 2012, at 1:50 p.m., with licensed nurse Employee E11, in preparation for wound treatment, found a folded bath towel tucked in the right side of the resident's incontinence brief, on top of a saturated dressing, labelled March 20, 2012, 7-3 (day shift). Interview with nursing Employee E12, on March 21, 2012, at 2 pm found that she had found Resident R42 that morning with a saturated hospital gown, brief, and linens wet from right hip wound drainage. Interview with licensed nurse Employee E11, on March 21, 2012, at 2 pm, found that she was unable to do the ordered pressure ulcer treatment, since the Santyl was unavailable. She confirmed that, the treatment was also not completed on March 20, 2012, during the 3-11 pm shift, and that a total of two ordered treatments were not completed on the pressure ulcer with large amount of drainage, and odor. Review of Wound Care Management Tracking documentation, dated March 19, 2012, found that the wound specialist physician had recommended packing the pressure ulcer with rope alginate, for drainage absorption. Clinical record review found physician's orders [REDACTED]. 28 Pa. Code 201.18(b)(1) Management Previously cited 4/28/11 28 Pa. Code: 211.12 (d)(1) Nursing services. Previously cited 6/22/11, 4/28/11, 2/03/11 and 1/06/11. 28 Pa. Code: 211.12 (d)(2) Nursing services. 28 Pa. Code: 211.12 (d)(5) Nursing services. Previously cited 6/22/11, 4/28/11, 4/13/11, 2/03/11 and 1/06/11.

Based on a review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to insure that preventative devices were in place and that residents were monitored for fall prevention, resulting in a fall with injury for one of three residents reviewed(Resident Cl1). Findings include: Review of Resident Cl1's Minimum Data Set, dated dated [DATE], revealed that the resident had [DIAGNOSES REDACTED]. This assessment further revealed that the resident had moderate impairment of cognition, and required one person assistance with transfers and ambulation. Review physician's orders [REDACTED]. Review of fall risk assessments, completed monthly, as part of the nursing summary, found that the resident had consistently presented as risk for falls, from admission onward (scoring consistently above 10, indicating fall risk). Review of the resident's plans of care found that a fall prevention care plan dated July 18, 2010 had been developed. Review of nurses's notes, dated November 2, 2010, revealed that the resident was found on the floor of the bedroom at 5:15 p.m., bleeding from a laceration to the left thumb. The physician was notified and ordered the resident to the hospital. A second nurses' note, also dated November 2, 2010, indicated that the resident returned from the hospital with 6 sutures in place. Review of a reportable event to the Department of Health, revealed that the resident was found on the floor of the dining room on November 3, 2010 at 5:00 a.m., complaining of pain to the left leg. The physician was notified and ordered the resident to the hospital which confirmed that the resident had sustained a fracture of the left hip. This report continued that the resident had been " very anxious and kept climbing out of bed" and had been placed in the dining room, specifically because he had experienced a fall, with injury, on November 2, 2010 and because of his "anxiousness." Review of nurses' notes, dated November 3, 2010, revealed that the resident was in the dining room being monitored by a nurse aide, Employee E3. The nurses' notes, dated November 3, 2011 stated that Employee E3, left the dining room and that when she was "walking back to the dining room" she saw the resident fall to the floor. This nurses' note, continued that on assessment, the resident grabbed his hip and stated he had broken his hip. The resident was sent to the hospital and x-rays at the hospital, dated November 3, 2011, confirmed a fracture to the hip. Nurses' notes, dated November 10, 2010, revealed that the resident was readmitted back to the facility on this date, status [REDACTED]. Review of the facility's incident investigation, dated November 3, 2010, revealed a statement from Employee E3 that confirmed that the aide had left the room to go to the restroom, leaving the resident in the dining room. Further review of this investigation found no evidence that the resident had a chair alarm as ordered and indicated under the heading "identify measures taken to prevent recurrence" that the licensed staff had written "ensure all resident's alarms are present and functioning." Review of the resident's care plan for fall risk, initiated July 8, 2010, revealed that the chair and bed alarm, first ordered in May 2010, were not added to this plan until November 3, 2010, after this fall. Interview with the administrator and the director of nursing on April 12, 2011, at 11:25 a.m. revealed that facility's investigation determined that the resident had been taken to the dining room for supervision as the resident had been awake, and attempting to climb from the bed, had a previous fall with injury and confirmed that the resident was to be monitored while in the dining room. This interview further confirmed that the resident should not have been left alone, that there was a lack of documentation concerning the resident's behavior, prior to this fall and that there was no evidence the chair alarm that was ordered, was in place at the time of the fall. The facility failed to insure that the resident had a chair alarm, as ordered and that the the resident was monitored to prevent falls, resulting in actual harm to this resident. 28 PA Code 201.18(a) Management. Previously cited 1/6/2011 28 PA Code 211.11(a)(c) Resident care plan. Previously cited 1/6/2011 28 PA Code 211.12(d)(5) Nursing services. Previously cited 1/6/2011