Every finding on record at Willows of Presbyterian Senior

Based on observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen which created the potential for cross contamination. (Main Kitchen)Findings include: During an observation on 9/22/25, at 9:30 a.m. it was revealed the ice machines in the main kitchen contained a brown substance inside the machine. During an interview on 9/22/25, at 9:50 am the Dietary Director E8 confirmed the brown substance in the ice machine and could not verify the last time it was sanitized creating the potential for cross contamination. 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for five of seven residents (Resident R38, R43, R44, R98, and R159), and failed to maintain the confidentiality of residents' medical information on one of nine medication carts (Third Floor West/Northwest Medication Cart).Findings include:Review of facility policy HIPAA (Health Insurance Portability and Accountability Act) -Privacy dated August 2025, indicated facility is dedicated to protecting the privacy of personal health information and is committed to maintaining confidentiality. During a tour and observation on 9/29/25, at 10:19 a.m. with Licensed Practical Nurse (LPN) Employee E4 the following sign was observed hanging on the wall in Resident R44's room:- Please help resident with her meals- My showers are Monday and Fridays 7-3- Hoyer lift at all times until further noticeDuring a tour and observation on 9/29/25, at 10:27 a.m. with LPN Employee E4 the following signs were observed hanging on the wall in Resident R98's room:- Right upper extremity passive range of motion with stretch to all joints, prior to putting on palm guard. - Resident to wear right palm guard for four hours daily, not during care.- Caregiver to perform skin integrity check pre and post wear and report any changes to nursing.- Gentle, slow, prolonged stretch to right wrist and knuckle joints when applying right palm guard- Palm guard -on in AM, off at dinner time to right hand. Complete skin checks and remove if irritation occurs- Positioning in wheelchair, Apply right half lap tray with pillow to elevate arm. If leaning left, apply rolled bath towel or personal pillow. During a tour and observation on 9/29/25, at 11:26 a.m. with LPN Employee E5 the following signs were observed hanging on the wall outside her room and above the bed in Resident R43's room:- Bilateral leg rests on except during meals- Resident fully to back of wheelchair- Resident midline in wheelchair- Towel roll between bilateral lower extremities at all times when up in wheelchair- Soft collar off at start of dinner, not to wear during meals- Maintain midline neck positionDuring a tour and observation on 9/29/25, at 11:27 a.m. with LPN Employee E5 the following sign was observed hanging on the wall in Resident R159's room:- Please do not transfer with right arm- Please no pink cream on at allDuring a tour and observation on 9/29/25, at 12:32 p.m. with Unit Manager LPN Employee E6 the following sign was observed hanging on the wall in Resident R38's room:- Resident up in wheelchair daily- Dycem (a nonslip material used to secure wheelchair cushions) on top of cushion- Resident to seat fully back in chair- Body midline- Armrest on left sideDuring an interview on 9/29/25, at 2:40 p.m. the Director of Nursing confirmed the above observations and that the facility failed to maintain the confidentiality of residents' medical information for five of seven resident rooms (Resident R38, R43, R44, R98, and R159).During an observation on 10/1/25, at 10:23 a.m. the Third Floor West/Northwest Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 10/1/25, at 10:25 a.m. Registered Nurse Employee E2 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the placement of a bed against the wall as a possible restraint, the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for three of three residents reviewed (Residents R6, R9, and R18).Findings include:Review of facility policy Physical Restraints dated August 2025, indicated physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed, and placing a resident on a concave mattress so that the resident cannot independently get out of bed.Review of facility policy Bed Rail dated August 2025, indicated bed rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). The use of bed rails as an assistive device will be addressed in the resident care plan.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/22/25, indicated diagnoses of gastroesophageal reflux disease (GERD - when stomach acid flows back into the esophagus, causing symptoms like heartburn), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and hemiplegia (paralysis on one side of the body). During an observation on 9/29/25, at 9:30 a.m. Resident R6 was observed lying in bed and the left side of the bed was pushed against the wall.Review of a physician order dated 9/30/24, indicated move bed against wall requested by family for better visitation and mobility. Review of Resident R6's comprehensive care plan failed to reveal goals and interventions related to placing the resident's bed against the wall. Review of Resident R6's clinical record failed to identify any assessments or ongoing evaluations for the placement of the resident's bed against the wall.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].Review of Resident R9's MDS dated [DATE], indicated diagnoses of aphasia (language disorder that affects communication), epilepsy (disorder of the brain characterized by repeated seizures), and anemia (too little iron in the blood).During an observation on 9/29/25, at 9:33 a.m. Resident R9 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on top and bottom portions. During an observation on 10/1/25, at 10:40 a.m. Resident R9's mattress was observed with bilateral raised edges on the top and bottom portions. During an interview on 10/1/25, at 10:46 a.m. Registered Nurse Employee E2 confirmed Resident R9's mattress had bilateral raised edges on the top and bottom portions, but was unsure if the raised edges were from bolsters or a concave mattress.During an interview on 10/1/25, at 1:04 p.m. Director of Rehab Services Employee E22 stated she was unsure if Resident R9 had bolsters applied to their bed or a concave mattress.Review of Resident R9's active physician orders on 9/29/25, failed to include an order for bolsters or a concave mattress.Review of Resident R9's comprehensive care plan on 9/29/25, failed to reveal goals and interventions related to the usage bolsters or a concave mattress.Review of Resident R9's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters or a concave mattress.Review of a physician order dated 10/1/25, indicated to install LAL (low air loss) mattress with bolsters for prevention of skin injury.Review of a physician order dated 10/1/25, indicated nurse will check LAL mattress with bolster for proper function every shift. Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE].Review of Resident R18's MDS dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and obesity. Section GG- Functional Abilities, Question GG0170A was coded 1, indicating Resident R18 was dependent upon staff to roll left and right. Section P - Restraints and Alarms, Question P0100 was coded 1, indicating Resident R18 used bed rails less than daily as a restraint.During an observation on 9/29/25, at 9:35 a.m. Resident R18 was observed lying in bed with bilateral side rails applied to the resident's bed.Review of a physician order dated 6/11/24, indicated bilateral side rails on bari-bed.Review of Resident R18's comprehensive care plan failed to include goals and interventions related to the usage of bilateral side rails. During an interview on 10/14/25, at 10:27 a.m. the Director of Nursing 2 confirmed that the facility failed to identify the placement of a bed against the wall as a possible restraint, the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for three of three residents reviewed (Residents R6, R9, and R18). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.8(e) Use of restraints.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Residents R7, R9, R10, R14 and R17).Findings include:Review of the facilties Transfer and Discharge policy dated August 2025, indicated each resident to remain in the community and not transfer or discharge the resident except in limited situations. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's Minimum Data Set (MDS - periodic assessment of care needs)dated 8/14/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fats in the blood).Review of the clinical record indicated Resident R7 was transferred to the hospital on 8/5/25, and returned to the facility on 8/9/25.Review of Resident R7's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].Review of Resident R9's MDS dated [DATE], indicated diagnoses of aphasia (language disorder that affects communication), epilepsy (disorder of the brain characterized by repeated seizures), and anemia (too little iron in the blood).Review of the clinical record indicated Resident R9 was transferred to the hospital on 6/21/25, and returned to the facility on 6/28/25.Review of Resident R9's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE].Review of Resident R10's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and chronic obstructive pulmonary disorder (COPD, a group of progressive lung disorders characterized by increasing breathlessness).Review of the clinical record indicated Resident R10 was transferred to the hospital on 7/24/25, and returned to the facility on 7/29/25.Review of Resident R10's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE].Review of Resident R14's MDS dated [DATE], indicated diagnoses of hyperlipidemia, arthritis (inflammation of one or more joints, causing pain and stiffness), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Review of the clinical record indicated Resident R14 was transferred to the hospital on 5/8/25, and returned to the facility on 5/13/25.Review of Resident R14's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.Review of Resident R17's admission record indicated the resident was admitted to the facility on [DATE].Review of Resident R17's MDS dated [DATE], included diagnoses of depression, cancer (a disease characterized by abnormal cell growth and division), and low back pain. Review of the clinical record indicated Resident R17 was transferred to the hospital on 9/14/25, and returned to the facility on 9/19/25.Review of Resident R17's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.During an interview on 10/14/25, at 10:04 a.m. the Director of Nursing 2 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Residents R7, R9, R10, R14 and R17).28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for four of seven residents (Residents R16, R18, R47, and R80).Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days), and an annual MDS assessment was to be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days.Resident R16 had an admission date of 8/27/25, with an MDS completion date of 9/9/25. The MDS was signed off as completed 9/10/25, one day after the due date.Resident R18 had an annual ARD of 6/6/26, and was due to be completed 6/20/25. The MDS was signed off as completed 6/22/25, two days after the due date.Resident R47 had an annual ARD of 5/27/25, and was due to be completed 6/10/25. The MDS was signed off as completed 6/11/25, one day after the due date.Resident R80 had an admission date of 7/7/25, with an MDS completion date of 7/20/25. The MDS was signed off as completed 7/21/25, one day after the due date.During an interview on 10/14/25 at 1:48 p.m. Registered Nurse Assessment Coordinator Employee E11 confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for four of seven residents (Residents R16, R18, R47, and R80)28 Pa. Code 211.5(f) Medical records.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for three of seven residents (Residents R19, R77, and R137).Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 calendar days after the Assessment Reference Date (ARD).Resident R19 had a quarterly ARD of 6/28/25, and was due to be completed 7/12/25. The MDS was signed as completed on 7/15/25, three days after the due date.Resident R77 had a quarterly ARD of 6/24/25, and was due to be completed 7/8/25. The MDS was signed as completed on 7/10/25, two days after the due date.Resident R137 had a quarterly ARD of 6/3/25, and was due to be completed 6/17/25. The MDS was signed as completed on 6/19/25, two days after the due date.During an interview on 10/14/25 at 1:48 p.m. Registered Nurse Assessment Coordinator Employee E11 confirmed that the facility failed to make certain that quarterly Minimum Data Set assessments were completed in the required time frame for three of seven residents (Residents R19, R77, and R137).28 Pa. Code 211.5(f) Medical records.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of five residents (Residents R1, R10, R98, R126, and R134).Findings include:Review of facility policy Oxygen Administration dated August 2025, indicated to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty or weekly. Keep delivery devices covered in plastic bag when not in use. Change nebulizer (a machine that delivers respiratory medication to person) tubing every week or as needed if they become contaminated. Keep delivery devices covered in plastic bag when not in use. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/13/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and end stage renal disease (ESRD, an inability of the kidneys to filter the blood). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Review of Resident R1's physician's orders dated 8/10/25, indicated oxygen two to four liters per minute via NC (nasal cannula - a lightweight tube that deliver oxygen through the nostrils) for chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Oxygen tubing and Humidifier change every night shift, every Sunday. Review of Resident R1's physician's orders dated 9/2/25, indicated to administer Ipratropium-Albuterol Inhalation Solution (a medication used to treat COPD) 3milligrams/3milliliters four times a day. During an observation on 9/29/25, at 10:00 a.m. Resident R1 was lying in her bed receiving two liters per minute of oxygen via NC. The oxygen tubing failed to have a date on it and the humidification bottle was dated 9/3/25. During an observation on 9/29/25, at 10:05 a.m. a nebulizer machine was sitting on Resident R1's counter. The nebulizer tubing failed to have a date on it and failed to be stored in a bag, when not in use.During an interview on 9/29/25, at 11:07 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed the missing dates on the humidification bottle, missing dates on the oxygen and nebulizer tubing, and the nebulizer not stored in a bag for Resident R1.Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE].Review of Resident R10's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the blood), high blood pressure, and chronic obstructive pulmonary disorder.Review of a physician order dated 7/29/25, indicated to administer oxygen at 2 liters per NC.Review of a physician order dated 7/29/25, indicated to apply BiPAP (noninvasive ventilation therapy used to assist with breathing) at bedtime for sleep apnea. Review of a physician order dated 9/11/25, indicated to change oxygen tubing and humidifier ever Wednesday night shift. During an observation on 9/29/25, at 9:26 a.m. Resident R10 was observed receiving oxygen at 2 liters per nasal cannula. The date on the humidification bottle was 9/18. During an observation on 9/29/25, at 9:28 a.m. Resident R10's BiPAP machine and mask were observed on the resident's dresser with the mask being stored on the dresser and not in a bag while not in use. During an observation on 10/1/25, at 10:38 a.m. Resident R10 was observed receiving oxygen at 2 liters per nasal cannula. The date on the humidification bottle was 9/18 and the bottle was empty. During this observation, Resident R10's BiPAP machine and mask were observed on the resident's dresser with the mask being stored on the dresser and not in a bag while not in use.During an interview on 10/1/25, at 10:48 a.m. Registered Nurse (RN) Employee E2 confirmed Resident R10's humidification bottle was empty and out of date and that Resident R10's BiPAP mask was not stored in a bag while not in use. During this interview, RN Employee E2 confirmed that the facility failed to provide appropriate respiratory care for Resident R10.Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE].Review of Resident R98's MDS dated [DATE], indicated diagnoses of heart failure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Review of Resident R98's physician's orders dated 1/11/25, indicated oxygen two liters per minute via nasal cannula every shift. Oxygen tubing and Humidifier change every night shift, every Wednesday. During an observation on 9/29/25, at 10:10 a.m. Resident R98 was lying in her bed resting with oxygen on. Observation of a portable oxygen tank (used when resident leaves room), sitting in the room, failed to have a date on the tubing and was not stored in a bag, when not in use. During an interview on 9/29/25, at 10:27 a.m. LPN Employee E4 confirmed the missing date on the portable oxygen tubing and was not stored in a bag, when not in use for Resident R98.Review of the clinical record indicated Resident R126 was admitted to the facility on [DATE].Review of Resident R126's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Review of Resident R126's physician's orders dated 6/16/25, indicated oxygen at two liters per minute. Oxygen tubing and humification change every week on Tuesday. During an observation on 9/29/25, at 10:27 a.m. Resident R126 was lying in her bed resting. The oxygen tubing was not hooked to the oxygen machine, and the nasal cannula was lying on the bed, not in Resident R126 ' s nostrils. The oxygen tubing and humidification failed to have a date on them. During an interview on 9/29/25, at 10: 29 a.m. the LPN Employee E4 confirmed the missing date on the oxygen tubing and the missing date on the humidification bottle for Resident R126. Review of the clinical record indicated Resident R134 was admitted to the facility on [DATE].Review of Resident R134's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure, and osteoporosis (condition when the bones become brittle and fragile). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Review of Resident R134's physician orders dated 9/30/25, indicated oxygen at two liters per minute via nasal cannula every eight hours as needed. Oxygen tubing and humification change every week on Wednesday.Review of Resident R134's physician orders dated 11/25/24, indicated Albuterol Sulfate Inhalation Nebulization Solution (medication used for respiratory conditions) three milliliters inhale orally via nebulizer every six hours as needed. During an observation on 9/29/25, at 11:00 a.m. Resident R134 was lying in her bed watching tv. The oxygen tubing was not dated. The nebulizer tubing was not dated and was not stored in a bag, when not in use.During an interview on 9/29/25, at 11:19 a.m. LPN Employee E5 confirmed the missing date on the oxygen tubing and the nebulizer tubing and was not stored in a bag for Resident R134.During an interview on 9/29/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for Residents R1, R98, R126, and R134.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for six of seven residents (Resident R43, R44, R57, R144, R150, and R159), and failed to maintain proper infection control practices related to the care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents (Resident R8). Findings include:Review of facility policy Infection Control - Infection Prevention and Control Program, most recently reviewed August 2025, indicated that this community has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our team member on infectious diseases, resident room placement, implementing isolation precautions, team member and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. All team members are responsible for following all policies and procedures related to the program.Review of facility policy Refrigerators and Freezers dated August 2025, indicated the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperature and will include time, temperature, initials, and action taken.During an observation on 9/29/25, at 10:19 a.m. Resident R44 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R44's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an observation on 9/29/25, at 10:20 a.m. Resident R144 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R144's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an observation on 9/29/25, at 10:21 a.m. Resident R57 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R57's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an observation on 9/29/25, at 10:22 a.m. Resident R150 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R150's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an observation on 9/29/25, at 11:26 a.m. Resident R43 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R43's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an observation on 9/29/25, at 11:27 a.m. Resident R159 had a small personal refrigerator on a counter in the room. The refrigerator failed to have a temperature log that included daily monitoring for Resident R159's personal refrigerator and failed to have a thermometer to determine acceptable temperature ranges. During an interview on 9/30/25, at 1:03 p.m. the Director of Nursing-1 (DON-1) stated the facility ordered thermometers for all the personal refrigerators and confirmed that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for Residents R43, R44, R57, R144, R150, and R159).Review of the clinical record indicated Resident R8 was originally admitted to the facility 5/16/25, recently readmitted [DATE].Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/1/25, indicated diagnoses of diverticulitis (inflammation of bulging pouches in the wall of the large intestine), atrial fibrillation (irregular heart rhythm), and bullous pemphigoid (rare autoimmune skin condition characterized by the formation of large, fluid-filled blisters). Section H0100 indicated that Resident R8 had an indwelling catheter. During a tour of the facility on 10/1/25, at 12:38 p.m., included Enhanced Barrier Precaution (EBP-a type of isolation), signage on Resident R8's door [with Personal Protective Equipment (PPE) stored in a bin prior to entering residents room.] Review of Resident R8's care plan revised on 9/29/25, indicated the resident has an indwelling urinary catheter related to skin breakdown and has the need for EBP related to potential for infectious disease as evidenced by indwelling foley catheter and multiple wounds. Review of Resident R8's current physician orders indicated EBP for multiple wounds. Additional current physician order indicated Urinary Catheter: 16 F (French), 5-10 cc (cubic centimeter) bulb.During an observation on 10/1/25, at 12:40 p.m., Resident R8's catheter draining bag was observed lying directly on the floor beside the bed.During an interview on 10/1/25, at 12:43 p.m., the Assistant Director of Nursing/Infection Preventionist (ADON/IP) Employee E3 confirmed observation that Resident R8's catheter draining bag was observed lying directly on the floor beside the bed, and that the facility failed to maintain proper infection control practices related to the care of indwelling urinary catheters for one of three residents (Resident R8).28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for two of seven residents (Resident R45 and R166).Findings include:Review of the facility policy Self-Administration of Medications dated August 2025, indicated residents in the facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. The staff and practitioner will document residents who are potentially capable of self-administering medications. The resident is asked to complete a bedside record indication of administration of the medication. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].Review of resident R45's Minimum Data Set (MDS-a periodic assessment of care needs) dated 7/24/25, indicated the diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and hyperlipidemia (a condition characterized by high levels of lipids(fats) in the blood).During an observation on 9/29/25, at 11:30 a.m. of Resident R45's room indicated a tube of Voltaren gel (a topical cream used to treat a specific area to reduce pain), a bottle of Miralax (used to treat constipation), and Systane eye drops was lying on the counter in residents ' room unsecured. Review of Resident R45's physician orders failed to include an order for self-administration of medications.Review of Resident R45's care plan failed to address self-administration of medications.Review of the clinical record indicated Resident R166 was admitted to the facility on [DATE].Review of R166's MDS dated [DATE], indicated the diagnoses of high blood pressure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).During an observation on 9/29/25, at 10:00 a.m. of Resident R166's room indicated a bottle of Venlafaxine (a medication used to treat depression) ER 150 mg (milligram) pills, a bottle of liquid pain reliever, a bottle of Emetrol (a medication used for upset stomach), and tube of Voltaren gel was lying on the counter in residents' room unsecured. Review of Resident R166's physician orders failed to include an order for self-administration of medications.Review of Resident R166's care plan failed to address self-administration of medications.During a tour and interview on 9/29/25, at 11:30 a.m. with Licensed Practical Nurse Employee E5 confirmed the unsecured medications at bedside and confirmed the absence of a physician order or care plan to self-administer medications for Residents R45 and R166.28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R19).Findings include:Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE].Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/19/25, indicated diagnoses of high blood pressure, arthritis (inflammation of one or more joints, causing pain and stiffness), and osteoporosis (condition when the bones become brittle and fragile).During an observation on 9/29/25, at 9:43 a.m. Resident R19 was sitting in a recliner in their room. The call bell was placed on Resident R19's bed, under the linens, out of the resident's reach.During an interview on 9/29/25, at 9:50 a.m. Registered Nurse Employee E1 confirmed Resident R19's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R19's call bell needs.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order for a wound vac for one of one resident (Resident R189).Findings include: A review of the clinical record indicated Resident R189 was admitted to the facility on [DATE], with diagnoses that included infection and inflammatory reaction due to internal right knee prosthesis, bacteremia (presence of bacteria in the bloodstream) and congestive heart failure (heart can ' t pump blood well enough to give your body a normal supply).A review of Resident R189's admission MDS (minimum data assessment) assessment- (periodic assessment of resident care needs) dated 9/29/25, indicated the diagnosis remained current. During an interview with Resident R189 on 9/29/25 at 10:30 a.m., R189 had a wound vac attached to the left hand side of her wheel chair. R189 stated it was for her knee. A review of Resident R189's physician orders dated 9/24/25 indicated no order for the wound vac.During an interview on 9/29/25, at 1:30 p.m. the Director of Nursing (DON)-1 confirmed the above findings and the facility failed to obtain an order for Resident R189's wound vac as required.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of three residents (Resident R6).Findings include:Review of facility policy Splinting dated August 2025, indicated there must be a physician's order for splinting. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/22/25, indicated diagnoses of gastroesophageal reflux disease (GERD - when stomach acid flows back into the esophagus, causing symptoms like heartburn), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and hemiplegia (paralysis on one side of the body). During an observation on 9/29/25, at 12:11 p.m. Resident R6 was observed wearing bilateral (both sides) palm guards (a brace used to prevent finger contractures and skin break down in the palm).During an interview on 9/29/25, at 12:12 a.m. Nurse Aide Employee E20 confirmed Resident R6 was wearing bilateral palm guards.During an observation on 10/1/25, at 10:32 a.m. Resident R6 was observed wearing bilateral palm guards.During an interview on 10/1/25, at 10:36 a.m. Registered Nurse Employee E2 confirmed Resident R6 was wearing bilateral palm guards and stated, Residents will have an order for splints and braces and it will be in their care plan.Review of Resident R6's active physician orders on 10/1/25, failed to include an order for bilateral palm guards.Review of Resident R6's comprehensive care plan on 10/1/25, failed to include the development of goals and interventions related to the resident's bilateral palm guard usage. During an interview on 10/14/25, at 12:52 p.m. the Nursing Home Administrator confirmed that the facility failed to develop a comprehensive resident-specific plan of a care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of three residents (Resident R6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R17).Findings include:Review of Resident R17's admission record indicated the resident was admitted to the facility on [DATE].Review of Resident R17's Minimum Data Set (MDS - periodic assessment of care needs) dated 8/29/25, included diagnoses of depression, cancer (a disease characterized by abnormal cell growth and division), and low back pain. During an observation on 9/29/25, at 9:24 a.m. Resident R17 was lying in her bed and a double lumen PICC line was observed in right upper arm. Resident R17 stated it was used for getting fluids once a week and for her chemotherapy medication.During a review of physician orders dated 9/24/25, indicated Sodium Chloride Solution 0.9% (a supplement of fluid used for hydration), give one liter every Wednesday.During a review of current physician orders on 10/1/25, failed to include any orders related to a PICC line, including the care of and maintenance. During an interview on 10/1/25, at 11:20 a.m. with Certified Registered Nurse Practitioner Employee E7 stated, She's been in and out of the hospital, so the orders probably just fell off her chart. I will put new orders in . During an interview on 10/1/25, at 11:26 a.m. Unit Manager Licensed Practical Nurse Employee E6 stated, I will reach out to the hospital to get the length of the PICC line for our records and confirmed that Resident R17's was missing orders for her PICC line.During an interview on 10/1/25, at 2:40 p.m. the Director of Nursing (DON)-1 confirmed that the facility failed to provide adequate treatment and care for a PICC line in accordance with professional standards of practice for one of two residents (Resident R17).28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, observation, and staff interviews, it was determined the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room).Findings:Review of facility Medication Disposal-Non-controlled Medications policy dated August 2025, indicated discontinued medications and medications left in the facility after a resident ' s discharge or death should be disposed of in a timely manner. Any non-controlled medication product that is discontinued should be appropriately documented on a Medication Reconciliation form.During a medication room review on 9/30/25, at 10:18 a.m. a plastic bin over filled with medication was observed sitting in the corner of the medication room, unsecured and unaccounted for. The medications observed were:- Tylenol (used for fever or pain) - 28 pills- Lovenox injections (used to prevent blood clots) - Two injections- Omeprazole (used to treat acid reflux) - Three pills- Gas Relief - Two bottle- Immodium (used to treat diarrhea) - 30 pills- Lactated ringers (used to replace fluid loss) - Three liters- Zebeta (used to treat high blood pressure) - Two pills- Atenolol (used to treat high blood pressure) - One pill- Namenda (used to treat dementia- a group of symptoms that affects memory, thinking and interferes with daily life) - Two pills- Heparin (used to treat or prevent blood clots) - Nine vials- Scopolamine (used to treat nausea) - 35 patches- Zofran (used to treat nausea)- 20 pills- Tylenol suppositories - 93 suppositories- Zoloft (used to treat depression) - Three pills- Mucinex (used to treat congestion) - Two bottles- Latanoprost eye drops - One bottle- Zyprexa (used to treat mental disorders) - One vial and one pill- Seroquel (used to treat mental disorders) - Two pillsDuring an interview on 9/30/25, at 10:45 a.m. When asked, What do you do with discontined medication? Licensed Practical Nurse Employee E21 responded, Overnight writes all the medication up.We have a reconciliation form to complete. Usually, they are medications that were discontinued or if resident is discharged , then they go back to pharmacy. The pharmacy delivers every day . During an interview on 9/30/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room).28 Pa. Code211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (Fourth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of nine medication carts (Third Floor West/Northwest Medication Cart).Findings include:Review of facility policy Skilled Nursing - Medication Storage dated [DATE], indicated during a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. All drugs and biologicals will be stored in locked compartments under proper temperature controls. Facility will ensure all medications housed on our premises will be stored in medication rooms according to recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a medication storage room review on [DATE], at 10:02 a.m. the following were observed:- Three 27 guage needles expired on [DATE].- Twelve 23 guage needles expired on [DATE].- Eleven 23 guage needles expired on [DATE].- Three ESwab (used to detect viruses or bacteria through a laboratory) expired.- Tuberculosis vial (a medication used to detect the presence of respiratory disease) was opened and failed to have an expiration date.During an interview on [DATE], at 10:18 a.m. Licensed Practical Nurse (LPN) Employee E21 confirmed the above findings. During an interview on [DATE], at 2:45 p.m. the Director of Nursing confirmed that the facility failed to properly store medical supplies in one of two medication rooms (Fourth Floor Medication Room).During an observation on [DATE], at 10:23 a.m. the Third Floor West/Northwest Medication Cart at the nurses station was left unlocked and unattended.During an interview on [DATE], at 10:25 a.m. Registered Nurse Employee E2 confirmed the above observation and that the facility failed to properly secure a medication cart while not in use.28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, facility submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers, which resulted in actual harm of a head contusion (bruise) for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134), and failed to ensure that residents were free from neglect for an unknown skin condition injury for one of four residents reviewed (Resident R134).Findings include:Review of facility policy Skilled Nursing - Abuse dated August 2025, indicated neglect is defined as the failure of the community, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of facility policy Skilled Nursing - Lifting and Transferring Residents dated August 2025, indicated it is the policy to lift/transfer residents as safely as possible. All residents requiring assistance with transfer will be transferred and/or lifted using mechanical device unless otherwise indicated by a physician order, or unless the resident is able to bear weight on his/her own. Mechanical lifts are done by 2 nursing/therapy personnel.Review of the facility policy Unexplained Injuries dated August 2025, indicated an investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual to ensure that the safety of our residents has not been jeopardized.Review of the facility policy Investigation of Incidents dated August 2025, indicated it is the policy of the facility to conduct a thorough and timely investigation of incidents and accidents.Review of facility Nurse Aide (NA) job description indicated the NA will follow each resident's/patient's plan of care to provide direct care to improve or maintain resident's/patient's abilities.Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE].Review of Resident R28's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/25, indicated diagnoses of high blood pressure, glaucoma (a group of eye conditions that can cause blindness), and anemia (too little iron in the blood). Review of facility submitted document dated 12/7/24, indicated the following: Administration was made aware on 12/9/24, that on 12/7/24 at 1930, the CNA (Certified Nurse Aide) was assisting the resident in the bathroom and bumped heads with the resident causing the resident to sustain a contusion (a bruise) to the left side of her head. The area was raised and bruised. It was 3 cm (centimeters) x 2 cm. There was no bleeding or laceration (a tear or cut in the skin). Upon investigation, it was noted that the CNA transferred the resident independently instead of a Sara lift (a mechanical lift). The aide stated that she wanted to hurry up and transfer the resident off of the toilet. Review of a witness statement dated 12/11/24, completed by NA Employee E9 stated, On 12/7/24 I was providing care from 3 pm - 7 pm on the 3rd floor. Prior to providing care for any patients I grabbed a day planner that correlated with my given assignment for that evening. Around 6:40 p.m. I provided care for Resident R28. When I went to transfer her, I transferred as a one assist no one was around to help, and the nurse also did not help with the transfer, so I transferred as a one assist. As I was transferring Resident R28 we had collided heads, she did not hit the floor, I was trying to prevent that, and that's when we collided heads. I got her in bed provided my care for her. When I was done with care, I noticed she had a knot forming on her head and that I was starting to swell and gain a headache as well. I got the nurse immediately to let her know what happened. We provided an ice pack for Resident R28, and I wrote my statement. I also asked one of the supervisors for medication because at that point I had a severe migraine. Review of a physician order dated 7/14/23, indicated Resident R28 transferred with Sara lift and assist x 2 at the time of the incident on 12/7/24.Review of the clinical record indicated Resident R117 was admitted to the facility on [DATE].Review of Resident R117's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of a facility submitted document dated 4/1/25, indicated the following: It was brought to administration's attention that on 4/2/25, Resident R117 sustained a skin tear to her right lower extremity following a transfer into her wheelchair and assistance was needed with first aid. The RN (Registered Nurse) immediately went to assess the resident and there was a 3 cm skin tear noted to Resident R117's right skin that was actively bleeding. Resident R117 stated, her CNA was transferring her from the toilet onto the chair and resident stood up and went to turn around and sit in her chair, then her CNA stated that she is bleeding. Resident R117 said I did not know how or what happened until CNA said I was bleeding she did not feel anything. Upon investigation, although Resident R117 is a transfer assist x 2, the CNA assigned to her did confirm that she transferred her by herself.Review of a witness statement dated 4/4/25, completed by NA Employee E10 stated, On Monday March 31, 2025. It was the beginning of my shift 3 pm - 11 pm. I went to my section to check on my residents as I always do. I can't remember if Resident R117 put her call light on or if was in her room already, but she said she needed to go to the bathroom. I said let me see where my aide is or find someone else to help, but everyone was busy with their residents. My hall aide still hasn't arrived yet. So, I went back to Resident R117's room to let her know I'm still looking for help. That's when Resident R117 said I really need to go can we just go in and I can stand and turn. I told her we need help. Resident R117 said I really need to go. I said I'll be back, so I went to look for help again but everyone was still busy. I still didn't know when my all aide was coming. Went back to Resident R117 room. Resident R117 said she really needs to go. Yes, I always use the Sara lift on her. I couldn't find help and I felt bad that Resident R117 needed to use the bathroom, so I took her in she did great. When Resident R117 turned to get back into her chair is when she got a skin tear. The nurse came in to fix Resident R117 leg up. After I got Resident R117 settled in chair, in her room.Review of a physician order dated 9/21/24, indicated Resident R117 transferred with Sara lift assist x 2 at the time of the incident on 3/31/25.Review of Resident R134's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R134's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and osteoporosis (condition when the bones become brittle and fragile). Resident R134's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R134's BIMS score was a 10 indicating Resident R134 was moderately impaired.During a review of a facility submitted document dated 1/9/25, indicated the following: It was brought to nursing administration's attention that at 0900, Resident R134 sustained a skin tear to her left lower extremity following a transfer into her wheelchair and assistance was needed with first aid. RN immediately went to assess the resident and there was a 6cm skin tear noted to Resident R134's left shin that was actively bleeding. I asked Resident R134 what happened, and she stated, I had to go to the bathroom and when I was transferred into my chair, I bumped my leg and got a cut. She also denied pain. First aid was completed and family and physician was made aware. Description of Follow-up Action: Upon investigation, although Resident R134 is a transfer assist of two, the NA assigned to her did confirm that she transferred her by herself. Although she had a day planner and nameplate sticker indicating Resident R134's transfer status, she immediately was educated on safe transfers and following transfer statuses. NA was then sent home and suspended pending investigation.During a review of witness statement dated 1/9/25, completed by NA Employee E23 stated, On 1/9/25, at around 8:00 a.m. Resident R134 put her call light on. I went to answer it and she told me she had to go to the bathroom. I did know she was a two person assist for transfers from shift-to-shift report, as well as my day planner. I walked down the north hall to check the charting station to see if anyone was there to help but I didn't see anyone. When I transferred Resident R134, her leg hit the wheelchair, and she got a skin tear. I got the nurse who started to apply first aid. The supervising nurse came to speak with me after this occurred to learn more about what happened. I told her everything that happened and that I did transfer her by myself since I didn't see anyone in the north hall.During an interview on 10/14/25, at 2:36 p.m. Assistant Director of Nursing (ADON) Employee E3 stated, I was the nurse that night who went to assess Resident R134. She was transferred with an assist of one and it should have been an assist of two. There was nothing wrong with her wheelchair, I checked it to make sure nothing was wrong with it. There was no sharp objects or anything. It ' s because her leg hit off the wheelchair due to a wrong transfer.During a review of a physician order dated 11/25/24, Resident R134 transferred with an assist of two at the time of the incident on 1/9/25.During an interview on 10/14/25, at 10:20 a.m. NA Employee E15 stated, We have a day planner that is updated daily to find a transfer status and our name badges have color codes on them that tell us what a residents transfer status is according to the color of sticker by their name. We also have relay radios that we can call for help if needed. We have skill reviews throughout the year and go over transfers. I would prepare the resident and call for help before I would transfer someone.During an interview on 10/14/25, at 11:11 a.m. NA Employee E16 stated, I wouldn't transfer a resident by myself if someone was an assist of two. We have papers we get every morning that tell us the transfer status. Something could happen or someone could get hurt if we transferred someone by ourselves.During an interview on 10/14/25, at 11:27 a.m. NA Employee E17 stated, I would check the color sticker on a resident's door and look on my name badge to find a transfer status. We have a day planner and care plans to look at. We have education all year long. I wouldn't transfer someone myself if they required two. They could get hurt.During an interview on 10/15/25, at 9:47 a.m. NA Employee E12 stated, Resident transfer statuses are on our census sheet and in a daily planner that tells you how to take care of a resident. If a resident was ordered to be transferred using a mechanical lift, I would never not follow the order. You need two people.During an interview on 10/15/25, at 9:51 a.m. NA Employee E13 stated, Resident transfer statuses are on our day planners. I absolutely would not transfer someone by myself if they were ordered to be transferred using a lift.During an interview on 10/15/25, at 9:54 a.m. NA Employee E14 stated, Resident transfer statuses are posted in several places. We have our day planner, and each resident has colored sticker outside of their room that correlates with a transfer status. No, I would never transfer someone by myself and against the order if they were ordered to be transferred using two people. During an interview on 9/30/25, at 2:24 p.m. the Director of Nursing (DON)-1 confirmed that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers, which resulted in actual harm of a head contusion (bruise) for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134).During an interview on 9/29/25, at 11:01 a.m. Resident R134 was sitting at bedside in a wheelchair with the tv on. Observation was made of a clear, see through, bandage on Resident R134's left forearm dated 9/4/25. During an interview on 9/29/25, at 11:19 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed the dressing and the date on the dressing. During a review of facility provided documentation of incidents and accidents failed to include an incident involving Resident R134's skin condition that required a dressing to her arm.During a review of Resident R134's clinical record on 9/29/25, at 11:30 a.m. Unit Manager LPN Employee E6 was unable to provide documentation for resident's skin condition, physician orders, progress notes, or skin follow up notes. Unit Manager LPN Employee E6 interviewed Resident R134, after State Agency (SA) brought it to the facility's attention. During an interview on 9/29/25, at 2:05 p.m. the Director of Nursing (DON) was made aware of Resident R134's dressing that was dated 9/4/25 and that no information, physician notification and orders, assessments, or progress notes were able to be provided. During an interview on 10/14/25, at 11:30 a.m. Unit Manager LPN Employee E6 stated, If an incident causing a skin condition happened, it should be measured, a nurse is to assess it and do an incident report. They should notify the physician for orders and notify family. I didn't see any of it was done. During an interview on 10/14/25, at 11:45 p.m. LPN Employee E18 stated, I would assess the site, measure, cleanse it, put a dressing on, document, and notify supervisor, physician and family. I would investigate and complete an incident report to figure out the cause.During an interview on 9/29/25, at 2:20 p.m. Director of Nursing confirmed that the facility failed to ensure that residents were free from neglect for an unknown skin condition injury for one of four residents reviewed (Resident R134).28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Findings include: Review of facility policy Skilled Nursing - Lifting and Transferring Residents dated August 2025, indicated it is the policy to lift/transfer residents as safely as possible. All residents requiring assistance with transfer will be transferred and/or lifted using mechanical device unless otherwise indicated by a physician order, or unless the resident is able to bear weight on his/her own. Mechanical lifts are done by 2 nursing/therapy personnel.Review of the facility policy Unexplained Injuries dated August 2025, indicated an investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual to ensure that the safety of our residents has not been jeopardized.Review of the facility policy Investigation of Incidents dated August 2025, indicated it is the policy of the facility to conduct a thorough and timely investigation of incidents and accidents.Review of facility Nurse Aide (NA) job description indicated the NA will follow each resident's/patient's plan of care to provide direct care to improve or maintain resident's/patient's abilities.Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE].Review of Resident R28's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/25, indicated diagnoses of high blood pressure, glaucoma (a group of eye conditions that can cause blindness), and anemia (too little iron in the blood). Review of facility submitted document dated 12/7/24, indicated the following: Administration was made aware on 12/9/24, that on 12/7/24 at 1930, the CNA (Certified Nurse Aide) was assisting the resident in the bathroom and bumped heads with the resident causing the resident to sustain a contusion (a bruise) to the left side of her head. The area was raised and bruised. It was 3 cm (centimeters) x 2 cm. There was no bleeding or laceration (a tear or cut in the skin). Upon investigation, it was noted that the CNA transferred the resident independently instead of a Sara lift (a mechanical lift). The aide stated that she wanted to hurry up and transfer the resident off of the toilet. Review of a witness statement dated 12/11/24, completed by NA Employee E9 stated, On 12/7/24 I was providing care from 3 pm - 7 pm on the 3rd floor. Prior to providing care for any patients I grabbed a day planner that correlated with my given assignment for that evening. Around 6:40 p.m. I provided care for Resident R28. When I went to transfer her, I transferred as a one assist no one was around to help, and the nurse also did not help with the transfer so I transferred as a one assist. As I was transferring Resident R28 we had collided heads, she did not hit the floor, I was trying to prevent that, and that's when we collided heads. I got her in bed provided my care for her. When I was done with care, I noticed she had a knot forming on her head and that I was starting to swell and gain a headache as well. I got the nurse immediately to let her know what happened. We provided an ice pack for Resident R28, and I wrote my statement. I also asked one of the supervisors for medication because at that point I had a severe migraine. Review of a physician order dated 7/14/23, indicated Resident R28 transferred with Sara lift and assist x 2 at the time of the incident on 12/7/24.Review of the clinical record indicated Resident R117 was admitted to the facility on [DATE].Review of Resident R117's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of a facility submitted document dated 4/1/25, indicated the following: It was brought to administration's attention that on 4/2/25, Resident R117 sustained a skin tear to her right lower extremity following a transfer into her wheelchair and assistance was needed with first aid. The RN (Registered Nurse) immediately went to assess the resident and there was a 3 cm skin tear noted to Resident R117's right skin that was actively bleeding. Resident R117 stated, her CNA was transferring her from the toilet onto the chair and resident stood up and went to turn around and sit in her chair, then her CNA stated that she is bleeding. Resident R117 said I did not know how or what happened until CNA said I was bleeding she did not feel anything. Upon investigation, although Resident R117 is a transfer assist x 2, the CNA assigned to her did confirm that she transferred her by herself.Review of a witness statement dated 4/4/25, completed by NA Employee E10 stated, On Monday March 31, 2025. It was the beginning of my shift 3 pm - 11 pm. I went to my section to check on my residents as I always do. I can't remember if Resident R117 put her call light on or if was in her room already, but she said she needed to go to the bathroom. I said let me see where my aide is or find someone else to help, but everyone was busy with their residents. My hall aide still hasn't arrived yet. So, I went back to Resident R117's room to let her know I'm still looking for help. That's when Resident R117 said I really need to go can we just go in and I can stand and turn. I told her we need help. Resident R117 said I really need to go. I said I'll be back, so I went to look for help again but everyone was still busy. I still didn't know when my all aide was coming. Went back to Resident R117 room. Resident R117 said she really needs to go. Yes, I always use the Sara lift on her. I couldn't find help and I felt bad that Resident R117 needed to use the bathroom, so I took her in she did great. When Resident R117 turned to get back into her chair is when she got a skin tear. The nurse came in to fix Resident R117 leg up. After I got Resident R117 settled in chair, in her room.Review of a physician order dated 9/21/24, indicated Resident R117 transferred with Sara lift assist x 2 at the time of the incident on 3/31/25.Review of Resident R134's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R134's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and osteoporosis (condition when the bones become brittle and fragile). Resident R134's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R134's BIMS score was a 10 indicating Resident R134 was moderately impaired.During a review of facility submitted document dated 1/9/25 indicated the following: It was brought to nursing administration's attention that at 0900, Resident R134 sustained a skin tear to her left lower extremity following a transfer into her wheelchair and assistance was needed with first aid. Registered Nurse (RN) immediately went to assess the resident and there was a 6cm (centimeter) skin tear noted to Resident R134's left shin that was actively bleeding. I asked Resident R134 what happened, and she stated, I had to go to the bathroom and when I was transferred into my chair, I bumped my leg and got a cut. She also denied pain. First aid was completed and family and physician was made aware. Description of Follow-up Action: Upon investigation, although Resident R134 is a transfer assist of two, the Nurse Aide (NA) assigned to her did confirm that she transferred her by herself. Although she had a day planner and nameplate sticker indicating Resident R134's transfer status, she immediately was educated on safe transfers and following transfer statuses. NA was then sent home and suspended pending investigation.During a review of witness statement dated 1/9/25, completed by NA Employee E23 stated, On 1/9/25, at around 8:00 a.m. Resident R134 put her call light on. I went to answer it and she told me she had to go to the bathroom. I did know she was a two person assist for transfers from shift-to-shift report, as well as my day planner. I walked down the north hall to check the charting station to see if anyone was there to help but I didn't see anyone. When I transferred Resident R134, her leg hit the wheelchair, and she got a skin tear. I got the nurse who started to apply first aid. The supervising nurse came to speak with me after this occurred to learn more about what happened. I told her everything that happened and that I did transfer her by myself since I didn't see anyone in the north hall.During an interview on 10/14/25, at 2:36 p.m. Assistant Director of Nursing (ADON) Employee E3 stated, I was the nurse that night who went to assess Resident R134. She was transferred with an assist of one and it should have been an assist of two. There was nothing wrong with her wheelchair, I checked it to make sure nothing was wrong with it. There were no sharp objects or anything. It's because her leg hit off the wheelchair due to a wrong transfer.During a review of a physician order dated 11/25/24, Resident R134 transferred with an assist of two at the time of the incident on 1/9/25.During an interview on 10/14/25, at 10:20 a.m. NA Employee E15 stated, We have a day planner that is updated daily to find a transfer status and our name badges have color codes on them that tell us what a residents transfer status is according to the color of sticker by their name. We also have relay radios that we can call for help if needed. We have skill reviews throughout the year and go over transfers. I would prepare the resident and call for help before I would transfer someone.During an interview on 10/14/25, at 11:11 a.m. NA Employee E16 stated, I wouldn't transfer a resident by myself if someone was an assist of two. We have papers we get every morning that tell us the transfer status. Something could happen or someone could get hurt if we transferred someone by ourselves.During an interview on 10/14/25, at 11:27 a.m. NA Employee E17 stated, I would check the color sticker on a resident's door and look on my name badge to find a transfer status. We have a day planner and care plans to look at. We have education all year long. I wouldn't transfer someone myself if they required two. They could get hurt.During an interview on 10/15/25, at 9:47 a.m. NA Employee E12 stated, Resident transfer statuses are on our census sheet and in a daily planner that tells you how to take care of a resident. If a resident was ordered to be transferred using a mechanical lift, I would never not follow the order. You need two people.During an interview on 10/15/25, at 9:51 a.m. NA Employee E13 stated, Resident transfer statuses are on our day planners. I absolutely would not transfer someone by myself if they were ordered to be transferred using a lift.During an interview on 10/15/25, at 9:54 a.m. NA Employee E14 stated, Resident transfer statuses are posted in several places. We have our day planner, and each resident has a colored sticker outside of their room that correlates with a transfer status. No, I would never transfer someone by myself and against the order if they were ordered to be transferred using two people. During an interview on 9/30/25, at 2:24 p.m. the Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and assistance for transfers to prevent accidents which resulted in actual harm of a head contusion for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134).28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. Findings include: Review of the facility policy Elopement Process dated August 2024, indicated an elopement assessment is completed upon admission, quarterly, annually, and if a resident actively attempts to elope. If they score a one or above on the elopement risk assessment an elopement device (alarm to alert staff of a resident going beyond a safe area), should be placed. Review of the facility policy Skilled Nursing- Elopement dated August 2024, indicated staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and history of falling. Review of the clinical admission V-19 form dated 5/10/25, at 10:17 p.m. indicated level of cognitive impairment as mild impairment (some confusion). Review of Elopement Evaluation Form dated 5/10/25, at 10:42 p.m. indicated that Resident R1 had an elopement score of zero. Not at risk. Review of Resident R1's progress note 5/12/25, at 3:09 p.m. indicated resident up ambulating (walking) with walker going into other resident rooms. Opening stairwell door. Redirected multiple times. EPD (elopement protection device) placed for safety. Review of Elopement Evaluation Form dated 5/13/25, at 11:08 a.m. indicated resident wanders aimlessly or non-goal directed: Yes. Wandering behavior likely to affect the safety or well-being of self/others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score 5. Review of physician orders dated 5/13/25, indicated wander guard (EPD) check function every day and placement every shift. Review of Resident R1's care plan dated 5/13/25, indicated resident is an elopement risk/wanderer. EPD applied to left upper extremity. Disoriented to place, impaired safety awareness, wanders aimlessly, significantly intrudes on the privacy or activities of others. Review of Resident R1's progress notes indicated the following: -5/13/25, at 8:32 p.m. thinking orientation: Person. Mental status: pleasant. Smiling delusions (misconceptions or beliefs that are firmly held, contrary to reality) Wandering. Ambulates with front wheeled walker and assist of one. Assist of one for all activities of daily living. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/14/25, at 9:36 a.m. thinking orientation: Person. Mental status: pleasant smiling delusions wandering. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/15/25, at 9:34 a.m. Thinking orientation: Person. Mental status: pleasant smiling delusions wandering. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/15/25, at 7:10 p.m. called to front lobby by Licensed Practical Nurse (LPN) Employee E1 who reports Resident R1 was found in parking lot walking with wheeled walker. When resident was found, EPD alarm was going off and the front door was pushed open. Resident was assessed, no injuries apparent. Weather at the time of occurrence was 72 degrees and sunny. Resident had no complaints of pain or discomfort. Appeared at baseline. On Call supervisor notified, physician ordered immediate transfer of resident to the fourth-floor dementia unit (a secure unit). -5/15/25, at 9:59 p.m. resident was seen in the parking lot of facility by a staff member about 7:00 p.m. with her front wheeled walker. She was redirected into the building. Elopement device intact and active at the time. Resident transferred to the lock down unit afterwards for safety. Resident's Son notified. Review of facility provided documentation dated 5/15/25, indicated Resident R1 was found in the front parking lot with her walker. Upon investigation the resident had an EPD on. The front entrance sliding doors where she exited were alarming and ajar as resident forced them open and off the hinges. The community's EPD system prevents the sliding doors from opening if the alarm sounds, but as they are also fire doors, they are able to be pushed open with force in case of emergencies. Entrance doors were pushed open and off hinges which showed this occurred. Resident was last seen by NA Employee E2 at 6:45 p.m. Further review of Resident R1's care plan dated 5/16/25, indicated the resident has impaired cognitive dementia, low safety awareness, has attempted to elope, wanders, need for locked memory unit. Review of Nurse Aide (NA) Employee E2's undated witness statement indicated he took Resident R1 back to her room at 6:45 p.m. while cleaning up after dinner. Placed her call bell, pinned to her shirt, in her room watching TV. Then, NA Employee E2 went on to care for other residents. Review of LPN Employee E1's witness statement dated 5/16/25, at 8:49 a.m. indicated at approximately 7:10 p.m. the front door was alarming. She turned off the alarm and noticed one of the sliding doors was pushed open. She looked outside and observed a resident walking in the parking lot and noticed an EPD on resident's walker. She redirected resident back inside the facility. When asked her name, the resident indicated an incorrect last name. Supervisor notified of both lobby and patio sliding doors being pushed open. Telephonic interview on 5/22/25, at 11:10 a.m. LPN Employee E1 indicated she was coming down off the elevator, heading towards the lobby. When she turned the corner, she could hear the alarm and proceeded to the front door where she saw Resident R1 outside with a EPD device. She indicated she did not hear the alarm until she turned the corner. When asked if she could hear the alarm at the nursing unit, she indicated no. Interview on 5/22/25, at 11:30 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and the failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. On 5/22/25, at 11:40 a.m., the Nursing Home Administrator was made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested. On 5/22/25, at 3:40 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R1 was moved immediately to the fourth-floor secured neighborhood after incident occurred on 5/15/25. Resident R1 was assessed for any injuries or psychosocial effects from incident, there were none. Physician and family were notified, care plan was reviewed and person-centered interventions were put into place. Administrator and Director of Nursing (DON) met with family the following day to review plan of care and interventions in place to reduce likelihood of reoccurrence. Residents: All residents in the facility will be assessed by the nursing team for elopement risk using the elopement evaluation tool within the electronic health record by 5/23/25. After all residents are assessed for elopement risk, their care plans will be audited by the nursing team or designee to ensure measurable, person-centered goals and interventions are implemented to prevent residents from eloping by 5/23/25. Root cause of elopement - due to team's lack of supervision, Resident R1 was able to elope outside of front entrance. On 5/16/25, vendor who oversees EPD system came in to ensure system functioned appropriately. Vendor installed four kiosks (One iPad kiosk in the neighborhood and three larger screens mounted on wall in each hallway) on each neighborhood that will audibly alarm in the event that a resident with an EPD is within range. This range was also expanded at this time to alert much earlier before the resident can get to the front entrance. Previously, this did not exist, and the audible alarm would be heard at the front of the building only. Moving forward, kiosks on each neighborhood were changed to ensure that they will alarm in the event that a resident with an EPD device gets in range of the front entrances and exits. System Correction: For any resident exhibiting new wandering behaviors, they will be placed on 15-minute checks by nursing team or designee. This will be documented within the electronic health record by the nursing team by 5/23/25. Physicians will be notified of their residents who are at wandering/elopement risk to collaborate for further interventions by 5/23/25. Administration will review and update policies to identify residents who are at risk for eloping by 5/23/25. A system check was completed on 5/21/25, by maintenance and administration to ensure entrances and exits alarms are functioning as intended. Vendor was contacted to install delayed egress feature on remaining stairwell doors. Monitoring: Whole house staff will be educated by the DON/designee on elopement risk and assessments, person-centered care plans, and supervision of residents before the start of their next shift. Ongoing audits will be completed to ensure residents are appropriately assessed for elopement risk, placed on proper safety checks, and person-centered care plan for elopement is implemented. This will be audited daily by DON/designee for seven days a week for two weeks, five days a week for two weeks and three days a week for two weeks. This incident will also be brought to Quality Assurance Performance Improvement meeting to review and prevent further incidents of this nature. Review of facility's Corrective Action Plan was verified and completed on 5/23/25, at 10:58 a.m. as follows: -Resident R1 was moved to the Fourth-floor secured neighborhood after elopement 5/15/25. -Resident R1 was assessed for injury and psychosocial effects with no new findings. -Physician and family were notified. -Care plan reviewed and person-centered interventions were put into place. Administrator and DON met with son to review the plan of care and interventions to reduce likelihood of recurrence. -All residents, 172 of 172, were re-assessed for elopement using the Elopement Evaluation within the electronic health record. Seven new wandering behavior residents were identified through this process. -Care plans for 172 of 172 residents were audited for measurable person-centered goals, and interventions were implemented to prevent residents from eloping. -Root cause of elopement was due to the team's lack of supervision. -Wander guard system was checked by the vendor to ensure functionality. Vendor installed four kiosks (one iPad in the neighborhood and three larger screens mounted on the wall in each hallway) that will audibly alarm in the event that a resident with a wanderguard was within range of the front entrance. -Prior to this installation, the audible alarm would only be heard if staff were in the front lobby. -All wandering/exit seeking residents' providers were updated 5/22/25, with a list of their respective residents who have been identified as wanders to ensure their collaboration is current. -Residents exhibiting new wandering behaviors will be placed on 15-minute checks by nursing team, moving forward. -New behaviors will be documented in the electronic health record by nursing upon discovery. -Physicians will be notified for further collaboration upon discovery. -The Administrator reviewed and updated the policy to identify residents who are at risk for elopement on 5/22/25, to include adequate supervision will be provided to help prevent accidents or elopements. -Five of five wandering exit/seeking behavior residents were care planned with person centered specific interventions on the Hickory Haven unit. -Nine of nine wandering exit/seeking behavior residents were care planned with person centered specific interventions on the Cedar Heights unit. 28 of 28 wandering exit/seeking behavior residents were care planned with person centered specific interventions on the [NAME] Gardens unit. Seven new residents identified as wandering exit/seeking behaviors through this process. Total of 42 of 42 wandering exit/seeking behavior residents had care plans reviewed. 289 of 298 signatures of all facility staff receiving and understanding education. 88 of all facility staff in person interviews verified receiving and understanding education on elopement and exit seeking behaviors. The Nursing Home Administrator was informed the IJ was lifted on 5/23/25, at 10:58 a.m. Exit interview on 5/23/25, at 11:30 a.m. information was disseminated to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement. This failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. 28 Pa. Code 201.14 Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29 Responsibility of Licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8). Findings included: Review of the facility policy Skilled Nursing-Comprehensive Care Plans dated August 2024, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the facility Elopement Process dated August 2024, indicated an elopement device should be placed if the resident scores a one or above on the elopement evaluation and are an elopement risk. Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and history of falling. Review of Resident R1's Elopement Evaluation Form dated 5/13/25, at 11:08 a.m. indicated resident wanders aimlessly or non-goal directed: Yes. Is the Resident's wandering behavior likely to affect the safety or well-being of self/others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of five. Review of the admission Record indicated Resident R2 was admitted to the facility on [DATE], with the diagnoses of dementia, repeated falls, and depression. Review of Resident R2's Elopement Evaluation Form dated 5/20/25, indicated resident wanders aimlessly or non-goal directed: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of two. Review of the admission Record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses of dementia, high blood pressure, and insomnia (a sleep disorder where individuals experience difficulty falling asleep, staying asleep or both, leading to daytime impairment). Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/10/25, indicated the diagnoses remain current. Review of Resident R3's Elopement Evaluation Form dated 4/22/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Elopement score of three. Review of the admission Record indicated Resident R4 was admitted to the facility on [DATE], with diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R4's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R4's Elopement Evaluation Form dated 4/1/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Elopement score of two. Review of the admission Record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hyperlipidemia (high levels of fat in the blood), and depression. Review of Resident R5's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R5's Elopement Evaluation Form dated 4/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of four. Review of the admission Record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses of heart failure (heart doesn't pump blood as well as it should), insomnia, and hyperlipidemia. Review of Resident R6's Elopement Evaluation Form dated 5/12/25, indicated Does the resident wander: Yes. Elopement score of one. Review of the admission Record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), high blood pressure, and heart failure. Review of Resident R7's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R7's Elopement Evaluation Form dated 4/26/25, indicated Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.): Yes. Elopement score of three. Review of the admission Record indicated Resident R8 was admitted to the facility on [DATE], with diagnoses of anemia, high blood pressure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident R8's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R8's Elopement Evaluation Form dated 3/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of three. Review of eight of eight exit seeking/wandering resident care plans mimicked each other and did not identify any resident person-centered interventions and/or goals specific to each resident. -Resident R1's care plan dated 5/13/25. -Resident R2's care plan dated 5/20/25. -Resident R3's care plan dated 5/21/25. -Resident R4's care plan dated 4/2/25. -Resident R5's care plan dated 4/3/25. -Resident R6's care plan dated 5/15/25. -Resident R7's care plan dated 5/21/25. -Resident R8's care plan dated 5/14/25. Eight of eight resident care plans had almost identical goals of the following: -The resident's safety will be maintained through the review date. -The resident will demonstrate happiness with daily routine through the review date. -The resident will not leave facility unattended through the review date. Eight of eight resident care plan interventions had almost identical interventions of the following: -Assess for fall risk -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers: -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -Monitor for fatigue and weight loss. -Provide structured activities; toileting walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Interview on 5/23/25, at 11:30 a.m. the Director of Nursing confirmed the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8). 28 Pa. Code 201.24(e)(1)-(5) Admissions Policy 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policies, documents and staff interviews it was determined that the facility failed to report to the State agency an allegation of misappropriation of resident property as required. (Allegation of misappropriation of resident property). Findings include: A review of facility Skilled Nursing - Abuse policy dated 8/24, revealed that the purpose of the policy is to comply with the seven step approach to abuse and neglect detection and prevention. Abuse is defined to include misappropriation of resident property. Step seven of the approach includes reporting the allegation to the proper agencies. During a review of facility documents submitted to the state agency it was revealed that the facility failed to notify the state agency of allegations of facility staff improperly destroying medications no longer prescribed for the resident as required. During a staff interview on 5/21/25 at 9:00 am the Nursing Home Administrator and Director of Nursing revealed that they were aware of allegations of staff members inappropriately destroying resident medications. The facility began an investigation into the allegation and developed new procedures for the destruction of medications no longer prescribed for the resident but failed to report the investigation to the state agency. During a staff interview on 5/21/25, at 9:00 am the Director of Nursing confirmed that the facility failed to notify the state agency of allegations and an investigation of the allegation for improper destruction of resident medications (misappropriation of resident property) as required. Pa Code: 201.14(a)(c) Responsibility of licensee Pa Code 201.20(b) Staff development

Based on review of facility policy and documents, clinical record, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella (knee) fracture, for one of two residents reviewed (Resident R1). Findings include: Review of facility policy, Skilled Nursing - Investigation of incidents update August 2024, indicated the purpose is to establish guidelines for investigations of incidents and accidents to determine the root cause of the event and to identify systemic changes and measures needed to prevent future incidents. The facility will conduct a thorough and timely investigation of incidents and accidents. If the accident/incident is related to resident care, in order to decide whether or not to substantiate abuse/neglect, begin by establishing the facts of the situation. Review of the clinical record indicated Resident R1 was admitted to facility 4/7/2020. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/4/25, included diagnoses epilepsy (brain condition that causes reoccurring seizures), history of falls, and muscle weakness. Section C0500 the Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact. Resident 1's score of 15. Review of Resident R1's clinical record progress note date 4/7/25, at 1:55 p.m., indicated CNA (nurse aide) came to this nurse due to resident complaining of pain. Resident stated that the driver was transferring her off the van and her left leg fell off the footrest and her left leg dragged under the wheelchair, and she told him to stop, and he keep pushing her in the wheelchair and she then came back to the facility and keep feeling the pain in her left leg. This nurse contacted CRNP (certified registered nurse practitioner) to obtain x-ray on the left leg tib (tibia), fib (fibula), knee. Review of facility submitted information dated 4/8/25, indicated, Resident R1 was complaining of left leg pain. Resident R1 stated her leg fell off the leg rest and got caught under the wheelchair during transport from her audiology appointment earlier in the day. The driver accidentally dragged her foot under the wheelchair causing her to say, ouch, stop. The knee was painful to touch and slightly swollen. CRNP was notified and ordered imaging. Imaging showed a patella fracture to left leg. Order obtained to send Resident R1 to the hospital for evaluation. The driver stated, her leg fell off the footrest and he didn't notice. He also stated that he did not realize she was hurt so he did not notify anyone. Review of facility provided document dated 4/7/25, indicated that Van Driver (VD) Employee E1 was transporting Resident R1 back to the facility from an appointment. He (Employee E1) took her (Resident R1) down the lift with no issue. After getting into building, Resident R1 said Ouch, which alerted Employee E1 to stop and see what the issue was; he noticed that the footrest had fallen off and that her (Resident R1) left leg was caught under the wheelchair. He (Employee E1) pulled the wheelchair backwards to get her leg free. He picked up the footrest, placed it back on the wheelchair, and put her (Resident R1) foot back on the footrest. Review of an employee statement written by Receptionist Employee E2 dated 4/17/25, indicated that Resident R1 was coming from an appointment. As the driver was pushing her through the first set of sliding doors, a scream of pain was heard. The second set of doors opened, and a bystander stopped them and put her foot back on the footrest; it was bent under the footrest. Resident R1 told him (VD Employee E1) that she was okay, and they went to the elevator. Review of facility provided document dated 4/7/25, indicated a diagnostic X-ray (medical imaging used to capture pictures of the inside of the body, particularly the bones) was completed of the left knee revealing a mid-patella fracture. Review of emergency room documentation dated 4/8/25, indicated that Resident R1 was treated for acute nondisplaced transverse fracture inferior patella of the left leg. Review of Resident R1's clinical progress note dated 4/8/25, at 4:28 a.m., indicated resident returned from hospital. Left leg in locking brace. Discharge instructions reviewed and approved by physician services. During an interview on 5/8/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella fracture, for one of two residents reviewed (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies.