Every finding on record at York Nursing and Rehabilitation Center

Based on observations, clinical record review, facility documentation, and staff interviews, it was determined that the facility failed to ensure residents were free from physical restraint that was not required to treat the resident's medical or behavioral symptoms for one of three residents reviewed (Resident R1). This deficiency was cited as past noncompliance. Findings include: Review of facility policy titled Nursing Home Abuse and Restraints, last revised December 13, 2024, states, Anything that restricts movement and the resident cannot remove independently examples include lap belts, tied wheelchairs, restrictive bed rails, geri chairs used to prevent standing. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of parkinsonism (umbrella term that refers to brain conditions that cause slowed movements, stiffness, and tremors), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), dysphagia (difficulty swallowing), unspecified hearing loss, and history of falling. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated May 23, 2026, revealed a Brief Interview for Mental Status (BIMS - cognitive assessment used to evaluate orientation and memory) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment. A review of Resident R1's comprehensive care plan dated October 15, 2025, revealed that Resident R1 had an Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). The goal stated that Resident R1 will maintain their current level of functioning throughout the review period. The intervention for locomotion indicated that Resident R1 uses a Geri chair (large, padded chairs with wheeled bases) for mobility. Continued review of Resident R1's comprehensive care plan revealed the resident has a communication problem due to a language barrier; the resident speaks Korean and can understand English but has an unspecified hearing loss in the left ear. The communication intervention includes communicating with Resident R1 in Korean. Further review of Resident R1's comprehensive care plan revealed the resident is at high risk for falls related to the new environment and independent ambulation. Fall interventions include following the fall protocol, such as using a Geri chair for positioning, removing excess equipment, supplies, and furniture to prevent falls, securing locks on beds, stretchers, and wheelchairs, keeping the bed in the lowest position when practical, maintaining clutter free and obstacle free floors, and ensuring adequate lighting. A review of facility documentation submitted to the state survey agency, dated July 4, 2026, revealed on July 4, 2026, allegations of resident abuse was reported to the Nursing Home Administrator (NHA), Employee E1, that Resident R1 was found at the nurse's station with a sheet wrapped around him/her. Nurse aide, Employee E5, assigned to Resident R1, was suspended pending outcome of abuse investigation. Review of facility documentation revealed an investigation update was submitted to the state survey agency on July 8, 2026, that revealed the alleged perpetrator, Nurse Aide, Employee E5, was subsequently terminated as the facility substantiated allegations of abuse against nurse aide, Employee E5. Statements obtained indicated that Resident R1 was last seen in his/her geri chair at the nurse's station at approximately 6:00 a.m., with nothing securing the resident. At 6:15 a.m. a sheet was observed around Resident R1's lower chest, securing him/her to the geri chair. Sheet was removed at 6:15 when observed. Supervisor assessed Resident R1, a skin check and pain assessment were completed, and no injuries noted from this event. Resident R1 showed no signs of emotional distress. Review of facility documentation/investigation revealed a written statement dated July 4, 2026, submitted by Nurse Aide, Employee E7. Nurse aide, Employee E7, reported, When I went to get Resident R1 ready in the morning-because I was assigned to dress him/her every morning-I tried to help him/her out of the chair, but I couldn't. Then I realized Resident R1 was tied to the chair. I called the nurse, Employee E6, and he/she saw it too. The nurse, Employee E6, asked who had tied Resident R1. Nurse aide, Employee E5, said it wasn't him/her, even though he/she was the one who had been assigned to watch Resident R1 throughout the night. Review of facility documentation/investigation revealed a written statement dated July 4, 2026, submitted by Licensed Nurse, Employee E6, revealed Licensed Nurse, Employee E6, walked over to nurses' station to get something. Licensed nurse, Employee E6, heard nurse aide, Employee E7, asking Resident R1 to stand up to get dressed. It was further observed Resident R1 could not move and was tied to [NAME] chair with flat sheet. Per the statement, at 6:00 a.m. Resident R1 was not covered in sheets or blankets. At 6:15 a.m. nurse noted Resident R1 had sheet around him/her. Review of facility documentation/investigation revealed a written statement dated July 4, 2026, submitted by nurse aide, Employee E5, who was identified as the alleged perpetrator who tied Resident R1 to the geri chair with a sheet. Review of the written statement by nurse aide, Employee E5, revealed he/she wrapped up Resident R1 in several blankets and sheets but denied to have tied him/her up. Nurse aide, Employee E5, stated he/she wrapped Resident R1 with sheets because the air conditioning was on and Resident R1 was cold. Telephone interview conducted on July 22, 2026, at 12:14 p.m. with Nurse Aide, Employee E7, who worked from 11:00 p.m. to 7:00 a.m. on the overnight shift from July 3, 2026, to July 4, 2026. Interview with nurse aide, Employee E7, revealed Resident R1 was not on his/her assignment, but he/she typically gets Resident R1 up every morning at approximately 5:50 a.m. Nurse aide, Employee E7, reported he/she saw Resident R1 in the geri-chair covered with a sheet. Nurse aide, Employee E7, asked Resident R1 to get up, and Resident R1 could not stand, although noted Resident R1 was always able to stand up. Nurse aide, Employee E7, removed the sheet covering off Resident R1, and saw that Resident R1 was tied to the geri-chair with another sheet. Resident R1 was observed with a sheet wrapped around his/her waist and stomach area and was tied in the back. Resident R1's arms and hands were not tied, only the waist area. Nurse aide, Employee E7, notified Licensed Nurse, Employee E6. Licensed Nurse, Employee E6, saw Resident R1 tied up, and questioned Nurse Aide, Employee E5, who stated he/she was unsure who tied the resident and did not know how long Resident R1 was tied for. Telephone interview on July 22, 2026, at 12:30 p.m., with Licensed Charge Nurse, Employee E8, revealed he/she worked from 11:00 p.m. to 7:00 a.m. on the overnight shift from July 3, 2026, to July 4, 2026. Licensed nurse, Employee E8, revealed Resident R1 is a fall risk and normally stays at the nurse's station. Resident R1 is frequently awake and does not sleep through the night. Resident R1 is always getting up and walking into other residents' rooms. Licensed nurse, Employee E1, indicated Resident R1 has dementia, walks independently, and does not need a walker or wheelchair. Telephone interview on July 22, 2026, at 12:30 p.m., Licensed nurse, Employee E8, reported around midnight during his/her overnight shift on July 3-July 4, 2026, he/she administered Resident R1's medications. Resident R1 was in the geri chair that night around midnight, reclined, while Employee E5 was eating lunch. Resident R1 attempted to get up out of the geri chair and nurse aide, Employee E5, became frustrated. Resident R1 was able to successfully get up. Licensed nurse, Employee E8, told nurse aide, Employee E5, to be patient with Resident R1. Licensed nurse, Employee E8, went to get lunch and came back around 12:20 a.m., and Resident R1 was asleep. Continued telephone interview on July 22, 2026, at 12:30 p.m., Licensed nurse, Employee E8, reported he/she was coming back from a break around 6:30 a.m. on July 4, 2026, and was informed by Licensed Nurse, Employee E6, that Resident R1 was found tied to the geri chair. When licensed nurse, Employee E8, arrived at the nursing unit, Resident R1 was already untied. Licensed nurse, Employee E8, stated on July 4, 2026, at approximately 6:30 a.m. he/she pulled nurse aide, Employee E5, into the room and asked if he/she tied Resident R1 to the chair. Nurse aide, Employee E5, admitted to tying Resident R1 and said, 'Yes, I did tie him/her but then wrote a statement denying the allegations. Licensed nurse, Employee E8, did not know how long Resident R1 was tied up for. On July 22, 2026, at 12:53 p.m., an attempted telephone call was made to obtain a phone interview with, nurse aide, Employee E5, however, the attempt was unsuccessful. On July 22, 2026, at 1:17 p.m., an interview was conducted with Resident R1, who was sitting in the activity room in a wheelchair. Resident R1 was not able to answer any questions due to impaired cognitive status. Resident R1 was not in any distress. On July 22, 2026, at 2:17 p.m. an interview conducted with the Nursing Home Administrator, Employee E1, confirmed that facility substantiated the allegation of abuse related to use of physical restraint and terminated nurse aide, Employee E5. This deficiency was cited as past non-compliance. Review of the facility's action plan revealed the following information: Assigned aide was placed on suspension. Resident R1 was assessed for injury. Pain assessment completed on Resident R1 and Skin assessment completed on Resident R1. 27 residents in geri chair were audited to ensure blankets/sheets were not secured around the resident restricting movement. Residents on nurse aide, Employee E5, unit screened as follows: Residents with BIMS of 11 or less had skin assessment completed, residents with BIMS of 12 or greater were interviewed for any care related and safety concerns. Social service visited resident for emotional support. Trauma Informed Care plan for Resident R1 was initiated on July 8, 2026. House wide education on Abuse with a focus on the use of restraints or any unauthorized mechanism of restraints. Director Of Nursing education to Supervisors, Managers regarding timely reporting for incidents. Administrator and DON reviewed abuse, type of abuse, abuse reporting and reviewed resident's rights. Continued Quality Assurance and Performance Improvement (QAPI) audits implemented to ensure enhanced system compliance or stabilized improvement. Based on the completed corrective actions and monitoring, the facility determined the deficient practice to be past noncompliance effective as of July 8, 2026. Facility education records and subsequent audits were verified as complete. Staff were interviewed to confirm completion of education on the facility's policies regarding physical restraints, abuse, and the improper use of geri chairs and sheets as a form of physical restraint. Additional staff interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, staff interviews, or observation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.12(d)(1) Nursing services. 28 Pa. Code 211.8(e)(f) Use of restraints.

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for seven of thirty-four residents reviewed (Residents R1, R2, R3, R5 and R6).Findings include: Review of the Food Temperatures policy, effective January 17, 2019, revealed that foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 50 degrees for cold foods and at or above 125 degrees for hot foods. Point of service temperatures should be palatable to the taste. A tour of the nursing units on June 4, 2026, revealed the following: Interview with Resident R1, at 11:17 a.m. revealed that he thought the food sucks, that it's cold all the time and was just terrible. Interview with Resident R2, at 11:25 a.m. revealed that she thought the food was not great, it was always late and not very warm when it comes. Interview with Resident R3, at 11:30 a.m. revealed that food sucks, they don't care what we ask for they just send us whatever they want. The menu is monotonous, it seems like it is always chicken. I'm a diabetic and I always get starchy things like pasta, spaghetti and meatballs, etc. Breakfast today was after 9:00 a.m., what happened to 8:30 a.m. When they deliver the carts, they just push them off the elevator and don't tell anyone, no wonder our trays are always late. Interview with Resident R5, at 11:36 a.m. revealed that they give him foods that he is allergic to. The meal trays are late, the food is cold by the time we get it. They do not provide me an alternative to the foods that I do not like or can't have, like pork. Interview with Resident R6, at 11:17 a.m. revealed that the food is the same thing all the time. The food is not warm when it comes and overcooked, the fish is like a brick. Observations during a test tray conducted with the Assistant Food Service Director, (AFSD) Employee E12, on June 4, 2026, at 12:05 p.m. revealed that the mixed vegetable was 122 degrees, Cheesesteak sandwich was 124 degrees. The rice was served with gravy and was not appetizing, the hot food was barely warm and not an appetizing temperature. Interview with the AFSD on June 4, 2026, at 12:25 p.m. confirmed the above findings and that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on interview with resident and staff, review of clinical record and facility provided documentation, it was revealed that facility did not ensure to administer medications according to professional standards of practice for two of five residents reviewed (Residents R1, R12)Findings include: Review of facility policy 'Administering Medications,' revised June 1, 2025, states that the individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Review of medication administration report revealed Resident R1 was administered the following medications at times which were not in accordance with physician orders on, April 9, 2026: Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol, Powder, breath activated Give 2 puff by mouth two times a day for SOB, Scheduled time at 9:00 a.m.; Administered at 10:41 a.m.; Scheduled time: 5:00 p.m.; Administration Time: 6:47 p.m.Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT Scheduled time: 9:00 a.m.; Administration Time: 10:37 a.m.Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduled time: 9:00 a.m.; Administration Time: 10:41a.m.Mucinex Oral Tablet Extended Release 12 Hour 600, MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days; Scheduled time: 9:00 a.m.; Administration Time: 10:38 a.m.Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI (urinary track infection) for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 10:37 p.m.Albuterol Sulfate Nebulization Solution (2.5 MG/3ML), 0.083% 3 ml inhale orally via nebulizer every 6 hours for COPD Supplementary; Scheduled time: 12:00 p.m.; Administration Time: 1:48 p.m.Review of medication administration report revealed Resident R1 had the following medications administered on April 10, 2026 which were not in accordance to the time frame prescribed by the physician.Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder, breath activated Give 2 puff by mouth two times a day for SOB; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days: Scheduled time: 9:00 a.m.; Administration Time: 11:35 a.m.Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 11:35 a.m.Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduled time: 9:00 a.m.; Administration Time: 11:35 p.m.Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale orally via nebulizer every 6 hours for COPD Supplementary; Scheduled time: 12:00 p.m.; Administration Time: 1:14 p.m.Review of medication administration report revealed Resident R1 was administered the following medications at times which were not in accordance with physician orders on April 11, 2026 (a.m.): Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth every 12 hours for DVT; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder, breath activated Give 2 puff by mouth two times a day for SOB; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for 14 Days: Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every 12 hours for UTI for 5 Days X 5 days; Scheduled time: 9:00 a.m.; Administration Time: 11:05 a.m.Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 2 sprays in both nostrils two times a day for seasonal allergies for 30 Days; Scheduled at 9:00 a.m., administered at 11:05 a.m. Interview with Resident R12 on Monday, April 20, 2026, at 10:00 am, indicated that medications were not administered timely on April 15, 2026, April 16, 2026, and April 17, 2026; Resident R12 expressed concerns for late medication administration since (she/he) takes medications for diabetes and heart issues. Review of medication administration audit report revealed Resident R12 had the following medications administered on Wednesday, April 15, 2026:Metoprolol Succinate Extended Release (ER) 25 mg scheduled at 8:00 a.m., administered at 3:21 p.m.Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 3:33 pm.Provera 10 mg, scheduled at 9:00 a.m , administered at 3:21 pm.Diltiazem HCL ER 120 mg, scheduled at 9:00 a.m., administered at 3:32p.m.Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 3:21 p.m.Losartan Potassium 100 mg, scheduled at 9:00 a.m, administered at 3:21 p.m.Further review of Resident R12 medication administration audit report revealed the following medications were administered on Thursday, April 16, 2026:Metoprolol Succinate ER 25 mg scheduled at 8:00 a.m., administered at 1:25 p.m.Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.Provera 10 mg, scheduled at 9:00 a.m., administered at 1:26 p.m.Diltiazem HCL ER 120 mg, scheduled at 9:00 am, administered at 1:29 pm.Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.Losartan Potassium 100 mg, scheduled at 9:00 a.m., administered at 1:25 p.m.Further review of Resident R12 medication administration audit report revealed the following medications were administered on Friday, April 17, 2026:Metoprolol Succinate ER 25 mg scheduled at 8:00 a.m., administered at 2:12 p.m.Metformin HCL 500 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.Provera 10 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.Diltiazem HCL ER 120 mg, scheduled at 9:00 a.m., administered at 2:12 p.m.Hydrochlorothiazide 25 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.Losartan Potassium 100 mg, scheduled at 9:00 a.m., administered at 2:13 p.m.Review of medication administration audit report for Resident R13 revealed the following medications were administered on Thursday, April 16, 2026:Amiodarone HCL 200 mg, scheduled at 9:00 a.m., administered at 2:01 p.m.Aspirin 81 mg, scheduled at 9:00 a.m., administered at 1:59 p.m.Magnesium Oxide 400 mg, scheduled at 9:00 a.m., administered at 1:59 p.m. The above findings were confirmed with Facility Nursing Administrator , Employee E1, and assistant Director of nursing, Employee E2, on Monday, April 20, at 2:30 pm. 28 Pa. Code 211.10(c) Resident care policiies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record, review of facility documents, review of policy and procedures, and interview with staff, it was determined that the facility failed to ensure that medications were administered according to physician's instructions and failed to provide treatments according to physician's instructions for one resident (Resident R1) Review of facility policy on Administering Medications reviewed: December 11, 2024, and revised on June 1, 2025, revealed that under section POLICY: Medications shall be administered in a safe and timely manner, and as prescribed. Under section PROTOCOL:2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.3. Medications must be administered in accordance with orders, including any required time frame.6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. 12. The individual administering the medications must sign it out as being administered (or held/refused) per protocol in the electronic health record. 15. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medications shall document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Presence of Right Artificial Knee Joint, Radiculopathy of Cervical region (a condition caused by compression or irritation of a nerve in the neck, leading to pain, numbness, or weakness radiating into the shoulder, arm, or hand.) Review of facility medication audit for Resident R1 revealed the following: Naproxen Oral Tablet 500 MG (Naproxen) Give 1 tablet by mouth two times a day for arthritis pain with meals-Start Date-01/29/2026 was scheduled to be administered on January 29, 2026, at 8:00AM was administered at 9:23AM. Lidocaine HCl External Patch 4 % (Lidocaine HCl) Apply to RLE topically one time a day for pain-Start Date-01/29/2026 0900 was scheduled to be administered on January 29, 2026, at 9:00, was documented as administered at 3:36PM. Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) Apply to RLE (right leg) topically four times a day for pain Apply 2gram-Start Date-01/28/2026 was scheduled to be administered on January 29, 2026, at 9:00am, was documented as administered at 3:34PM. Further, 12PM dose was also documented as administered at 3:34PM. Celebrex Oral Capsule 200 MG(Celecoxib) Give 1 capsule by mouth one time a day for pain for 30 Days-Start Date-01/29/2026 was scheduled to be administered on January 29, 2026, at 9:00AM was administered at 3:35PM. Review or Resident R1's treatment administration record (TAR) for January 2026, revealed that Remove Mepilex dressing on Right knee per physician orders on 1/31/26. Leave open to air one time only for right TKR (total knee replacement) for 1 Day-Start Date-01/31/2026. There was no documented evidence that the treatment was completed on 1/31/2026. Saline Solution (Soft Lens Products) Apply to right knee topically every 4 hours as needed for wound care Cleanse Right knee incision with NSS (normal saline solution), pat dry and cover with Bordered Gauze Dressing Daily and PRN (as needed) for soiling-Start Date -01/31/2026. There was no documented evidence that the treatment was completed on January 31, 2026. Interview with Regional Nurse, Employee E2 confirmed that the above medications were administered late. 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility policy, facility documentation, resident clinical records, observations, and staff interviews, it was determined the facility failed to provide adequate supervision for one of three residents assessed as at risk for elopement (Resident R223). Resident R223 exited the second-floor nursing unit via elevator and walked out the back rear entrance of the facility. Resident R223 was located by local law enforcements approximately four hours after the resident exited the facility, approximately 1.5 miles away in a busy [NAME] area. This failure resulted in actual harm to Resident R223 who was admitted to the hospital with hypothermia and resulted in an Immediate Jeopardy situation. (Resident R233)Findings Include:Review of facility policy titled Elopement reviewed September 23, 2024, revealed an elopement is defined as when a resident leaves the premises or a safe area without authorization and or necessary supervision. Further review of facility policy revealed multi-faceted interventions for residents identified as at risk include, but are not limited to, Increase supervisor (checks). The facility should adjust staffing as indicated; particularly during times when the resident is agitated and/or making attempts to exit.Review of undated facility policy Resident Elopement Protocol revealed any staff person who determined a resident may be missing will immediately notify their unit manager/supervisor. If the resident cannot immediately be found, the Unit Manager/Supervisor will notify the Administration, Director of Nursing, and Security. The Administrator/Director of Nursing/Supervisor or Security staff will announce code yellow (responding to elopement) with the resident's name and room number to notify all staff of the need to perform the internal/external search.Review of facility policy Elopement Prevention/Wander-guard Assessment dated January 2021, revealed the unit manager/designee will perform an assessment of the resident's behaviors and history. Prevention measures may include, but are not limited to, interdisciplinary team meeting and care planning, staff monitoring plan, and family observations and ideas for prevention.Review of Resident R223's clinical record revealed the resident was admitted to the facility's 2nd Floor North Side nursing unit on December 11, 2025, and had diagnoses of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Apraxia (neurological disorder that affects motor planning and coordination), Diabetes Mellitus (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), and Hypertension (high blood pressure).Review of Resident R223's hospital documentation dated December 11, 2025, revealed Resident R223 was brought to the emergency department for inability to care for self and need for long-term placement. Resident R223 was noted to be living with a caregiver but due to patient's agitation and frequent elopements they were no longer able to care for Resident R223.Continued review of Resident R223's clinical record revealed a Brief Interview for Mental Status assessment conducted on December 12, 2025, determined that Resident R223 had severe cognitive impairment.Review of Resident R223's comprehensive care plan revised December 12, 2025, revealed the resident was an elopement risk/wanderer related to history of dementia and wandering. Wander guard applied to left ankle. Interventions dated December 12, 2025, included placing resident photograph at reception/exit and Resident R223 was on Center Watch Program (facility elopement binder maintained at front desk) for elopement risk.Review of Resident R223's physician order summary revealed an order dated December 12, 2025, for monitor wander guard/watchmate to left ankle/check placement and function every shift (morning, evening, and night shift).Review of Resident 223's nursing note dated December 12, 2025, at 5:41 a.m. noted that the resident was easily redirected back to his/her room several times as he/she attempted to enter other residents' rooms.Review of Resident R223's nursing note dated December 12, 2025, at 11:26 p.m. revealed that the resident was repeatedly walking the halls.Continued review of Resident R223's nursing notes dated December 13, and 14, 2025, revealed that Resident R223 ambulated the unit.On December 17, 2025, at 9:00 a.m., the Director of Nursing, Employee E2, informed Department of Health surveyors that a resident [identified as Resident R223] eloped from the facility in the evening of December 15, 2025.Interview on December 17, 2025, at 9:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed that revealed that she, as well as the Director of Nursing, Employee E2, were informed Resident R223 was missing on 12/15/2025 at approximately 10:30 p.m. Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, both arrived at the building by approximately 11:30 p.m. to conduct a search of the building and perimeter with no luck in locating the resident.Review of statement dated December 15, 2025, by Registered Nurse Supervisor, Employee E28, revealed on 12/15/2025 around 9:30 p.m. he/she was informed by the care nurse (identified as nurse aide, Employee E25) that Resident R223 was missing. Registered Nurse Supervisor, Employee E28, announced a code yellow and performed an in-house and outside perimeter search for the resident. Resident R223 was still unable to be located, and administration was made aware.Review of witness statement dated 12/16/2025 by Regional Registered Nurse, Employee E18, revealed per interview with the dispatcher, on 12/15/2025 an owner of a home in a nearby neighborhood (located approximately 1.5 miles away from the facility) called 911 (Emergency Medical Services) at 9:36 p.m. because Resident R223 was knocking on their door. The police called (EMS) at 9:42 p.m. to request assistance and EMS was dispatched at 9:43 p.m.Review of Resident R223's hospital records revealed the resident was admitted to the emergency department (ED) on December 15, 2025, at 10:13 p.m. for altered mental status. Resident R223 was found to be walking around knocking on doors in the cold. When Resident R223 was brought to the ED, he/she was found to be confused and had Hypothermia (a medical condition that occurs when the body temperature drops below 95 degrees Fahrenheit, leading to potentially life-threatening consequences) for which he/she was put on Bair Hugger (warming unit). The average temperature on December 15, 2025, ranged from 19 degrees Fahrenheit to 28 degrees Fahrenheit.Further interview with the Nursing Home Administrator, Employee E1, on December 17, 2025, at 9:00 a.m. revealed she was notified by the police on 12/16/2025 around 7:00 a.m. that Resident R223 was located at a near-by hospital. The Nursing Home Administrator, Employee E1, promptly went to the hospital on [DATE] to positively identify Resident R223. Per the Nursing Home Administrator, Employee E1, when the police arrived at the scene on 12/15/2025 Resident R223 was not able to identify him/herself, so he/she was taken to the hospital as an unknown patient. Nursing Home Administrator, Employee E1, stated that the hospital obtained fingerprints and that is how they identified Resident R223 and informed the facility of his/her whereabouts.Nursing Home Administrator, Employee E1, reportedly reviewed security camera footage for the front door and back door cameras with no success in identifying when/how Resident R223 left the building.Subsequently, surveyors requested review of security camera footage to determine how and what time Resident R223 left the building.Review of security camera footage was conducted on December 17, 2025, at 10:15 a.m. with the Nursing Home Administrator, Employee E1, and Assistant Nursing Home Administrator, Employee E2. Per security camera footage, on 12/15/2025 at 5:37 p.m. an individual wearing a dark colored crewneck sweatshirt, dark colored sweatpants, and dark colored house slippers was seen exiting the building via the ground floor, out the back rear door (loading dock). The individual was observed to effortlessly push open the back door without resistance.The individual was subsequently identified as Resident R223 by the Nursing Home Administrator, Employee E1, and Assistant Nursing Home Administrator, Employee E2. Interview on December 17, 2025, at 11:30 a.m. with Regional Registered Nurse, Employee E18, and Regional of Operations, Employee E14, revealed the elevators or stair wells do not have a wander guard sensor. Therefore, no alarms were triggered when Resident R223 left the 2nd floor nursing unit.Further interview and observation on December 17, 2025, at 11:30 a.m. with Regional Registered Nurse, Employee E18, and Regional of Operations, Employee E14, revealed the back doors in which Resident R223 exited the building can only unlocked/opened via a code on the key pad located next to the door or via a button used by the receptionist at the front desk.Observations and interview with Regional Registered Nurse, Employee E18, on 12/19/2025 revealed there are four wander guard sensors and alarms, and are only located on the ground floor. When a wander guard alarm is triggered, it sounds an alarm and also sends a notification to the front desk. The wander guard alarm can be turned off via a button at the front desk or by entering a code into the keypad of the alarm triggered.Interview on December 17, 2025, at 1:22 p.m. with Unit Manager, Employee E17, revealed this employee last saw Resident R223 on 12/15/2025 walking around the nurses station at approximately dinner time.Review of facility documentation Food Truck Delivery Log dated 12/15/2025 revealed dinner trays were delivered to the 2nd floor nursing unit between 4:45 p.m. and 5:00 p.m.Continued interview on December 17, 2025, at 1:22 p.m. with Unit Manager, Employee E17, revealed this employee applied a wander guard to Resident R223's left ankle on December 12, 2025. The Unit Manager, Employee E17, reported to have checked the functionality of the wander guard at the front door entrance before applying it to Resident R223's ankle. Front desk receptionist, Employee E15, was informed Resident R223 was an elopement risk, and his/her picture was put in the elopement risk binder at the front desk. Further interview with Unit Manager, Employee E17, revealed Resident R223 would often independently, ambulate the hallways and try to get on the elevator. Unit manager, Employee E17, was unaware that the elevators or stairwells did not have wander guard sensors/alarms. Unit manager, Employee E17, reported Resident R223 did not have an order for frequent checks. Interview on December 17, 2025, at 4:08 p.m. with Licensed Nurse, Employee E24, (identified as Resident R223's 3:00 p.m. to 11:00 p.m. assigned nurse) revealed Resident R223 was known to wander the unit and try to go up to doors. Licensed nurse, Employee E24, reported seeing the resident at the start of his/her shift and confirmed the placement of Resident R223's wander guard. When questioned, Licensed Nurse, Employee E24, reported not knowing how to check the functionality of the wander guard.Licensed Nurse, Employee E24, revealed he/she could not remember the last time Resident R223 was seen on the unit after the start of his/her shift. Licensed Nurse, Employee E24, was informed by nurse aide [identified as Employee E25] that the resident refused dinner.Interview on December 17, 2025, at 4:15 p.m. with Nurse Aide, Employee E25, revealed, he/she saw Resident R223 walking around on 2-South nursing unit around 3:30 p.m. Nurse Aide, Employee E25, reported Resident R223 refused to eat dinner. Nurse aide, Employee E25, reportedly found Resident R223's meal tray untouched in the dining room and assumed the resident was wandering back on 2-South.Continued interview on December 17, 2025, at 4:15 p.m. with Nurse Aide, Employee E25, revealed after returning from his/her 30-minute break and tending to other residents for bathing/bedtime, Resident R223 could not be located. After searching the 2nd, 1st, and ground floors the nurse aide, Employee E25, informed the nursing supervisor Resident R223 was missing. Nurse aide, Employee E25, could not recall specific times.Interview on December 18, 2025, at 10:05 a.m. with the Director of Nursing, Employee E2, and Regional Registered Nurse, Employee E18, revealed often the front desk receptionist will see staff members on the security cameras at the back door and assist by unlocking the back door by buzzing them out. Front desk receptionist (2nd shift, 3:00 to 11:00 p.m.), Employee E19, reportedly could not remember if he/she buzzed anyone out the back door on 12/15/2025 around 5:30 p.m.Continued interview on December 18, 2025, at 10:05 a.m. with the Director of Nursing, Employee E2, and Regional Registered Nurse, Employee E18, reportedly that there was nothing noted to be wrong with the door that would have prevented it from being locked/latched.Review of witness statement by Human Resources (HR) Director, Employee E23, dated December 17, 2025, revealed on December 15, 2025, around 5:30 p.m. Resident R223 was seen walking past his/her office (located on the ground floor) headed toward the front desk. A few seconds later HR Director, Employee E23, saw the same resident walk past HR again but this time Resident R223 was headed toward the elevator. HR, Employee E23, reportedly didn't think anything of it because it was right before smoke break and no alarms were triggered.Review of witness statement by Director of Housekeeping, Employee E22, dated December 19, 2025, revealed on December 15, 2025, Employee E22 was sitting in the office of Human Resources Director, Employee E23. Resident R223 was seen walking by the office two times around 5:30 p.m. Director of Housekeeping, Employee E22, stated I just observed him/her coming by no conversation was held.Based on a review of facility documentation, observations, and staff interviews, it was determined that Resident R223 eloped from the facility at 5:37 p.m. on 12/15/2025. A code yellow - elopement protocol, was not implemented until 9:30 p.m. (four hours after the resident exited the building) Resident R223 was located by local law enforcements 1.5 miles away from the facility in sub-freezing temperatures and brought to the local hospital at approximately 10:15 p.m. where he/she was treated for hypothermia. Resident R223 had no identification and was unable to identify him/herself. Hospital staff needed to obtain fingerprints and subsequently notified the facility on 12/16/2025 at approximately 7:00 a.m. of Resident R223's whereabouts.An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on December 17, 2025, at 12:58 p.m. for the facility's failure to adequately supervise a resident with a diagnosis of Dementia and history of exit seeking behaviors. This failure resulted in Resident R223 exiting and eloping from the facility, traveling approximately 1.5 miles away in a busy [NAME] area.An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on December 17, 2025, at 1:05 p.m.The facility submitted a written plan of action on December 17, 2025, at approximately 4:28 p.m. and implemented the plan of action which included: On 12/15/2025 at 9:30 p.m. [Resident R223] was noted to be missing. On 12/25/2025, a Code Yellow-Responding to Elopement was called at around 9:30 p.m. by the nursing supervisor. On 12/15/2025, elopement protocol initiated and whole building and outside perimeter was searched. On 12/15/2025 all other residents were verified as being present through a whole house bed check, and the police/911 and physician were called between 9:30 p.m. and 9:50 p.m. There was no response from police or 911. Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified at on 12/15/2025 at 10:24 p.m. that Resident R223 was missing. Ground level door audits and wander guard system audit was completed on 12/15/2025 by NHA to ensure proper function. On 12/16/2025 the police/911 was called again with response to the facility around 3:36 a.m. Police notified NHA on 12/16/2025 around 7:00 a.m. that Resident R223 was located at the local hospital. Subsequently, NHA and nurse aide verified Resident R223's identity at the local hospital. On 12/16/2025 it was determined that Resident R223 was picked up by Emergency Medical Services (EMS) about 1.2 miles from the facility and taken to the local hospital at approximately 10:13 p.m. on 12/15/2025. On 12/16/2025 and ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with department heads. Whole house wander guard audit was completed to verify placement and function for resident's to have been assessed as needing one on 12/16/2025. Whole house elopement assessments completed on 12/16/2025 with no new residents identified as being at risk for elopement. Elopement binder reviewed and audited to ensure book is up to date and current with completion of new assessments on 12/16/2025. Every 1-hour loading dock door checks initiated on 12/16/2025 and are ongoing. Facility contacted wander guard service provider on 12/16/2025 to obtain quotes to add wander guard sensors to elevators, stairwells, and service hallways. On 12/17/2025 it was determined that the resident exited out of the loading dock doors. Frequency of loading dock door check increased to every 30-minutes. On 12/16/2025, education on Code Yellow-Responding to Elopement initiated at 12:35 a.m. with in-house nursing staff. Elopement policy reviewed on 12/17/2025. On 12/17/2025 education initiated with all facility staff on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility. This will be added to new hire orientation. 85% of facility staff will be educated by 12/18/2025. Facility is completing loading dock and font entrance door audits every 30 minutes daily for 30 days. Facility will review findings of audits during QAPI meeting. Resident R223 at hospital and will be re-assessed upon re-admission.Review of facility documentation confirmed all other residents were accounted for on 12/15/2025.Review of facility documentation confirmed loading dock and front door entrance audits were completed.Review of facility documentation confirmed audits were completed for residents with wander guards to ensure placement and functionality. Further, audits were completed to ensure all residents had accurate/up to date elopement assessments. No new residents were identified.Elopement binder maintained at the front desk was reviewed and confirmed to be accurate/up to date with residents at risk for elopement.Interviews were conducted with 26 staff members from all departments on December 18, 2025. Interviews confirmed staff were educated on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility. Further staff confirmed they were educated on a code yellow responding to an elopement.The Immediate Jeopardy was lifted on December 18, 2025, at 3:40 p.m.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility documentation, observations, and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on two of two nursing units (2-North and 1-North) Findings include: Review of facility policy titled Resident Rights-Safe Clean Comfortable Homelike Environment dated April 1, 2022, revealed that the facility policy affirms residents' rights to a safe, clean, comfortable, and homelike environment. It specifically requires the facility to maintain comfortable and safe temperature levels as part of ensuring resident comfort and well-being. Maintaining appropriate room temperatures is a core responsibility of the facility's housekeeping and maintenance services and is essential to providing care and services safely while respecting resident rights. Failure to maintain comfortable temperatures would be inconsistent with the facility's obligation to provide a homelike environment as outlined in this policy and required under CMS standards. Observation during the initial tour of the facility on December 15, 2025, at 09:55 a.m. revealed, multiple resident rooms on the second-floor nursing unit were observed to feel cold and uncomfortable. Resident R125 was observed in the hallway wrapped in blankets. Continued observation with the Maintenance Director employee E11 at 10:52 AM revealed the following room temperature readings: room [ROOM NUMBER]: 68.9 degrees Feirenheight room [ROOM NUMBER]: 68.9 degrees Feirenheight room [ROOM NUMBER]: 64.6 degrees Feirenheight room [ROOM NUMBER]: 64 degrees Feirenheight room [ROOM NUMBER]: 65 degrees Feirenheight room [ROOM NUMBER]: 65.5 degrees Feirenheight Recreation Room: 66 degrees Feirenheight These temperatures were below the expected comfort range for resident living areas and were inconsistent with maintaining a comfortable, homelike environment. Interviews with the Maintenance Director Employee E11at the time of observation revealed that it was his first day of employment at the facility. He stated he was previously unaware of the temperature issues and believed the problem was related to malfunctioning P-Tech heating units in individual rooms. He stated he would immediately contact the HVAC company to address the issue. Interviews with residents on the nursing unit revealed no resident complaints related to room temperature. Some residents stated they preferred cooler temperatures and described them as invigorating. However, despite the lack of resident complaints, temperatures remained below acceptable comfort standards. Interview with Maintenance director employee E 11 on December revealed the following corrective actions: Conducted an audit of all individual P-Tech heating units and the overall heating system, relocated residents from rooms with significantly low temperatures to ensure comfort, provided additional blankets to residents as needed, installed portable heating units in common areas, including activity rooms and dining rooms. Contracted an external HVAC company to assess and repair the heating system and malfunctioning P-Tech units and implemented daily temperature audits for resident rooms and common areas. Observation On December 16, 2025, at 09:10 a.m., of the first- and second-floor nursing units revealed that temperatures were within acceptable standards in all resident rooms, with the exception of two rooms. Residents from those rooms had already been relocated for comfort. Documentation of daily temperature audits was provided by the Maintenance Director, along with confirmation that the HVAC company evaluated the system and initiated necessary repairs. All residents interviewed during follow-up stated they felt the facility living spaces were comfortable and had no concerns regarding temperature. Observations on December 15, 2025, at 11:40 a.m. in the 2-North lounge revealed a large, white commercial refrigerator toward the back left side of the room. Up to 8 residents were observed sitting in the lounge, waiting for lunch to be delivered. Surveyor proceeded to open the refrigerator and observed an old, rotting supplement (intended to be refrigerated) shake. The box was rotting and discolored. A foul odor proceeded to take over the room. Interview on December 15, 2025, at 11:45 a.m. with Unit Manager, Employee E17, revealed the refrigerator in the 2-north lounge has been broken and was supposed to be removed from the room. Unit Manager, Employee E17, confirmed the rotting supplement left in the fridge and is not sure when it was from. Follow-up observations on December 15, 2025, at 12:45 p.m. in the 2-North lounge revealed the fridge was removed, however mouse droppings were left on the floor that was beneath the fridge. Up to 8 residents were observed sitting in the lounge having lunch. Unit Manager, Employee E17, confirmed mouse droppings in the 2-North lounge on December 15, 2025, at 12:45 p.m. Observations on December 15, 2025, at 11:50 a.m. revealed Resident R185's foot board (in room [ROOM NUMBER]-A) was missing on the bed. Resident R185 reported it fell off, and maintenance did not fix it correctly. Observations on December 16, 2025, at 12:20 p.m. in room [ROOM NUMBER] revealed the window was unable to be closed all the way, allowing a constant flow of cold air in from the outside. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 204.19 Plumbing, Heating, Ventilation, Air-condition, and Electrical

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers and discharges for two of six months reviewed (July and August).Findings Include: Review of documentation provided by the Nursing Home Administrator on December 16, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of facility-initiated transfers during the months of June and July. The Nursing Home Administrator was able to provide documentation for the month of September, October, and November. Interview on December 17, 2025, at 10:15 a.m. with the Social Worker, Employee E7, confirmed the ombudsman was not made aware of the discharges. Employee E7 stated that she started working at the facility at the end of July. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2) Management

Based on policy review, observations, clinical record review, and interviews it was determined that the facility did not ensure the comprehensive care plan was implemented for three of thirty-six residents reviewed (Resident R87, R156, and R56). Findings Include: Review of the facility policy titled, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates with a revision date on October 1, 2024 states, Policy Statement-the facility will follow a uniform process for initiating the baseline care plan upon admission, the Comprehensive care plan upon CAA completion, and ensuring care plans are updated to reflect the resident's status. Review of Resident R87's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Dementia (severe decline in mental abilities, like memory, thinking, and reasoning), Anxiety (natural feeling of worry, tension, or fear about future events, often with physical symptoms like a rapid heart rate or sweating, acting as a stress response to potential threats), and Bi-polar Disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, from high manic (elated, irritable, energetic) episodes to low depressive (sad, hopeless) episodes, significantly impacting daily function, sleep, and thinking). Review of Resident R87's current care plan with a date of August 28, 2025, there is no focus, goal, or interventions for the diagnosis of Anxiety or B Bipolar Disorder. Review of Resident R156's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Alcohol Abuse in remission, Cocaine Abuse in remission, Sedative Hypnotic or Anxiolytic Dependence in remission. Review of Resident R156's current care plan with a date of November 14, 2025, there is no focus, goal, or interventions for the diagnosis of Alcohol Abuse in remission, Cocaine Abuse in remission, Sedative Hypnotic or Anxiolytic Dependence in remission despite documented evidence in the care plan of the resident abusing the current smoking policy. The current care plan dated November 14, 2025 states, Focus-The resident has a behavior problem hoarding personal medication from outside facility, vaping devices. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Review of Facility policy titled Baseline Care plan, Comprehensive Care Plan, and Ongoing Care Plan Updates last revised October 1st 2024 revealed that the facility policy requires the development of a baseline care plan within 48 hours of admission and a comprehensive, person-centered care plan within 7 days of the comprehensive assessment. Care plans must identify all medical, nursing, mental, and psychosocial needs, including measurable goals and interventions to maintain the resident's highest practicable well-being. The policy mandates that care plans be developed by an interdisciplinary team in consultation with the resident and/or representative and must reflect all diagnoses, treatments, and risks identified in the resident's assessments, physician orders, and PASARR recommendations. Care plans must include clear instructions for staff to monitor, manage, and respond to conditions, including acute or potentially life-threatening medical issues, and be updated promptly when a resident's condition or physician orders change. Failure to include specific diagnoses, such as pulmonary embolisms or tachycardia, and corresponding interventions, monitoring parameters, and notification instructions constitutes noncompliance with this policy. Review of Resident R56's Minimum Data Set (MDS), a federally mandated assessment tool, revealed a quarterly assessment dated [DATE], which indicated the resident was admitted to the facility on [DATE] with diagnoses including cardiac arrest, (defined as the sudden cessation of effective heart function resulting in loss of blood flow to vital organs); respiratory failure(inability of the lungs to adequately exchange oxygen and carbon dioxide); anoxic brain injury (brain damage caused by a complete lack of oxygen resulting in cognitive and functional impairment); and dysphasia (a communication disorder characterized by impaired ability to understand or express speech). The MDS further documented a Brief Interview for Mental Status (BIMS) score of seven (7), indicating severe cognitive impairment. Review of the resident's clinical record revealed hospital documentation indicating the resident was evaluated in the emergency department for tachycardia, defined as an abnormally elevated heart rate, with documented heart rates ranging from 140 to 150 beats per minute, and was diagnosed with multiple pulmonary embolisms, defined as blood clots that obstruct blood flow in one or more pulmonary arteries and can be life-threatening. Hospital records further indicated the resident was started on medications including metoprolol, a beta-blocker used to control heart rate and blood pressure; clonidine, an antihypertensive medication used to reduce blood pressure and heart rate; and Lovenox (enoxaparin), an anticoagulant medication used to prevent and treat blood clots, for management of these conditions. Review of the resident 56s care plan revealed no identified problem statements, goals, or interventions addressing the diagnoses of pulmonary embolisms or tachycardia, including no instructions for monitoring heart rate or blood pressure, identifying signs and symptoms of complications, medication-related precautions, or guidance regarding when and whom staff should notify of changes in condition. The care plan also failed to include interventions related to the resident's increased risk for cardiopulmonary compromise. The facility's failure to incorporate these significant diagnoses and treatments into the resident's care plan placed the resident at risk for delayed recognition and treatment of potentially life-threatening conditions. An interview with director of nursing employee E 2 On December 19, 2025, at approximately 9:15 a.m. confirmed that Resident R56's care plan has not been properly updated according to facility policy and standards

Based on review of facility documents, review of facility records, review of facility policy and interview with staff, it was determined that the facility failed to ensure that controlled substances are accounted for in order to identify diversion and lost narcotics in a timely manner for one of thirty-six residents reviewed (Resident R89). Review of facility policy on Controlled Substance Log dated April 24, 2023Revised: November 2025 revealed that under section POLICY The facility shall comply with all laws, regulations, and other requirements related to receiving, handling, storage, disposal, and documentation of Schedule II and other controlled substances. Under section GUIDELINES: Storage and Maintenance of Controlled Drugs: 1. Two licensed nursing staff are required to immediately log the received medication into the Controlled Substances Book Index Page, assign an Inventory Page number, and log or place pharmacy label onto assigned Inventory Page. One licensed nursing staff will log the required information for each entry and sign the entry. The second licensed nursing staff will witness the documentation and sign the entry.4. On first line of Inventory Page, enter: Date drug received; Total quantity received by Center; Signature of both receiving licensed nursing staff6. If a discrepancy is found after the controlled drug has been accepted: Notify pharmacy. Give drug to DON or designee for disposition according to federal and state regulations. NOTE: A controlled drug cannot be returned to the pharmacy once it has been accepted by the Center. Review of facility reported incident revealed that on November 4, 2025, the facility received narcotics for ten residents. The RN Supervisor Employee E31 signed for the delivery. He then proceeded to dispense the narcotics to the appropriate unit, gave his report, and signed off of his shift. Upon, audit of the delivery, it was determined that Resident R89's Suboxone was signed for, but not in the appropriate cart. The nursing team initiated an investigation, and interview conducted with Employee E31, and he stated that he reported signing for Resident R89's medication but didn't see it, and that he may have inadvertently thrown it away with the pharmacy bags from that delivery, eventhough he signed for it. Interview with DON (Director of Nursing) Employee E2 conducted on December 18, 2025, at 1:26PM revealed that when pharmacy delivers the narcotics, the supervisor on duty signs off the narcotics as received. The supervisor then delivers the narcotics to the respective units. The nurse on duty in the respective units then documents the number of narcotics received. Further Employee E2 revealed that the nurses on the respective units are only accountable for the controlled substances they received from the supervisor. Further interview with the Employee E2 confirmed that there is no process in place that ensures that all controlled substances received by the supervisor from the pharmacy are accounted for before they are delivered to the unit and that there is no system in place to identify missing narcotics after the supervisor receives the narcotics from the pharmacy. 28 Pa. Code 211.5(d) Drug accountability

Based on observations, interviews with staff, and a review of facility documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety (Main Kitchen and 1-South Pantry). Findings include: An initial tour of the Food Service Department was conducted on December 15, 2025, at 10:00 a.m. with Employee E14, Food Service Director (FSD), which revealed the following: Observation in the kitchen near the hand sink revealed paint peeling and wall uneven near baseboard. Observation of the wall behind the reach-in refrigerators revealed paint peeling and dirty walls. Observation in the kitchen production area revealed a double convection oven with a heavy build-up of dark brown and black burned on food spatters on the outside of the oven and on the interior surfaces of the lower oven. Observation of the steam table in the tray-line area revealed a heavy build-up of dark burned on food spillage on the hot wells and water pans. Observation in the dish room revealed a low temperature, chemical sanitizing dish machine. When the rinse water was tested there was no reading indicating that there was no chlorine present. Interview with the FSD on December 15, 2025, at 10:30 a.m. confirmed the above observations and could not say how long the machine was not pumping sanitizer. Interview with the Administrator on December 15, 2025, at 10:45 a.m. confirmed that the dish machine was not sanitizing the dishes and that the facility would switch to disposable paperware and plasticware until the machine was repaired. Observations in the kitchen during a follow-up visit on December 17, 2025, at 12:05 p.m. revealed the following: Observation in the kitchen prep area and near the doorway revealed 50-gallon trash can with the lids off with trash inside open to the air. Observation in the prep area near the can-opener revealed a heavy black build-up of sticky black substance on baseboard under the wall plug. Observation of the coffee urn in the kitchen area revealed corrosion and burned on black coffee-colored stains and buildup of black substance on the top of the coffee urn. Interview with the FSD on December 15, 2025, at 10:30 a.m. confirmed the above observations. Observations on December 15, 2025, at 10:50 a.m. revealed a kitchenette on 1-south equipped with an ice machine, refrigerator, sink, and cabinets. Interview with Licensed Nurse, Employee E29, revealed the refrigerator is used to store resident food items (whether it be leftover takeout or pre-made sandwiches from the kitchen). Observations inside the refrigerator revealed multiple undated food items without labels/dates such as turkey sandwich in bag open to air, cake on Styrofoam plate wrapped in plastic wrap, roll in bag, and unknown food item in Ziplock bag. Further observations revealed an opened container of thickened, lemon water that had an expiration date of November 5, 2025, and three unlabeled Tupperware containers with leftover food. Observations were confirmed on December 15, 2025, at 10:50 a.m. by Licensed Nurse, Employee E29. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to promptly notify a residents representative of a change in condition related to an elopement for one of 36 residents reviewed (Resident R223).Findings Include:Review of undated facility policy Resident Elopement Protocol revealed the unit manager/supervisor would be responsible to notify the resident representative of the elopement.Review of Resident R223's clinical record revealed the resident was admitted to the facility's 2nd Floor North Side nursing unit on December 11, 2025, and had diagnoses of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Apraxia (neurological disorder that affects motor planning and coordination), Diabetes Mellitus (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), and Hypertension (high blood pressure).Review of Resident R223's hospital documentation dated December 11, 2025, revealed Resident R223 was brought to the emergency department for inability to care for self and need for long-term placement. Resident R223 was noted to be living with a caregiver but due to patient's agitation and frequent elopements they were no longer able to care for Resident R223.Continued review of Resident R223's clinical record revealed a Brief Interview for Mental Status assessment conducted on December 12, 2025, determined that Resident R223 had severe cognitive impairment.Review of Resident R223's comprehensive care plan revised December 12, 2025, revealed the resident was an elopement risk/wanderer related to history of dementia and wandering. Wander guard applied to left ankle. Interventions dated December 12, 2025, included placing resident photograph at reception/exit and Resident R223 was on Center Watch Program (facility elopement binder maintained at front desk) for elopement risk.On December 17, 2025, at 9:00 a.m., the Director of Nursing, Employee E2, informed Department of Health surveyors that a resident [identified as Resident R223] eloped from the facility in the evening of December 15, 2025.Interview on December 17, 2025, at 9:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed that revealed that she, as well as the Director of Nursing, Employee E2, were informed Resident R223 was missing on 12/15/2025 at approximately 10:30 p.m. Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, both arrived at the building by approximately 11:30 p.m. to conduct a search of the building and perimeter with no luck in locating the resident.Further interview with the Nursing Home Administrator, Employee E1, on December 17, 2025, at 9:00 a.m. revealed she was notified by the police on 12/16/2025 around 7:00 a.m. that Resident R223 was located at a near-by hospital. The Nursing Home Administrator, Employee E1, promptly went to the hospital on [DATE] to positively identify Resident R223. Further interview on December 17, 2025, with Nursing Home Administrator, Employee E1, revealed Resident R223's representative was not notified that Resident R223 eloped from the building on 12/15/2025, and was subsequently missing overnight in freezing temperatures, until after the resident was found and identified at the hospital on [DATE]. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure pre-admission screening and resident review, (PASRR Level I screenings(a program that ensures Individuals with a serious mental illness or intellectual development developmental disabilities aren't unnecessary place in nursing homes and if they are they receive specialized services.) were accurately completed for two (2) residents. Specifically, the facility did not correctly identify or document indicators of serious mental illness and/or intellectual disability on the PASRR Level I screens, resulting in inaccurate PASRR determinations for these residents. (resident R 79 and R184) Review of the facility's PASRR policy titled Preadmissions screening and Resident Review PASRR Program dated April 1, 2022, and reviewed December 2025, requires that all residents admitted to the facility receive a complete and accurate Pre-admission Screening and Resident Review (PASRR) in compliance with State and Federal regulations. The policy requires the facility to fully coordinate with the PASRR program and ensure that PASRR Level I and Level II determinations, evaluations, and recommendations are accurately identified, documented, and incorporated into the resident's assessment, care plan, and transitions of care, including correct identification of serious mental illness, intellectual disability, or related conditions. The policy further requires referral for a Level II PASRR review when a resident has a known or suspected mental illness or intellectual disability or experiences a significant change in condition that may indicate such diagnoses. In addition, the policy prohibits admission of individuals with mental illness or intellectual disability without a prior State determination confirming the need for nursing facility level of care and whether specialized services are required, and mandates timely notification to the State authority when significant changes occur. Failure to accurately and completely complete PASRR screenings, initiate required Level II reviews, or incorporate PASRR findings into resident assessments results in incomplete and inaccurate PASRR determinations and is inconsistent with facility policy and CMS PASRR requirements.Review of Resident #12's Minimum Data Set (MDS- a federally mandated assessment tool required for all residents), revealed that a quarterly assessment dated [DATE], indicated the resident was admitted to the facility on [DATE]. The assessment documented a Brief Interview for Mental Status (BIMS) score of zero (0), indicating severe cognitive impairment and the need for maximum assistance with functional abilities. The MDS further identified Resident #12 with diagnoses of dementia (defined as a progressive neurocognitive disorder characterized by memory loss, impaired reasoning, and diminished ability to perform daily activities); anxiety(a mental health condition involving excessive fear or worry that interferes with functioning); depression( a mood disorder characterized by persistent sadness, loss of interest, and impaired daily functioning); and bipolar disorder(a serious mental illness characterized by episodes of depression and mania or hypomania that significantly affect mood, behavior, and functional capacity).Review of Resident #12's PASRR dated September 12, 2023, revealed the resident was inaccurately identified as not having any mental health condition that may lead to a chronic disability, despite documented mental health diagnoses in the resident record.Review of Resident R184's PASRR dated January 27, 2021, revealed the resident had a documented diagnosis of schizophrenia. Further review of this document indicated the resident was treated by a psychiatrist and participated in an outpatient mental health program. However, continued review of the same PASRR reflected contradictory information, stating the resident had not been treated in an outside psychiatric setting and had not participated in a partial psychiatric program or received mental health services. The facility failed to ensure accurate identification of serious mental illness and failed to ensure the PASRR information was complete and accurate. 28 Pa. Code 211.5 (f)(xi)(i) Medical Records28 Pa. Code 211.10 (a) Resident Care Policies

Based on review of clinical record, observations, and staff interviews it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of 36 residents reviewed (Resident R135).Findings Include:Review of Resident R135's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 3, 2025, revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), muscle weakness, and muscle wasting.Further review of Resident R135's comprehensive MDS dated [DATE], revealed the resident had severe cognitive impairments.Review of Resident R135's hospital discharge instructions dated October 21, 2024, revealed Resident R135 was found to have a fracture in the vertebral column that was further assessed by the orthopedic team. Recommendations from the orthopedic team included a thoracic lumbar sacral orthosis (TSLO) clamshell brace (a hard plastic brace worn around the entire trunk of the body) for Resident R135 to wear when out of bed.Review of Resident R135's physician order summary revealed an order dated October 23, 2025, for TSLO clamshell brace to be worn when out of bed to wheelchair due to fracture of spine.Observations on December 16, 2025, at 11:00 a.m. revealed Resident R135 was in the dining room, sitting in his/her wheelchair, wearing the TSLO clamshell brace.Review of Resident R135's report of consultation for orthopedics dated October 28, 2024, revealed recommendations included an MRI (imaging) of the spine, and to refer to endocrinology for osteoporosis (weak and fragile bones).Continued review of Resident R135's clinical record revealed the facility did not get an MRI done for Resident R135 until March 4, 2025. Review of Resident R135's clinical record revealed no documented evidence a follow-up was scheduled with orthopedics regarding the follow-up results of the MRI completed March 4, 2025.Further review of Resident R135's clinical record revealed no documented evidence the facility scheduled a consult with endocrinology per the recommendations from the orthopedic consult on October 28, 2025. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility documentation, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents received proper treatment and care to maintain good foot health for one of 36 residents reviewed (Resident R44).Findings Include:Review of Resident R44's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 29, 2025, revealed the resident was cognitively intact and had diagnoses of cerebral palsy (neurological condition that affects movement and posture) and muscle wasting.Review of Resident R44's comprehensive care plan revised July 3, 2025, revealed the resident had an activity of daily living self-care performance deficit related to weakness and impaired mobility.Interview on December 15, 2025, at 11:30 a.m. Resident R44 expressed he/she has been requesting to see podiatry for months. Observations revealed Resident R44's had long toenails, up to 1/2 inch long. Further the bottom of Resident R44's feet were dry and peeling.Observations on December 18, 2025, at 11:15 a.m. with Unit Manager, Employee E17, confirmed the conditions of Resident R44's feet. Unit Manager, Employee E17, reported podiatry comes to the facility monthly, and as needed.Review of Resident R44's podiatry consult dated March 27, 2025, revealed the resident was seen for continued foot care and evaluation. Resident R44 was noted with long toenails and callus.Further review of Resident R44's podiatry consult dated March 27, 2025, revealed Resident R44 presented with mycotic nails. Professional debridement (removal of dead, damaged, or infected tissue) needed to manage infection and prevent complications. Recommendations included follow-up in nine to twelve weeks.Review of Resident R44's entire clinical record revealed no documented evidence Resident R44 had follow-up podiatry services.28 Pa. Code 211.12 (d)(5)

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to ensure that residents were properly supervised. This resulted in an Immediate Jeopardy situation for a resident, who had had a diagnosis of dementia and history of exit seeking behaviors, to exit and elope from the building.Findings Include:Review of the job description of the Nursing Home Administrator (NHA) revealed that, the employee assumes full-time administrative authority, responsibility and accountability for the operations of the nursing facility. The employee manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. The employee implements operational and financial objectives of management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.Review of the job description of the Director of Nursing (DON) revealed that, the employee assumes full time administrative and clinical authority, responsibility, and accountability for the delivery of nursing services in the facility. The employee manages employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and state and federal laws and regulations. In collaboration with the Nursing Home Administrator, allocates department resources in an efficient manner to enable each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The employee communicates and interprets policies and procedures to nursing staff and subsequently monitors practice for effective implementation.Review of Resident R223's clinical record revealed the resident was admitted to the facility's 2nd Floor North Side nursing unit on December 11, 2025, and had diagnoses of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Apraxia (neurological disorder that affects motor planning and coordination), Diabetes Mellitus (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), and Hypertension (high blood pressure).Review of Resident R223's hospital documentation dated December 11, 2025, revealed Resident R223 was brought to the emergency department for inability to care for self and need for long-term placement. Resident R223 was noted to be living with a caregiver but due to patient's agitation and frequent elopements they were no longer able to care for Resident R223.Continued review of Resident R223's clinical record revealed a Brief Interview for Mental Status assessment conducted on December 12, 2025, determined that Resident R223 had severe cognitive impairment.Review of Resident R223's comprehensive care plan revised December 12, 2025, revealed the resident was an elopement risk/wanderer related to history of dementia and wandering. Wander guard applied to left ankle. Interventions dated December 12, 2025, included placing resident photograph at reception/exit and Resident R223 was on Center Watch Program (facility elopement binder maintained at front desk) for elopement risk.Review of Resident R223's physician order summary revealed an order dated December 12, 2025, for monitor wander guard/watchmate to left ankle/check placement and function every shift (morning, evening, and night shift).On December 17, 2025, at 9:00 a.m., the Director of Nursing, Employee E2, informed Department of Health surveyors that a resident [identified as Resident R223] eloped from the facility in the evening of December 15, 2025.Interview on December 17, 2025, at 9:00 a.m. with the Nursing Home Administrator, Employee E1, revealed that she, as well as the Director of Nursing, Employee E2, were informed Resident R223 was missing on 12/15/2025 at approximately 10:30 p.m. Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, both arrived at the building by approximately 11:30 p.m. to conduct a search of the building and perimeter with no luck in locating the resident.Review of statement dated December 15, 2025, by Registered Nurse Supervisor, Employee E28, revealed on 12/15/2025 around 9:30 p.m. he/she was informed by the care nurse (identified as nurse aide, Employee E25) that Resident R223 was missing. Registered Nurse Supervisor, Employee E28, announced a code yellow and performed an in-house and outside perimeter search for the resident. Resident R223 was still unable to be located, and administration was made aware.Review of witness statement dated 12/16/2025 by Regional Registered Nurse, Employee E18, revealed per interview with the dispatcher, on 12/15/2025 an owner of a home in a nearby neighborhood (located approximately 1.5 miles away from the facility) called 911 (Emergency Medical Services) at 9:36 p.m. because Resident R223 was knocking on their door. The police called (EMS) at 9:42 p.m. to request assistance and EMS was dispatched at 9:43 p.m.Review of Resident R223's hospital records revealed the resident was admitted to the emergency department (ED) on December 15, 2025, at 10:13 p.m. for altered mental status. Resident R223 was found to be walking around knocking on doors in the cold. When Resident R223 was brought to the ED, he/she was found to be confused and had Hypothermia (a medical condition that occurs when the body temperature drops below 95 degrees Fahrenheit, leading to potentially life-threatening consequences) for which he/she was put on Bair Hugger (warming unit). The average temperature on December 15, 2025, ranged from 19 degrees Fahrenheit to 28 degrees Fahrenheit.Further interview with the Nursing Home Administrator, Employee E1, on December 17, 2025, at 9:00 a.m. revealed she was notified by the police on 12/16/2025 around 7:00 a.m. that Resident R223 was located at a near-by hospital. The Nursing Home Administrator, Employee E1, promptly went to the hospital on [DATE] to positively identify Resident R223. Per the Nursing Home Administrator, Employee E1, when the police arrived at the scene on 12/15/2025 Resident R223 was not able to identify him/herself, so he/she was taken to the hospital as an unknown patient. Nursing Home Administrator, Employee E1, stated that the hospital obtained fingerprints and that is how they identified Resident R223 and informed the facility of his/her whereabouts.Nursing Home Administrator, Employee E1, reportedly reviewed security camera footage for the front door and back door cameras with no success in identifying when/how Resident R223 left the building.Subsequently, surveyors requested review of security camera footage to determine how and what time Resident R223 left the building.Review of security camera footage was conducted on December 17, 2025, at 10:15 a.m. with the Nursing Home Administrator, Employee E1, and Assistant Nursing Home Administrator, Employee E2. Per security camera footage, on 12/15/2025 at 5:37 p.m. an individual wearing a dark colored crewneck sweatshirt, dark colored sweatpants, and dark colored house slippers was seen exiting the building via the ground floor, out the back rear door (loading dock). The individual was observed to effortlessly push open the back door without resistance.The individual was subsequently identified as Resident R223 by the Nursing Home Administrator, Employee E1, and Assistant Nursing Home Administrator, Employee E2. Based on a review of facility documentation, observations, and staff interviews, it was determined that Resident R223 eloped from the facility at 5:37 p.m. on 12/15/2025. A code yellow - elopement protocol, was not implemented until 9:30 p.m. (four hours after the resident exited the building) Resident R223 was located by local law enforcements 1.5 miles away from the facility in sub-freezing temperatures and brought to the local hospital at approximately 10:15 p.m. where he/she was treated for hypothermia. Resident R223 had no identification and was unable to identify him/herself. Hospital staff needed to obtain fingerprints and subsequently notified the facility on 12/16/2025 at approximately 7:00 a.m. of Resident R223's whereabouts.Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation.Refer to F689.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (c) Nursing services.

Based on observation, interview, and record review it was determined that the facility failed to maintain and implement infection control program related to handwashing for one of thirty-six residents observed (Resident R47). Observation on Resident R47 conducted on December 2, 2025, during mediation administration revealed that Employee E32 administered Artificial Tears to the resident's right and left eye.Further observation revealed that Employee E32 did not perform hand hygiene between administering eye drops to the right and left eyeFurther observation revealed that Employee E32 administered Oxymetazoline HCl 0.05% Nasal Spray to Resident R47 left and right nostrils. Further observation revealed that Employee E32 did not perform hand hygiene prior to administering the nasal spray and between administration to left and right nostrils.Interview with Employee E32 confirmed that she did not sanitize her hands during administration of artificial tears between the left and right eyes and that she did not sanitize her hands during administration of Oxymetazoline HCl 0.05% Nasal Spray between left and right nostrils.

Based on observation, employee interviews and a review of facility policies, it was determined that the facility failed to maintain the dish machine in a safe operating condition.Findings include: A review of the undated facility policy, Chlorine Sanitizer Test Procedure revealed that staff should verify that dish machine is operating properly and allow it to run one full cycle and if the test strip reveals a chlorine reading below 50 parts per million (ppm) to notify the supervisor, adjust the sanitizer feed and retest. Observations during the initial tour of the kitchen on December 15, 2025, at 10:00 a.m. with Employee E14, Food Service Director (FSD), which revealed that the dish machine final rinse gage was reading between 140 degrees. The FSD indicated that the dish machine was a chemical sanitizing low temperature machine. Testing of chemical sanitizing dish machine with chlorine test strips revealed that no sanitizer was present in the final rinse confirming that the machine was not sanitizing the dishes that were being run through. After several attempts to adjust the sanitizer, the FSD could not get the machine to pump the sanitizing chemical into the rinse water and the machine and could not get a reading on the test strips. Interview with the FSD on December 15, 2025, at 10:30 a.m. confirmed the above findings, and that he was not certain how long the machine was operating without sanitizer as no one had reported testing concerns to him. Interview with the Administrator on December 15, 2025, at 10:50 a.m. confirmed that the dish machine was not working, that the dishware could not be properly sanitized and that she instructed the FSD to serve on disposable paperware and plasticware. The facility failed to maintain the dish machine in proper working order. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management

Based on interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure one resident was free from misappropriation of resident funds and exploitation for one out of two residents reviewed (Resident R1). Findings include: Review of the facility Abuse policy with a review date of July 22, 2025.residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Review of the August 2025 physician orders for Resident R1 included the diagnoses of heart failure (a syndrome caused by an impairment in the heart's ability to fill with and pump blood); hypertension (high blood pressure); cerebral infarction (a stroke); depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and age-related cognitive decline. Review of documentation submitted to the State Survey Agency indicated that the facility became aware of an allegation when the resident's daughter contacted the facility social worker and completed a Concern Form on July 21, 2025 at approximately 3:30 p.m. regarding bank statements indicating that resident was transferring funds through a money transfer mobile phone application to someone who the family suspected was at the facility. Documentation from money transfer mobile application indicated that the money was being sent to a nurse aide who the facility verified worked at the facility (Employee E3). Continued review of the reportable event revealed that the nurse aide admitted to obtaining funds from the resident, and the resident admitted during the interview with the Director of Nursing (DON) that he provided funds to the nurse aide. The reportable event indicated that the resident admitted to giving the nurse aide money and claimed that he was in a romantic relationship with the nurse aide. Review of the facility investigation indicated that the facility was provided with statements from the resident's daughter which indicated that the resident sent money to the nurse aide on several occasions through a money transfer mobile phone application from at least January 2025 through May 2025, and that his account transferred money to an account that displayed the first and last name of the referenced nurse aide. The resident's daughter, and the facility's investigation estimated the amount sent to the nurse aide to be between $1,7800-$1,754.72. Review of an interview conducted by the facility on July 21, 2025 indicated that the resident reported that he was in love with the resident and that he chose to give her money. I am in love with this young lady I chose to give her money. Continued review of the interview indicated that the resident reported that he gave the nurse aide money on two occasions . to buy him (the resident) food. During an interview with the resident on August 18, 2025, at 11:19 a.m. the resident reported that he was romantically involved with the nurse aide. The resident denied any sexual contact or touching of each other when he was asked during this interview what he meant by being romantically involved with her. Review of an interview conducted by the facility on July 22, 2025, with the nurse aide regarding money taken by the nurse aide from Resident R1 revealed that the aide admitted that she had taken money from the resident, and that the first time the resident sent money was January 2025. The nurse aide also reported in her statement that throughout the months, the resident continued to send her money through money transfer mobile phone application. Continued review of the statement from the nurse aide documented that she reported during her interview that she paid the money back. The facility documented in their investigation that the nurse aide provided no proof of paying any of the funds back to the resident. Continued review of the investigation revealed documentation that the resident's daughter sent which documented several money transactions that were sent to the nurse aide from the resident from January 2025 through May 2025. The transactions included, but are not limited to the following dates from January 2025 through May 2025: January 28, 2025 $100January 30, 2025 $50February 10, 2025 $50February 18, 2025 $40 February 18, 2025 $30 February 19, 2025 $25 March 17, 2025 $25 March 18, 2025 $30 March 20, 2025 $35 April 15, 2025 $25 March 24, 2025 $40 March 26, 2025 $20 March 26, 2025 $20 March 26, 2025 $20 March 27, 2025 $20March 31, 2025 $25April 1, 2025, $2 April 2, 2025 $20 During an interview with the resident's daughter on August 20, 2025, at 10:03 a.m. the resident's daughter reported that the she and her mother (the resident's wife) noticed funds being sent though a mobile money transfer application to someone that they did not know and that they transactions took place from January 2025-May 2025. The daughter stated that she contacted the facility on July 21, 2025, and notified them of her concern. The daughter also confirmed that the individual that her father was transferring money to was a nurse aide, and that approximately $1,700 was transferred to the nurse aide. Documentation from the investigation revealed that the nurse aide was terminated from the facility on July 24, 2025 for professional misconduct related to receiving mobile money transfers from the resident. During an interview with the Director or Nursing (DON) and the Nursing Home Administrator (NHA) on August 4, 2025 at 2:30 p.m. the investigation was reviewed and the DON confirmed that the nurse aide admitted to taking money from the resident, and that the nurse aide was terminated from the facility for professional misconduct on July 24, 2025. The facility failed to ensure one Resident R1 was free from misappropriation of resident funds and exploitation. 28 Pa. Code 201.18(b)(1)(2)(e)(1) Management28 Pa. Code 201.29 (a)(c) Resident rights28 Pa Code 211.12 (c) Nursing services

Based on interviews with staff, review of clinical records, facility policies and facility documentation, it was determined the facility failed to implement interventions to assure one resident (Resident R3) was free from physical abuse resulting in actual harm to Resident R3 who was struck by Resident R4 in the face with a leg rest, and sustained a chipped tooth for one of 10 resident records reviewed. (Resident R3 and Resident R4) Findings include: Review of facility policy titled, Abuse revised December 13, 2024, revealed, each resident will be free from abuse including verbal, mental, sexual, or physical abuse. Further review indicated, residents will be protected from abuse, neglect, and harm while they are residing at the facility and facility will educate staff in techniques to protect all parties. Review of Resident R3's clinical record revealed the resident was admitted on [DATE], with diagnoses including Cervical Disc Disorder, muscle weakness, difficulty walking, cognitive communication deficit, Atherosclerosis (coronary artery bypass graft), and Arterial Fibrillation (irregular rapid heart rate). Review of Resident R3's admission Minimum Data Set (MDS is an assessment of resident's care needs) dated January 28, 2025, revealed Resident R3 was cognitively intact, required maximal assistance with lower body dressing, and used a manual wheelchair for mobility. Review of Resident R3's care plan, initiated on January 22, 2025, revealed Resident R3 has an ADL (activity of daily living) self-care performance deficit related to muscle weakness, difficulty walking, and muscle wasting and atrophy (reduce muscle mass). Further review of Resident R3's care plan revealed the resident had oral/dental problems and was a smoker. Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, muscle weakness, Rhabdomyolysis (breakdown of skeletal muscle), Bipolar Disorder (condition in which a person has periods of depression of being extremely happy), and Depression (major loss of interest in pleasurable activities). Review of Resident R4's quarterly MDS assessment dated [DATE], revealed Resident R4 was cognitively intact and used a manual wheelchair for mobility. Review of Resident R4's care plan initiated on August 16, 2024, revealed Resident R4 had a behavior problem related to insomnia, depression, anxiety. Continued review of Resident R4's care plan revealed a single intervention, administer medications as ordered. Monitor for side effects and effectiveness. Review of Resident R3's clinical records including a Social Services note, dated March 24, 2025 revealed, a violent incident occurred outside in the smoking area. Resident was hit with leg rest from a wheelchair by another resident and Resident R3 was struck resulting in the loss of one tooth. Review of facility documentation titled, Injury Report, dated March 24, 2025, revealed Resident R3 had a chipped tooth inside of mouth. Interview conducted on April 2, 2025, at 9:55 a.m., with the Activity Aides, Employee E6, and Employee E5, who were supervising residents during the smoke break on March 24, 2025, approximately 1:30 p.m. revealed Employee E5 and Employee E6 announced to the residents, the facility staff would no longer provide cigarettes to the residents. Resident R4 responded with verbal aggression using foul language toward Employee E5 and Employee E6. Continued interview revealed when Resident R3 intervened in an effort to stop Resident R4 expressing foul language towards the activity aides, [Resident R4] got up with the leg rest in [his/her] hand and started chasing me (Employee E5), attempting to hit me. When [Resident R3] stood up from (his/her) wheelchair to defend (himself/herself), [Resident R4] swung at [Resident R3] in the face with the leg rest. Continued interview revealed Resident R3 dropped back into the wheelchair after the hit and Resident R4 tackled Resident R3 in [his/her] wheelchair and continued to punch (him/her) for approximately 15 seconds. During the interview, Activity Aides, Employee E5 and E6, revealed Resident R4 portrayed verbal aggression in the past with profanity towards staff during smoke breaks. During the Interview with Nurse Aide, Employee E11, conducted on April 2, 2025, Employee E11 stated, Resident R3 threatened to beat up [his/her] roommate because [his/her] television was loud, and now [his/her] roommate won't watch TV anymore. Interview with Nurse Aide, Employee E10, conducted on April 2, 2025, at 11:22 a.m. revealed that last month she heard Resident R4 shout at the roommate, I will beat you up. The facility failed to implement interventions to assure Resident R3 was free from physical abuse resulting in actual harm to Resident R3 who was struck in the face with a leg rest and sustained a chipped tooth. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for three of 10 residents reviewed. (Resident R3, Resident R6, Resident R7) Findings include: Review of facility policy titled, Food Temperatures, dated January 17, 2019, revealed, All hot food items must be cooked to appropriate internal temperatures, held and served from steam table at temperature of at least 135 F. Take temperatures often to monitor for safe temperature ranges of at or below 41 F for cold foods and at or above 135 F (Fahrenheit) for hot foods. Continued review revealed, Hot food items may not fall below 135 F after cooking and all cold food items must be maintained and served at a temperature of 41 F or below. Interview with Resident R6 on April 1, 2025 at 10:00 a.m. revealed some food does not have flavor. Interview with Resident R7 on April 1, 2025, at 10:10 a.m. revealed the food is warm, not hot. Interview with Resident R3 on April 1, 2025, at 1:30 p.m. revealed, they never get my food right. Observations during a test tray conducted with the Foodservice Director, Employee E12, on April 1, 2025, at 12:26 p.m. revealed chicken registered 118 degrees Fahrenheit (F); [NAME] registered 118 degrees F; Steamed Broccoli 106.7 degrees F; and cold pears registered 46.2 degrees F. Follow-up interview with the Food Service Director, on April 1, 2025 at 12:32 p.m. revealed that that foods should be at at least 120 degrees F and confirmed that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on the review of clinical records, facility policies, interviews with resident and staff, it was determined that the facility failed to ensure that the residents were free from verbal and mental abuse, which resulted in a staff member verbally and mentally abusing a resident (Resident R178) with documented history of mental health disorders. This failure caused the resident to experience fear and intimidation for one of 39 residents reviewed (Resident R178). This failure also put the resident at risk for potential physical abuse and bodily injury and resulted in an immediate jeopardy situation. This deficiency was identified as past non-compliance. (Resident R178) Findings Include: Review of an undated facility policy, titled, Abuse, revealed Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of abuse and neglect from the Draft State Operations Manual Appendix PP effective November 28, 2016. a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm i. Verbal abuse is defined as the use of oral, written or gestured language that willfully incudes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. iii. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. iv. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. It is the policy of [facility's company] that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Review of Minimum Data Set (MDS- Assessment of resident care needs) for Resident R178 dated May 13, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14 which indicated that the cognitive status of the resident was intact. Review of Pennsylvania Preadmission Screening Resident Review (PASRR) for Resident R178 dated May 9, 2023, revealed that the resident had a history of mild or major neurocognitive disorder and the resident had a mental health diagnosis of dementia. Review of psychiatric consult dated June 9, 2023, revealed that the resident had a history of major depressive disorder, delusional disorder, dementia, and generalized anxiety disorder. Review of care plan for Resident R178 dated October 5, 2022, revealed that the resident has behavior problem related to psychotic episode. The care plan also revealed that the resident used psychotropic medication related to behavior management. Interview with Resident R178 on October 25, 2023, at 11:46 a.m. stated that he experienced abuse in the facility that a staff member verbally and mentally abused him using derogatory language and lifted a trash can to hit me. Resident R178 stated Employee E9, Nursing Assistant, (employed through a staffing agency), bumped my bedside table [on June 4, 2023], while she was providing care to the roommate. He stated: I asked her to be careful because it had my drink on it, I did not want her to spill it over me, but she immediately turned and stated, f*** you. Resident said he felt upset because he lost his mother prior to the incident in a sad situation and asked her to repeat what she said, then she replied, f*** you, f*** your mother, f*** your brother. Resident stated he then put on his footwear and started walking towards her. Resident R178 stated she then asked me to come to her and picked up a trash can over her head and said, I'll f*** you up. Resident R178 also stated the supervisor who overheard the conversation asked her to drop the trash can three times, but she did not drop it. Resident R178 stated if the supervisor did not have interfered, they would have got onto a fight and the staff would have hurt him. Resident R178 stated he felt fear and intimidated from the incident, and he was still upset over the incident. Resident R178 stated the staff should protect the residents not hurt them or curse at them. Review of facility investigation dated June 4, 2023, revealed that the staff reported verbal abuse from nursing assistant, Employee E9. The allegation was substantiated, and the staff was placed on a do not return list. Review of a statement from Resident R178 dated June 6, 2023, obtained and signed by Employee E1, Nursing Home Administrator (NHA), revealed that the NHA interviewed Resident R178 due to the allegation of verbal abuse/aggravated behavior from Employee E9, Nursing Assistant. Resident R178 stated Employee E9 came into his room, while providing care bumped into his cart/tray. He told Employee E9 to be careful, that she almost knocked over his drink. Employee E9 responded, F you, I don't care. He was surprised and asked please repeat what she just said she responded, F you and F your momma. Resident R178 stated he got angry and told the aid to wait here while I put on my shoes. Then the aid said again F you and F your momma. Resident R178 stated he started walking towards the aide and she picked up the trash can and threatened to hit him with it. Review of an undated statement from Employee E9, Nurse Aide, revealed that she was giving care around 8:30 a.m. to his roommate and when she was finishing give care, she hit Resident R178's table. Resident R178 said what the h*** you doing. Resident R178 started to come to charging at her with his fist balled up so she backed out the room with a trash can, the acting supervisor charge nurse (Employee E10) witnessed it. Review of a statement from Employee E10, Licensed Practical Nurse Supervisor, dated June 4, 2023, revealed that on June 4, 2023, at 8:30 a.m. she was working on second floor south. She saw Employee E9, Nurse Aide, walking backwards holding a trash can above her head with both hands. Resident R178 was walking towards her. Employee E9 stated I'll f*** you up- go head hit me. Resident R178 stated to Employee E9 what did you say. Further review of the statement revealed that Employee E10 asked Employee E9 to put the trash can down and walk away, she repeated that three times to Employee E9. She then got in between the employee and the resident. She told Resident R178 to go to his room and told him, she was there, and he was safe. She also stated sorry to the resident for what happened. Review of statement from Employee E11, Licensed Practical Nurse, dated June 5, 2023, revealed that while administering medication she overheard Resident R178 and Employee E9 arguing. Resident R178 was saying you better not hit me with that trash can, I don't care if you are a girl. Employee E9 was heard saying I don't give a f***. Charge nurse told Employee E9 to get her things and leave. She went to Resident R178's room to check on the resident. He was upset but said he would be okay. He stated he just did not understand why she would do that to him. Review of a statement from Employee E12, Nursing Assistant, dated June 4, 2023, revealed that she overheard Resident R178 saying to Employee E9, Don't hit me with that trash can. Review of a statement from Resident R136, dated June 6, 2023, obtained and signed by Employee E1, Nursing Home Administrator (NHA), revealed that the NHA interviewed the resident and asked if he witnessed any altercation between Resident R178 and Employee E9, he stated he overheard the incident. Review of the statement completed by NHA revealed that Employee E13, Nursing assistant was interviewed, and she witnessed the aid holding the trash can and threatening. Employee E10 was interviewed and stated she witnessed and overheard aggressive behavior from Employee E9. Interview with Nursing Home Administrator, Employee E1, on October 26, 2023, at 12:30 p.m. stated Resident R178 told him that the staff used derogatory language towards the resident and threatened to hit him with the trash can. Employee E1 confirmed that Employee E9 could have walked away instead of threatening Resident R178 verbally and using trash can. Employee E1 confirmed that the staff failed to protect Resident R178 who had a history of documented mental disorders from physical and mental abuse which caused resident to experience fear and intimidation and placed the resident at the risk for potential physical abuse and bodily injury. Employee E1 also confirmed that Resident R178 lost his mother prior to that incident and using derogatory and abusive language against his mother made him upset. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on October 26, 2023, at 3:24 p.m. for the facility's failure to ensure that residents were free from verbal and mental abuse. This failure resulted in a staff member verbally and mentally abusing a resident (Resident R178) with a documented history of mental health disorders. The verbal and mental abuse caused Resident R178 to experience fear and intimidation and placed the resident at risk for potential physical abuse and bodily injury. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 26, 2023, at 3:24 p.m. On June 4, 2023, the facility initiated a plan of correction to to ensure that residents were free from verbal and mental abuse, which resulted in a staff member verbally and mentally abusing a resident (Resident R178). The resident had a documented history of mental health disorders which caused Resident R178 to experience fear and intimidation. Placing Resident R178 at risk for potential physical abuse and bodily injury. Facility plan of correction included the following: -Staff member immediately suspended and removed from assignment. 6/4/2023 (completed) -Resident offered emotional support. 6/4/2023 (completed) -Resident received skin check to ensure no physical harm. 6/4/2023 and 6/5/2023 (completed) -Other residents on assignment received skin checks to ensure no physical harm. 6/5/2023(completed) -Residents on assignment were interviewed to ensure no verbal/mental or abuse of any kind. 6/5/2023 (completed) -Staff member involved in investigation DNR and removed from schedules. 6/5/2023 (completed) -Resident questionnaire for Abuse prevention ongoing monthly. 6/5/2023 (completed) Abuse and Neglect in-service training reinitiated. 6/5/2023 (completed) 100% of nursing staff employed after 6/5/2023 have abuse and neglect in-servicing. Abuse and neglect education with post-test. 6/5/2023 (completed) 100% of nursing staff have post-test completed. -Abuse fair planning initiated and successfully completed. (completed 7/14/2023) Freedom from abuse posters were hung around facility. 6/21/2023 - (completed) Staff signed freedom from abuse PLEDGE. 7/14/2023-7/17/2023- (completed) -IDT Review of new and at-Risk residents -via questionnaire. 6/5/2023 - (completed) Ensure awareness of residents rights to be free from abuse - via signage and ongoing education and tests. 6/5/2023 (completed) -Adhoc/QAPI Meeting - Adhoc 6/8/2023 and QAPI 7/31/2023 (completed). Date of compliance was documented as July 14, 2023. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on June 4, 2023. Education was completed and audits were initiated to ensure that the residents were free from verbal and mental abuse. The action plan was accepted on October 26, 2023, at 6:50 p.m. On October 27, 2023, the action plan was reviewed, which revealed that the Employee E9 was immediately removed from the schedule and placed on Do Not Return list. Resident was offered emotional support and seen by psychiatrist on June 9, 2023. Other residents were interviewed, and skin check provided for residents that were not able to be interviewed were provided skin check. Staff were provided education on abuse and neglect prevention. Freedom from abuse signs were posted. Abuse fair was completed, and it was also revealed that the staff signed freedom from abuse pledge. Interviews were conducted with Licensed Nursing staff, Registered Nurses and Nursing Assistants regarding education related to abuse/neglect prevention and reporting of abuse. Staff also stated that they received sufficient trainings from the facility. Staff verbally demonstrated knowledge of abuse/neglect prevention and reporting protocols. The Assistant Nursing Home Administrator, Employee E3, was notified that the Immediate Jeopardy was lifted on October 27, 2023, at 2:44 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, review of facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that Resident R1 was free from resident abuse, which resulted in physical and psychosocial harm to Resident R1 who sustained pain and redness to right wrist, and emotional anguish for one of six residents reviewed. (Resident R1) Findings include: Review of undated facility policy title Abuse revealed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Review of Resident R1's MDS (Minimum Data Set- Assessment of Resident care needs) dated February 17, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 0 which indicated that resident's cognitive status was impaired. Review of facility documentation dated April 9, 2023, revealed that On 4/9/2023, Charge nurse walked into the resident's room to find the resident crying and shaking. Resident reported to charge nurse while receiving care from Employee E8, Nursing Assistant (Employed by staffing agency) she accidentally scratched the care nurse's hand and told her she was sorry. In response the nursing assistant stated, I'm not trying to hear that [sh*t] and bent the residents' right hand backwards. During the assessment redness was noted to resident hand this was a clear indication that it has been altered. Review of nursing notes from April 9, 2023, at 3:39 p.m., revealed resident made a statement saying her aide bent her right hand back. The aide stated resident scratched her. When asked the resident she admitted she did it by mistake and she was sorry, and the aide stated she was not trying to hear that and bent her right hand backwards. Review of nursing notes from April 9, 2023, at 4:04 p.m., revealed resident complained of pain level 9 out of 10 (Pain level of 7-10 (Sever Pain) (disabling or unable to carry out normal daily activities, ranges from impacts your social relationships, or sleep to being bedridden or even delirious.), resident was alert and oriented, resident stated she accidentally scratched nursing assistant. Resident stated she apologized to the nursing assistant, but the nursing assistant stated, I don't believe you, you don't know who you are dealing with. Resident was tearful and stated she was trying to hurt me because I scratched her. Resident was given the pain medication Motrin (medication to treat mild to severe pain). Review of skin assessment for Resident R1 dated April 9, 2023, revealed there was a new skin issue noted. Right hand was noted with redness. Pain was noted when moving hand and wrist. Review of nursing notes from April 9, 2023, at 10:46 p.m., revealed that resident received as needed pain medication. Review of witness statement from Resident R1 obtained by the Social Service Director dated, April 9, 2023, revealed, when asked resident was there an incident with anyone recently, resident stated yes. When asked if resident felt safety at the facility, resident replied that she did not feel safe because of the nursing assistant. Social worker provided the resident with emotional support. Review of statement from Licensed Nurse, Employee E9, revealed that I walked in the resident room and found her crying and shaking. I asked her what's wrong and the nursing assistant stated she scratched me. I asked if she scratched you, why is the resident crying. I then proceeded to ask the resident what happened the resident stated she did scratch her (nursing assistant) by mistake when turning she was trying to reach the side rail. The resident stated she said sorry to the nursing assistant, but the nursing assistant stated, I am not trying to hear that shit you got the wrong one and bent her right hand back. (Hand is red) I walked in seconds after the incident was supposed to happen. Review of the facility investigation revealed that the facility concluded that resident hand was bent/twisted by Nurse aide, Employee E8. Interview with Licensed Nurse, Employee E9 on April 19, 2023, at 11:49 a.m., stated the incident involving Resident R1 and Nurse aide, Employee E8 happened around 2.30 p.m. When she walked into the room, the door was shut, and the aide was in the room. Employee E9 stated she opened the door and walked into the room. When she got there, the resident was saying, she (Employee E8) hurt me, and the resident was crying. Resident stated when I accidently scratched the aide's hand, she bent her hand. The hand was hot to touch and red. Interview with Resident R1 on April 19, 2023, at 11:57 a.m., with the presence of Licensed Nurse, Employee E9, confirmed the nursing assistant hurt her by bending her hand when she accidently scratched her. Resident did not answer any other questions. The facility failed to ensure that Resident R1 was free from resident abuse, which resulted in physical and psychosocial harm to Resident R1 who sustained emotional anguish, pain and redness to right wrist after resident's wrist was bend back by Nurse aide, Employee E8. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of clinical records, facility documentation and policies, interviews with resident and staff, it was determined that the facility failed to protect one of 38 residents (Resident R172) from Resident R91 who displayed behavioral disturbances. This failure resulted in actual psychological and physical harm to Resident R172 who was punched on the face by Resident R91. Findings include: Review of facility policy Freedom from Abuse, Neglect, and Exploitation, not dated, stated, The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from verbal, mental .or physical abuse. Review of Resident R172's clinical record revealed the resident was diagnosed with Type 2 Diabetes Mellitus (failure of the body to produce insulin), bilateral above knee amputation, and major depressive disorder. Resident R172's Quarterly MDS (Minimum Data Set, an assessment of resident's needs) dated September 7, 2022 revealed the resident was cognitively intact, with impairment on both sides of her lower extremities and required extensive assistance from staff with bed mobility, transfers, dressing, toileting, eating and personal hygiene. During an interview on October 4, 2022 at 1:37 p.m. Resident R172 stated her roommate (Resident R91), Accuses me that I am jealous of her and she is always taking my stuff. Review of Resident R91's clinical record revealed the resident was admitted on [DATE] with Type 2 Diabetes Mellitus, [CONDITION(S)] (mental disease characterized by loss of reality contact, delusions and hallucinations) and was diagnosed with conduct disorders on September 7, 2022. Resident R91's psychiatric note dated, May 11, 2022 described the resident as impulsive,with poor safety awareness, having anxiety and depression, thought content with delusions, poor judgement. Resident R91's Quarterly MDS dated [DATE], revealed cognitive impairment and required supervision (oversight) with all activities of daily living. Review of Resident R91's care plans for behavioral problems related to [CONDITION(S)] dated May 19, 2022 with goals to have the resident experience fewer episodes of [CONDITION(S)] behaviors and interventions that included administering the medications and monitoring/documenting for side effects and effectiveness. Interventions also included anticipating and meeting the resident's needs and monitoring/documenting behavior episodes with attempts to determine underlying cause and praise the resident for any progress. Resident R91's physician note dated May 27, 2022 references that she is Very verbal with delusional content. Resident R91's nursing progress note dated, August 15, 2022 stated at 10:30 p.m. a police officer went to the residents' room to file a complaint and the resident was noted with Extreme confusion and Agitated. When the resident followed the police officer out into the hallway the nurse reminded the resident (in this state of confusion and agitation) to use her walker. The resident said, You are not my mother, you can't tell me what to do and tried to reach for the officer's gun and said, I want to kill that B. Review of the facility's incident report indicated the police officer subdued the resident. Surveyor requested the facility's incident report for August 15, 2022 but no further documented evidence was available for review. On October 6, 2022 at 11:45 a.m. the Nursing Home Administrator (NHA) said, That's it, that's all I got. When the Administrator was asked what brought the police to the facility on [DATE] the Administrator responded , It had nothing to do with [Resident R91]. Continuing review of Resident R91's clinical record revealed that the resident was admitted [DATE] to the hospital for psychiatric treatment and readmitted to the facility on [DATE]. Review of psychiatric progress note dated September 14, 2022 noted Resident R91's behaviors as restless, anxious, impulsive, with poor safety awareness, had hallucinations/delusions, and her thought process was illogical and disorganized. Behavior note dated, October 5, 2022 indicated Resident R91 was making threats against her roommate (Resident R172) stating her roommate was the devil and needed to have the devil removed from her. It was noted that the resident was Unable to be redirected. Nursing progress note dated, October 5, 2022 at 7:08 a.m. from Licensed Nurse, Employee E35 stated Resident R172 was Afraid of roommate, stating she keeps coming over to her side of the room and moving things around and cursing at her. Progress note dated October 6, 2022 at 2:52 a.m. from Licensed nurse, Employee E35 stated Resident R172, Remains afraid of roommate. Reassured resident that staff would check on her frequently during the night. Interview with Resident R172 on October 6, 2022 at 10:00 a.m. stated today she was sleeping and woke up to Resident R91 spraying something on me. Resident R172 said she held her arms out trying to protect her face from Resident R91 and She punched me in the eye. Resident R172 was observed with broken blood vessel in her right eye and the area swollen. During an interview with the Nursing Home Administrator on October 6, 2022 at 11:30 a.m., the Nursing Home Administrator was questioned when Resident R172 stated in the progress notes she was afraid of Resident R91 on October 5th and [DATE]th, 2022 why did they remain in the same room? The NHA replied, They should have moved her. Interview on October 10, 2022 at 8:39 a.m. with Licensed Nurse, Employee E35, stated she reported the October 5th and 6th, 2022 incident to her supervisor, Registered Nurse, Employee E36. The Licensed nurse stated she was told to put it on the 24-hour report so the Director of Nursing would be notified, Hoping someone would see it and have something done. The facility failed to ensure that Resident R172 was protected from Resident R91 who displayed aggressive behaviors, resulting in actual harm to Resident R172 who was punched on the face by Resident R91. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policies, clinical record reviews, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that one resident remained free from neglect, which resulted in actual harm to Resident R4 who sustained an elbow fracture. Additionally, the facility failed to ensure that Resident R3 remained free from physical abuse, of seven residents reviewed. Findings include: Review of facility policy, Freedom from Abuse, Neglect and Exploitation dated June 13, 2020, revealed that, The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. Observation on June 10, 2022, at 2:32 p.m. revealed Resident R4 sleeping in bed with a hard cast over her left arm and elbow. Clinical record review revealed a Quarterly MDS (Minimum Data Set - a mandatory periodic assessment) dated April 12, 2022, which indicated that the resident was admitted to the facility November 9, 2017, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of two, which indicates that the resident was severely cognitively impaired. Review of Resident R4's care plan, dated initiated April 14, 2022, revealed that the resident required restorative nursing programs related to poor balance with interventions including encouraging the resident to ambulate on the unit with hand-held assistance. Continued review of Resident R4's care plan, dated last revised June 26, 2020, revealed that the resident has a behavior problem refusing baths/showers, vital signs, labs and evaluations related to cognitive deficits with interventions including encouraging the resident to ambulate and provide opportunities for positive interactions. Review of facility documentation submitted to the Department of Health on May 4, 2022, at 5:12 p.m. with the date of the event being May 3, 2022, at 12:00 p.m. revealed that Resident R4 was escorted to her room by Employee E10, LPN. Employee E10 let go of Resident R4 who subsequently fell and hurt her elbow. Employee E10 was found to be negligent by the facility. Review of facility documentation revealed a witness statement from Employee E11, agency nurse aide, who noted, On Saturday April 30, 2022, I witnessed [Resident R4] was trying to get shower but someone else was in shower room. So nurse escorted her back to her room during the time the resident and nursing was pulling from each other and the nurse was pulling [Resident R4] as she was tugging to get away. The nurse let her go and she fall as nurse was leaving out the room. I screamed and told nurse she fell . She came back and pick her up and sat her on the bed. No vitals or anything was done. I told nurse resident was complaining of pain to the elbows and legs. Continued review of facility documentation revealed a witness statement from Employee E12, nurse aide, dated May 4, 2022, who noted that on May 1, 2022, she went to look at Resident R4's arm, observed a bruise on her elbow and reported it to the nurse [Employee E10]. Continued review of facility documentation revealed a witness statement from Employee E10, licensed nurse, dated May 3, 2022, who noted that on May 1, 2022, a nurse aide approached and informed me that the resident stated she had fallen. Upon entering the resident's room, I observed the resident resting in bed. Upon assessment, the resident denied having fallen and there was no signs or symptoms of injury and no complaints of pain or discomfort at that time. An additional statement provided by Employee E10 on May 12, 2022, revealed that Employee E10 confirmed that she did not do an incident report or document an assessment in response to Resident R4's reported fall. Employee E10 confirmed that Employee E11 was in Resident R4's room, providing care to a roommate, when Employee E10 escorted Resident R4 back into her room. Review of Resident R4's progress notes revealed a nurses note, dated May 2, 2022, at 3:30 p.m. which indicated that resident had a possible fracture to her arm from a fall happened on the weekend . resident left elbow slightly swollen and complained of pain to touch. Resident reported that she fell . The nurse practitioner was notified and ordered x-rays of the left shoulder and elbow. Review of radiology results, dated May 3, 2022, revealed that Resident R4's x-ray to her left elbow was suspicious for a subtle hairline fracture through the base of the olecranon (the bony tip of the elbow) extending into the greater sigmoid cavity (area where arm bones fit together) Review of an orthopedic (bone doctor) consult, dated May 4, 2022, revealed that Resident R4 was diagnosed with a left olecranon fracture, a long arm cast was placed with recommendations for non-weight bearing status for the left upper arm and to follow-up in four weeks for cast removal and new x-rays. Employee E10 failed to complete an incident report or document an assessment for Resident R4 upon a report of a fall, resulting in neglect and the delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on June 10, 2022, at 10:00 a.m. revealed Resident R3 continuously ambulating around the halls of the One South nursing unit. Review of Resident R3's Quarterly MDS, dated [DATE], revealed that the resident was admitted to the facility April 30, 2019, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed a BIMS score of five, which indicated that the resident was severely cognitively impaired. Review of Resident R3's care plan, dated last revised July 2, 2019, revealed that the resident has the potential for elopement related to cognitive loss with interventions including to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation and television. Continued review of Resident R3's care plan, dated initiated May 23, 2022, revealed that the resident has behaviors of urinating on the floor with interventions including encouraging the resident to use the toilet often. Further review of Resident R3's care plan, dated last revised May 17, 2022, revealed that the resident has the potential to be physically aggressive with staff with interventions including to provide the resident with physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation and assist to set goals for more pleasant behavior. Review of facility documentation submitted to the Department of Health on May 6, 2022, at 1:06 p.m. revealed that Employee E13, housekeeper, allegedly pushed Resident R3. Review of facility documentation revealed a witness statement from Employee E14, agency licensed nurse, dated May 6, 2022, who noted that Resident R3 was walking in the hallway and picked up a wet floor sign then continued walking. The housekeeper went to get the sign from the resident, the resident turned and walked in the direction of the housekeeper. Then the resident turned to walk away. Employee E14 noted that she observed Employee E13 push the patient with both hands open in the back. Continued review of facility documentation revealed a witness statement from Employee E15, nurse supervisor, dated May 6, 2022, who noted that she assessed Resident R3 after Employee E14 reported that Employee E13 had pushed resident forcefully through doorway. Upon assessment, the resident was unable to describe what happened and that there were no signs of injuries. Continued review of facility documentation revealed a witness statement from Employee E13, dated May 6, 2022, who noted that Resident R3 had a wet floor sign and that he walked over to get the sign [Resident R3] had it I took back. An additional statement was provided by Employee E13 on May 10, 2022, which indicated, I started mopping and [Resident R3] grabbed the wet floor sign. I went to grab it from him and there was a little bit of back and forth struggle . My hand touched his hand to get the sign and he fell back a bit. Interviews on June 10, 2022, between 9:30 a.m. and 10:30 a.m. with Employee E3, agency licensed nurse, Employee E4, agency nurse aide, Employee E5 agency nurse aide, and Employee E8 agency nurse aide, revealed that they have not received any recent in-servicing education related to abuse and neglect. Interview on June 10, 2022, at 2:00 p.m. with the Director of Nursing (DON) revealed that Employees E11 and E14 no longer wish to work at the facility after reporting their allegations of neglect and abuse. The DON confirmed that Employee E10 was terminated for neglect related to not completing an incident report or evaluating the resident after being informed that Resident R4 had sustained a fall. The DON also confirmed that the allegation of physical abuse was substantiated and that Employee E13 was terminated from his position at the facility. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that licensed nurses, (Licensed Practical Nurse), maintained professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members when there is significant change in condition as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards which resulted in harm to a resident related to a lack of a timely nursing assessment and a delay of medical care to a resident who sustained a fall which caused an elbow fracture that required medical intervention for one of seven residents reviewed (Resident R4). Findings include: Observation on June 10, 2022, at 2:32 p.m. revealed Resident R4 sleeping in bed with a hard cast over her left arm and elbow. Clinical record review revealed a Quarterly MDS (Minimum Data Set - a mandatory periodic assessment) dated April 12, 2022, which indicated that the resident was admitted to the facility November 9, 2017, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of two, which indicates that the resident was severely cognitively impaired. Review of Resident R4's care plan, dated initiated April 14, 2022, revealed that the resident required restorative nursing programs related to poor balance with interventions including encouraging the resident to ambulate on the unit with hand-held assistance. Continued review of Resident R4's care plan, dated last revised June 26, 2020, revealed that the resident has a behavior problem refusing baths/showers, vital signs, labs and evaluations related to cognitive deficits with interventions including encouraging the resident to ambulate and provide opportunities for positive interactions. Review of facility documentation submitted to the Department of Health on May 4, 2022, at 5:12 p.m. with the date of the event being May 3, 2022, at 12:00 p.m., revealed that Resident R4 was escorted to her room by Employee E10, LPN. Employee E10 let go of Resident R4 who subsequently fell and hurt her elbow. Employee E10 was found to be negligent by the facility. Review of facility documentation revealed a witness statement from Employee E11, agency nurse aide, who noted, On Saturday April 30, 2022, I witnessed [Resident R4] was trying to get shower but someone else was in shower room. So nurse escorted her back to her room during the time the resident and nursing was pulling from each other and the nurse was pulling [Resident R4] as she was tugging to get away. The nurse let her go and she fall as nurse was leaving out the room. I screamed and told nurse she fell . She came back and pick her up and sat her on the bed. No vitals or anything was done. I told nurse resident was complaining of pain to the elbows and legs. Continued review of facility documentation revealed a witness statement from Employee E12, nurse aide, dated May 4, 2022, who noted that on May 1, 2022, she went to look at Resident R4's arm, observed a bruise on her elbow and reported it to the nurse [Employee E10]. Continued review of facility documentation revealed a witness statement from Employee E10, licensed nurse, dated May 3, 2022, who noted that on May 1, 2022, a nurse aide approached and informed me that the resident stated she had fallen. Upon entering the resident's room, I observed the resident resting in bed. Upon assessment, the resident denied having fallen and there was no signs or symptoms of injury and no complaints of pain or discomfort at that time. An additional statement provided by Employee E10 on May 12, 2022, revealed that Employee E10 confirmed that she did not do an incident report or document an assessment in response to Resident R4's reported fall. Employee E10 confirmed that Employee E11 was in Resident R4's room, providing care to a roommate, when Employee E10 escorted Resident R4 back into her room. Review of Resident R4's progress notes revealed a nurses note, dated May 2, 2022, at 3:30 p.m. which indicated that resident had a possible fracture to her arm from a fall happened on the weekend . resident left elbow slightly swollen and complained of pain to touch. Resident reported that she fell . The nurse practitioner was notified and ordered x-rays of the left shoulder and elbow. Review of radiology results, dated May 3, 2022, revealed that Resident R4's x-ray to her left elbow was suspicious for a subtle hairline fracture through the base of the olecranon (the bony tip of the elbow) extending into the greater sigmoid cavity (area where arm bones fit together) Review of an orthopedic (bone doctor) consult, dated May 4, 2022, revealed that Resident R4 was diagnosed with a left olecranon fracture, a long arm cast was placed with recommendations for non-weight bearing status for the left upper arm and to follow-up in four weeks for cast removal and new x-rays. Interview on June 10, 2022, at 2:00 p.m. with the Director of Nursing (DON) revealed that Employee E11 no longer wish to work at the facility after reporting their allegations of neglect and abuse. The DON confirmed that Employee E10 was terminated for neglect related to not completing an incident report or evaluating the resident after being informed that Resident R4 had sustained a fall. Employee E10, LPN, let go of Resident R4's arm on April 30, 2022, causing the resident to fall which caused a fracture to the resident's elbow. Then, Employee E10, LPN, picked up the resident and sat the resident in bed without assessing the resident for injury or communicating with the medical team to seek additional interventions for the resident. Employee E10, LPN, failed to maintain professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members when Resident R4 had a significant change in condition related to her fall contributed by Employee E10, LPN, as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards which resulted in harm to the resident related to a lack of a timely nursing assessment and a delay of medical care to the resident. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, interviews with staff and residents, review of clinical record and facility documentation, it was determined that the facility failed to ensure that Resident R1 was free from abuse from another resident (Resident R2) resulting in actual harm to Resident R1 sustaining a laceration to the resident's left eyebrow and five sutures to the eyebrow for one of four residents reviewed. (Resident R1) Findings include: Review of facility policy title Abuse, Neglect or Mistreatment, dated September 2019, revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when the facility staff fails to monitor and/or supervise delivery of resident care and services to assure care is provided as required. Further review of the policy under prevention it indicated to provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse/neglect and/or misappropriation of resident property is more likely to occur. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/ or are totally dependent on staff. Under Identification it stated to identify events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse. Review of Room Change Policy (undated) indicated, If a resident or the Resident Representative express a concern about a roommate(s) and request a room change, the resident who expresses the concern and request for a change in roommates, the resident expressing the concern will be offered another room. Review of Resident R1's quarterly Minimum Data Set Assessment (MDS-an assessment of resident's needs) dated February 10, 2020, revealed the Resident R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Further review of the MDS assessment identified the resident with a BIMS (Brief Interview of Mental Status) Score of 99, indicating Resident R1 was confused and unable to participate in this brief screening. A staff assessment was completed and the resident was assessed with [REDACTED]. The resident's cognitive skills for daily decision making were moderately impaired. The resident did not demonstrate any mood symptoms. The resident was assessed as requiring supervision with transfers and ambulation with the use of a walker. Further review revealed Resident R1's MDS indicated that the resident received antipsychotic and antidepressant medication daily. The assessment indicated Resident R1 demonstrated no physical behavioral symptoms or verbal behaviors directed toward others and no changes were noted with his current behavioral status. Review of Resident R2's quarterly Minimum Data assessment dated [DATE] revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was assessed as requiring limited assistant with transfer and ambulation. Review of Resident R2's nursing notes dated November 27, 2019, revealed, Patient noted with increased behaviors, yelling, throwing computer equipment, refusing care, refusing to let the other resident in his room, refusing redirection and intractable refusing care. Resident R2 was transferred to a psychiatric hospital form November 27, 2019 and readmitted to the facility on [DATE]. Further review of Resident R2's clinical record revealed a second admission to a psychiatric facility on December 27, 2019 until January 8, 2020 due to acute [MEDICAL CONDITION]. Review of Resident R2's January 2020, Medication Administration Record [REDACTED]. Review of Resident R2's care plan dated November 27, 2019, revealed The resident can be verbally aggressive (yelling/screaming racial slurs/vulgar profanity) and physically (throwing equipment) aggressive to patients and staff related to [MEDICAL CONDITION]. Interventions included to analyze times, places, circumstances, triggers and what de-escalates behavior and document and to assess resident's needs: food, thirst, toileting need and comfort level. Review of Resident R1's nursing note dated January 29, 2020, noted Observation with skin alteration to right side of neck and below right eye. Injuries were reported to responsible party and physician. An X-ray of right shoulder revealed no fracture and no acute abnormality. Resident now with abrasion bilaterally to bridge of nose, bruise to right cheek and open area to right side of neck. Topical treatment was provided and resident had no complaint of pain. Interview conducted on February 18, 2020, at 11:00 a.m. with Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that Resident R1's responsible party (his son) reported to the facility on [DATE]. Son was assured by facility administration that an investigation into his father's injuries of unknown origin was being conducted. The NHA and DON indicated that the resident's son requested that the resident's roommate be transferred out of the room. After being advised of facility policy (Room Change Policy) Resident R1's son did agree to have his father transferred out of the room for his safety. Review of Resident R1 nursing note dated January 30, 2020, indicated that the resident was transferred from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident R1 was oriented to the new room by a charge nurse who speaks Spanish and the resident was adjusting well to room change. Further review of Resident R1's nurse's note dated February 15, 2020, revealed a Resident to Resident Altercation: At 2:00 p.m., charge nurse heard yelling from room [ROOM NUMBER]. Upon entering room, charge nurses observed (Resident R1) seated in a chair holding his left eye, with the (Resident R2) who occupies the room standing over him with his fist balled up. Upon further observation, charge nurse noted a laceration to resident's left eyebrow with some bleeding noted. First aid provided, bleeding stopped and dry dressing applied. When asked what happened, resident did not respond. Both residents were separated, and resident seated in the common area under staff supervision. When the other resident was interviewed, he informed charge nurses that the resident would not leave his room so he punched him in his face. Supervisor notified. Physician notified and ordered (Resident R1) to be sent to the hospital for evaluation. Neuro checks initiated and within normal limits. Vital signs were also within normal limits. Resident's son (responsible party) notified. Nursing note dated February 15, 2020, noted that Resident R1 returned to the facility from the hospital at 11:45 p.m. Res (resident) has 5 sutures to the area of above the right eyebrow, no c/o (complain) of pain. Res (resident) at baseline ambulating with walker on unit. The facility failed to provide to provide an environment free from physical abuse to Resident R1, which resulted in actual harm to Resident R1 sustaining a laceration to the resident's left eyebrow, transfer to the hospital and requiring five sutures to the eyebrow. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Coode 211.10(d) Resident care policies 28 Pa. Code §211.11(d) Resident care plan 28 Pa. Code §211.12(d)(1) Nursing services 28 Pa. Code §211.12(d)(5) Nursing services

Based on review of medical records and facility documentation and resident and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans regarding bed mobility, constipation, medical equipment and falls, resulting in actual harm to one resident (Resident R19), related to an eye injury, for four of 40 residents reviewed (Resident R19, R122, R129 and R346). Findings include: Review of Resident R19's clinical record revealed a quarterly Minimum Data Set (MDS- periodic review of resident care needs) dated (MONTH) 13, 2019, which indicated that the resident had [DIAGNOSES REDACTED]. Continued review of the MDS revealed that Resident R19 had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 99, indicating that she was unable to complete the interview. Further review of MDS Assessment revealed Resident R19's cognitive skills for daily decision making were moderately impaired (decisions poor with cues/supervision required). The MDS Assessment further revealed that Resident R19 required the extensive physical assistance of two or more staff persons for bed mobility (how resident moves to and from a lying position, turns side to side and positions their body while in bed). Review of Resident R19's nursing progress note dated (MONTH) 18, 2019, at 14:22, documented by Employee E6, Licensed Nurse, revealed that Resident R19 was noted with the new onset of right eye swelling and discoloration. Review of Resident R19's care plan for activities of daily living self-care performance dated revised (MONTH) 8, 2019, revealed that Resident R19's plan of care was not updated following the revision of the Quarterly MDS Comprehensive Assessment on (MONTH) 13, 2019. The care plan did not address the resident's need for the physical assistance of two staff members with bed mobility. Review of facility investigation documentation dated (MONTH) 18, 2019, confirmed that Resident R19 was found to have swelling and discoloration of her right eye by the nursing assistant who was giving her a shower. Continued review of facility documentation revealed that staff repositioned Resident R19 in bed alone and failed to provide two person physical assistance with bed mobility as indicated in the resident's comprehensive quarterly assessment dated (MONTH) 13, 2019. Interview with Employee E6, Licensed Nurse, on (MONTH) 6, 2019 at approximately 10:30 a.m., confirmed, All staff members on the unit were interviewed and asked to provide a statement. Several staff members were interviewed a second time with Director of Nursing and Assistant Administrator for additional questions. Several staff were asked to demonstrate how the resident was being moved and transferred, which revealed that improper technique was being used. The facility failed to ensure that one resident who was assessed as needing the physical assistance of two staff persons for bed mobility received that assistance which resulted in actual harm to Resident R19 who sustained swelling and discoloration to her right eye as a result. Review of Resident R122's quarterly Minimum Data Set (MDS-periodic review of resident care needs) dated (MONTH) 2, 2019, revealed that in the seven day lookback period for the assessment, the resident was documented as having no bowel movements for the entire seven day period. Review of the medical record for Resident R122 revealed the resident was continent with a small sized formed bowel movement on Tuesday (MONTH) 23, 2019, at 10:17 a.m. and then was documented as having no bowel movements on 15 of 15 occurances for bowel records until he was continent with a medium sized formed bowel movement on Monday (MONTH) 6, 2019, at 8:27 p.m. (13 days of documented constipation). Review of Resident R122's medical records on (MONTH) 7, 2019, revealed a care plan for chronic pain with a goal of ensuring the resident would not have discomfort related to the side effects of [MEDICATION NAME] (pain medication). The care plan included an intervention to observe for constipation. Review of the Medication Administration Record [REDACTED]. Interview with Employee E10, Registered Nurse (RN), Regional Specialist, on (MONTH) 7, 2019, at 1:00 p.m. confirmed that Resident R122 was present in the facility since (MONTH) 1, 2019, that the quarterly MDS and bowel movement records indicated the resident had no bowel movement for a period of 13 days, that the resident was not receiving pain medications that could cause constipation during (MONTH) and (MONTH) 2019. Employee E10 further confirmed that the facility did not develop a comprehensive person-centered care plan to address Resident R122's constipation. Review of medical records for Resident R129 revealed that she was admitted to the facility on (MONTH) 30, 2019, with [DIAGNOSES REDACTED]. language area in the brain which leads to impairment of language, speech, comprehension, and the ability to read and write) and depression (a mental health disorder of having episodes of psychological depression with symptoms including feelings of sadness, low esteem, hopelessness). Observation of Resident R129 on (MONTH) 3, 2019, at 1:03 p.m. revealed the resident lying in bed with a right foot drop (the inability to raise the front of the foot due to weakness or paralysis) and in the wheelchair adjacent to her bed was a leg and foot brace called a multi podus boot (designed to suspend a resident's heel to prevent skin breakdown from occurring on the bottom of the heel). Interview with Resident R129, at the time of the observation, confirmed that she was supposed to be wearing the multi podus boot and that staff had not applied the boot to her leg since admission to the facility. Review of the medical record for Resident R129 revealed no progress notes referring to the resident having a foot drop or the need to wear a multi podus boot. Review of care plans revealed that no care plan for foot drop or the use of the multi podus boot had been developed. Observation of Resident R129 and interview with Employee E7, Licensed Practical Nurse (LPN) on (MONTH) 7, 2019, at 11:54 a.m. confirmed that the resident had a multi podus boot in her wheelchair and that the resident had right foot drop. Interview with Employee E22, Physical Therapy Assistant (PTA), Director of Rehabilitation Services (DRS), on (MONTH) 7, 2019, at 12:08 p.m. revealed that Resident R129's hospital discharge records stated the resident was supposed to wear her multi podus boot as tolerated for foot drop. Employee E22 confirmed that there was no active care plan for Resident R129 to wear a multi podus boot to treat her foot drop. Review of medical record for Resident R346 revealed that he was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of Resident R346's comprehensive nursing assessment dated (MONTH) 30, 2019, revealed that the resident was considered to be at moderate risk for falling related to the need for regular assistance with bowel and bladder elimination, poor vision and the use of assistive devices for gait and balance such as a cane or walker. Resident R346 was also identified as taking one to two high risk medications that increase the risk of symptoms that can cause falls. Review of medical records for Resident R346 revealed occupational therapy (OT) services were provided to the resident from (MONTH) 17, 2019, to (MONTH) 30, 2019, and during that period the OT care plan included a care plan for the resident being at risk of falls with fall prevention interventions stipulated. Further review of medical record for Resident R346 revealed that no care plan had been developed for the resident being at risk of falling. Further review of Resident R346's comprehensive nursing assessment dated (MONTH) 30, 2019, for falls revealed that section D, Care Plan was left blank and no interventions were selected or developed for the resident. The medical record further indicated that Resident R346 fell in his room on (MONTH) 21, 2019. Interview with Employee E10, Registered Nurse (RN), Regional Specialist, on (MONTH) 6, 2019, at 12:06 p.m. confirmed that the only time Resident R346 had a care plan developed for falls was while he received OT services. Employee E10 confirmed that the resident remained at risk of falling after he completed OT and still required a falls risk care plan. The facility failed to ensure that four of 40 residents reviewed had comprehensive care plans developed to meet their individual care needs. 28 Pa. Code 211.5(f) Clinical records Previously cited 05/25/19, 08/24/18 28 Pa. Code 211.10(d) Resident care policies Previously cited 05/25/19, 04/18/19, 08/24/18, 05/26/17 28 Pa. Code 211.11(c)(d) Resident care plan Previously cited 05/25/19, 08/24/18 28 Pa. Code 211.12(c) Nursing services Previously cited 05/25/19, 08/24/18, 05/26/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 05/25/19, 08/24/18, 06/16/17, 05/26/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/25/19 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/25/19, 08/24/18, 06/16/17, 05/26/17

Based on observation, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained for all residents when the temperature outside was declared a code blue for dangerously low temperatures. Findings include: Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on (MONTH) 22, 2019, at 10:00 a.m. confirmed that the facility had identified that temperatures inside the facility were out of range. NHA stated, I was notified yesterday afternoon (January 21, 2019) that temperatures were falling on the north side of the building. Maintenance staff were called in to monitor temperatures and to check all residents' rooms to determine if PTAC (room heating elements) were operating properly. It was determined that several rooms needed adjustments to the PTAC system and the PTAC in room [ROOM NUMBER] was not operating at all. room [ROOM NUMBER] was closed, and the two residents were relocated to room [ROOM NUMBER]. Three residents in room [ROOM NUMBER] were offered a different room but they declined. All residents were offered an additional blanket. The NHA further indicated that the HVAC system on the North Side of the facility which provides heat to the hallways was not operating properly. NHA continued, I placed a call to the HVAC company to come and repair our system. They stated that they would be out the first thing in the morning. Additionally, the NHA indicated that when she left the facility last evening, all PTACs were working. Review of facility temperature logs for the afternoon on (MONTH) 21, 2019, and for the morning on (MONTH) 22, 2019, revealed multiple rooms with temperatures in the 60 degree range, below the facility acceptable range of 71 to 81 degrees Fahrenheit (F). Further interview with the NHA on (MONTH) 22, 2019, at 11:40 a.m. confirmed that the facility had not monitored the temperatures inside the facility between the hours of 11:00 p.m. on (MONTH) 21, 2019, through 7:00 a.m. on (MONTH) 22, 2019. A tour of the North Side with the NHA on (MONTH) 22, 2019, at 10:30 a.m. was conducted to determine current resident room temperatures and to interview residents regarding temperatures in their rooms. The tour revealed that the resident rooms and hallways were cold. Temperatures in the resident rooms on the First Floor North Side ranged from 59 degrees to 70 degrees. The North Side First Floor Dining Room was 67 degrees and the North Side First Floor Hallway was 67 degrees. A tour of the North Side Second Floor resident rooms revealed temperatures ranging from 63 to 73 degrees. The North Side Second Floor Hallway was 64 degrees and the Second Floor Dining Room was 57 degrees. Twenty residents were seated in the Second Floor Dining Room. The NHA requested that staff assist residents out of the dining/activity room. The Dining/Activity Room was closed. Additionally, it was noted during the observation tour that in Resident Rooms 209, 211, 213 and 215 that staff had placed blankets on the window ledges to block draft from the outside. This was confirmed by Employee E4, Charge Nurse, on (MONTH) 22, 2019, at 11:15 a.m. Interviews and observations on (MONTH) 22, 2019, during the morning tour with the NHA confirmed that residents were cold, especially during the previous night. Resident R1 stated, I was cold last night. I am still cold. Resident R1 was observed dressed in a short sleeved tee shirt. Staff assisted Resident R1 with putting on a sweater. Resident R5 stated, I am warm enough now. Last night was freezing. Resident R6 stated, I am getting warm now. Resident R8 stated, It was cold last night. I wore this to bed. Resident R8 was observed wearing a hoodie with hood tied, sweatpants and gloves. Resident R9 stated, I am okay. Resident R9 was observed resting under the blankets. Resident R10 stated, It was cold in here the past two nights in a row. Resident R11 stated, I am cold now. Resident R11 observed resting in bed with a hospital gown on and one blanket. Resident R12 stated, Yeah, it is cold. I want a sweatshirt. Resident R12 was observed in a tee shirt and Resident R12 was assisted by the NHA in putting on a sweatshirt. Resident R13 stated, It was cold last night. I did not get an extra blanket. Resident R13 was observed in bed with one blanket. Resident R16 stated, Last night was cold. Now it is okay. Resident R18 stated, It was very cold in here. I called for the nurse last night but no one answered. Nobody came in. Resident R23 stated, It is warmer now. It was very cold last night. We could feel the air coming in through the windows. Resident R24 stated, I wrapped my extra blanket around my head, so I could fall asleep. Resident R25 stated, It was very cold last night. Resident R26 stated, It was so cold I did not sleep last night. So cold I could not sleep. Resident R27 stated, It was colder early this a.m. During observation tour of First Floor North, room [ROOM NUMBER] on (MONTH) 22, 2019, at 10:20 a.m. with NHA, a humidifier was found on a Chux pad (a disposable bed pad that protects beds and other surfaces from bodily fluids) placed on the floor. The humidifier was plugged in. The Administrator immediately unplugged the humidifier and notified a staff member to remove the humidifier from the room. The facility failed to monitor and maintain a temperature range of 71-81 degrees Fahrenheit and failed to maintain heating equipment during Code Blue conditions. This failure placed residents at risk for health consequences from extreme temperatures and caused an Immediate Jeopardy situation for all the residents. Immediate Jeopardy was declared on (MONTH) 22, 2019, at 11:55 a.m. The facility's Action Plan was accepted on (MONTH) 22, 2019, at 5:45 p.m. York Action Plan to Maintain Heat: The following Action Plan will be put into place immediately to ensure the safety of the residents at York Nursing and Rehabilitation Center and to ensure regulatory compliance with minimum temperature requirements of 71 degrees F. Unit Managers/designee will complete an audit of resident beds to ensure two blankets are available on each bed. DON and NHA will review. Laundry will make additional blankets available. Staff Development/designee will inservice nursing staff to ensure residents are properly dressed warmly when in bed and out of bed when it has been identified that room inside temps are below 71 degrees F or if a resident verbalizes that they feel cold. Maintenance will be notified of any temps below 71 degrees F for immediate intervention. If it is identified that a resident does not have appropriate clothing, family will be contacted to provide additional clothing and/or facility EVS (Environmental Services) Director will be notified, and residents may not have family and appropriate clothing will be provided by facility from donated clothing items. Staff development/designee will complete staff re-education instructing Nursing Management and staff that if they identify any change in building temperatures or reports that a resident room is cold, to notify the DON, NHA and Maintenance Director immediately, so situation or equipment issues can be evaluated timely. Nursing Management will be instructed to not delay in relocating resident to another room that is warmer if a room is identified as cold until maintenance can be onsite to evaluate and repair. Maintenance Director will place secured covers over thermostats in resident dining rooms on North side, first and second floors. Maintenance will audit all resident windows for air leaks and if identified, windows will be sealed with plastic to prevent draft. Facility vendor was called to repair rooftop HVAC heat unit that supplies heat to north side nursing unit hallways. Both rooftop units were repaired per vendor and warm air is coming from hallway ceiling vents. Facility maintenance will continue with every 2 hour resident room temps on each unit for the next 24 hours and temps will be monitored by Maintenance Director, NHA and DON for any temps below 71 degrees F. Maintenance will address heat issues with PTAC room heat units and if unable to get temp at or above 71 degrees, Nursing Manager will be notified and resident will be offered a room change to a room at compliance temperature. If the facility identifies that any section of a resident care area is unable to maintain adequate heat, NHA, DON or Maintenance Director will immediately notify VP Emergency Preparedness, HAP in PA for additional direction and resources to provide heat to the area affected in the center to ensure residents environment remains in a safe temp zone and the PA Dept. of Health will be notified. During an onsite visit of (MONTH) 23, 2019, temperature logs and audits of re-education were reviewed. A tour was conducted to re-check resident room temperatures, two blanket audit check and to interview staff about re-education when temperature drops below 71 degrees. At 10:00 a.m., all resident rooms were at 71 degrees F or higher. All beds had two blankets. Ten staff members, including licensed nurses and nursing assistants were interviewed and provided confirmation of re-education. Observations during tour revealed maintenance staff covering large windows in dining rooms with plastic insulation. Dining rooms remained closed until temperatures were at 71 degrees or above. Thermostats were secured with locked plastic covers. An onsite visit was conducted on (MONTH) 24, 2019, to tour and review temperature logs. Residents R22, R27 and R29 were interviewed and confirmed that they were warm enough. On (MONTH) 24, 2019, at 9:53 a.m. the Immediate Jeopardy was removed due to corrective actions that were implemented by the facility. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/24/18, 06/16/17 28 Pa. Code 201.18(a)(b)(1)(3) Management Previously cited 11/09/18, 08/24/18, 06/16/17 28 Pa. Code 201.18(e)(1) Management Previously cited 08/24/18 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 207.2(a) Administrators responsibility Previously cited 11/09/18

Based on observation, resident and staff interviews and review of facility documentation, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding maintaining temperatures throughout the facility which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that the NHA assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of Management and allocates resources an efficient and economical manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Review of the job description of the Director of Nursing (DON) revealed that the DON assumes full time administrative and clinical authority, responsibility and accountability for the delivery of nursing services in the facility. Manages employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and state and federal laws and regulations. Develops and implements policies and procedures consistent with current law. In collaboration with Nursing Home Administrator, allocates department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. Collaborates with other departments, professionals, consultants and organizations, including government agencies and advocacy groups, to develop support and coordination of resident care, related administrative functions and to represent the interests of the facility. An interview with NHA and DON on (MONTH) 22, 2019, at 9:45 a.m. revealed that low temperatures were identified after lunch on (MONTH) 21, 2019. Individual heating units (PTAC) in each residents' room were checked and adjustments were made to ensure each unit was working properly. However, the rooftop HVAC system which supplies heat to the hallways was not working. This created an Immediate Jeopardy situation because temperatures in the facility dropped and remained below the requirement of 71 degrees Fahrenheit. Based on the deficiencies identified in this report, the NHA and DON failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. Refer to F584. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/24/18, 06/16/17 28 Pa. Code 201.18(a)(b)(1)(3) Management Previously cited 11/09/18, 08/24/18, 06/16/17 28 Pa. Code 201.18(e)(1) Management Previously cited 08/24/18 28 Pa. Code 207.2(a) Administrators responsibility Previously cited 11/09/18

Based on clinical record review, review of facility documentation, review of facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that the residents were protected from neglect resulting in actual harm in the form of a fracture as a result of an improper transfer for one of 5 residents reviewed (Resident CL3). Findings include: A review of the facility policy titled Transfer of Resident Guidelines, undated, revealed guidelines for the safe and efficient transfer of the residents which included to determine the transfer needs of the resident by checking the personal care card and/or asking the nurse which method of transfer is required for the resident. If you have not assisted the resident in moving from or transferring from one surface to another request the help of a nursing assistant who is accustomed to moving the resident. Determine the resident's ability to follow directions and safely participate in the transfer. Consider any functional limitations such as: weakness, paralysis, pain, contractures, inability to maintain a sitting position. Assure that you and your partner communicate the method of transfer and move together with each step. Make sure you have the correct chair for the resident and any positioning device that are required. Procedure: Two persons are required if resident cannot stand and fully bear weight and cannot pivot. If a mechanical lift is required, the task must be completed by at least 2 persons who have been trained to use the lift. A review of Resident CL3's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident CL3's quarterly Minimum Data Set assessment (MDS-a periodic review of the resident's needs) dated April 5, 2017, revealed that the resident was moderately impaired in decision making skills. Further review revealed that the resident needed extensive assistance with all activities of daily living including: transfers, dressing, eating, hygiene, and toileting. The resident was unable to balance self while standing and had limitation of upper and lower extremities. A review of nursing notes dated April 15, 2017, at 8:49 p.m. revealed that the resident was lowered to the floor while being transferred to bed via a mechanical lift (a mechanical device used to transfer the resident from bed to wheelchair and back). Employee E10, nursing assistant stated the resident started to slip down before she reached the bed, I called for help. I (the writer of the nurse's note) was called to the room, the resident was helped back into bed with an assistance of 4 employees. The resident voiced pain 10 out of 10 in bilateral shoulders and left hip. The physician was made aware, ordered that the resident be sent to the hospital for evaluation. The resident has diminished range of motion in all extremities. Further review of the facilities documentation dated April 15, 2017, at 8:49 p.m. revealed that Employee E10 used the incorrect type of lift and failed to have another staff member present during this transfer. A review of the facility training log, on the use of lifts revealed that Employee E10 last had training on mechanical lifts on January 7, 2017. Further review of a nurse's note dated April 15, 2017, at 11:13 p.m. revealed that the resident returned to the facility with a [DIAGNOSES REDACTED]. A review of a nurse's note dated April 16, 2017, revealed that the resident yells out in pain whenever her left knee and left hip are touched. The physician ordered an X-ray of the left knee and left hip. Results of this X-ray revealed a questionable fracture to the pubic (pelvis) area. Resident CL3 was sent to the hospital and admitted with a closed [MEDICAL CONDITION] end of the left femur (the long bone of the upper leg). Further review of facility documentation dated April 15, 2017, revealed that Employee E10 admitted she did not have a second employee with her while using the sit to stand lift (a mechanical device that the resident holds on to a bar with her hands and a strap around her waist that assist the resident from a sitting to standing position). A review of the care cardex (a form the facility uses to inform the staff what the resident care needs are) dated September 16, 2016, revealed that for transferring the resident, a mechanical lift, a Hoyer lift (a mechanical device that places the resident in a sling that is then attached to a lift and moves the resident from the bed to the wheelchair) was to be used. Employee E10 admitted that she did not look at the care cardex to note what method of transfer needs the resident required. An interview with Employee E3, nursing assistant, on May 17, 2017, at 3:10 p.m. stated, she was called to the resident room by Employee E10 on April 15, 2017, Employee E10 was by herself with the sit to stand lift, I entered the room and saw the resident on the floor with the employee, I called for the nurse and assisted getting the resident back in bed after she was assessed by the nurse. The resident was crying. An interview with Employee E11, a nurse, on May 17, 2017, at 5:00 p.m. stated, I was called to the room, the resident was halfway in the sit to stand lift, the nursing assistant was by herself. The resident was crying, while assessing the resident she complained of bilateral shoulder pain and left hip pain. Employee E10 stated that she never transferred this resident before and did not check the care cardex. The facility failed to ensure that Resident CL3 was protected from neglect due to an improper transfer with a mechanical lift which resulted in fractures to Resident CL1's femur and pelvis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 08/27/15, 09/10/15, 07/01/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/27/15, 05/05/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 08/27/15, 09/10/15, 05/05/16, 07/01/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 08/27/15, 09/10/15, 07/01/16

Based on observations, interviews with staff and residents and a review of clinical records and facility documentation it was determined that the facility failed to provide adequate supervision for three of 5 residents reviewed. This resulted in actual harm to Resident CL3 and a potential for harm to Resident CL1 (Resident R1, CL1 and CL3). Finding include: A review of the facility policy titled Transfer of Resident Guidelines, undated, revealed guidelines for the safe and efficient transfer of the residents which included to determine the transfer needs of the resident by checking the personal care card and/or asking the nurse which method of transfer is required for the resident. If you have not assisted the resident in moving from or transferring from one surface to another request the help of a nursing assistant who is accustomed to moving the resident. Determine the resident's ability to follow directions and safely participate in the transfer. Consider any functional limitations such as: weakness, paralysis, pain, contractures, inability to maintain a sitting position. Assure that you and your partner communicate the method of transfer and move together with each step. Make sure you have the correct chair for the resident and any positioning device that are required. Procedure: Two persons are required if resident cannot stand and fully bear weight and cannot pivot. If a mechanical lift is required, the task must be completed by at least 2 persons who have been trained to use the lift. A review of Resident CL3's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident CL3's quarterly Minimum Data Set assessment (MDS-a periodic review of the resident's needs) dated April 5, 2017, revealed that the resident was moderately impaired in decision making skills. Further review revealed that the resident needed extensive assistance with all activities of daily living including: transfers, dressing, eating, hygiene, and toileting. The resident was unable to balance self while standing and had limitation of upper and lower extremities. A review of nursing notes dated April 15, 2017, at 8:49 p.m. revealed that the resident was lowered to the floor while being transferred to bed via a mechanical lift (a mechanical device used to transfer the resident from bed to wheelchair and back). Employee E10, nursing assistant stated the resident started to slip down before she reached the bed, I called for help. I (the writer of the nurse's note) was called to the room, the resident was helped back into bed with an assistance of 4 employees. The resident voiced pain 10 out of 10 in bi-lateral shoulders and left hip. The physician was made aware, ordered that the resident be sent to the hospital for evaluation. The resident has diminished range of motion in all extremities. Further review of the facilities documentation dated April 15, 2017, at 8:49 p.m. revealed that Employee E10 used the incorrect type of lift and failed to have another staff member present during this transfer. A review of the facility training log, on the use of lifts revealed that Employee E10 last had training on mechanical lifts on January 7, 2017. Further review of a nurse's note dated April 15, 2017, at 11:13 p.m. revealed that the resident returned to the facility with a [DIAGNOSES REDACTED]. A review of a nurse's note dated April 16, 2017, revealed that the resident yells out in pain whenever her left knee and left hip are touched. The physician ordered an X-ray of the left knee and left hip. Results of this X-ray revealed a questionable fracture to the pubic (pelvis) area. Resident CL3 was sent to the hospital and admitted with a closed fracture of the distal end of the left femur (the long bone of the upper leg). Further review of facility documentation dated April 15, 2017, revealed that Employee E10 admitted she did not have a second employee with her while using the sit to stand lift (a mechanical device that the resident holds on to a bar with her hands and a strap around her waist that assist the resident from a sitting to standing position). A review of the care cardex (a form the facility uses to inform the staff what the resident care needs are) dated September 16, 2016, revealed that for transferring the resident, a mechanical lift, a Hoyer lift (a mechanical device that places the resident in a sling that is then attached to a lift and moves the resident from the bed to the wheelchair) was to be used. Employee E10 admitted that she did not look at the care card to note what method of transfer needs the resident required. An interview with Employee E3, nursing assistant, on May 17, 2017, at 3:10 p.m. stated, she was called to the resident room by Employee E10 on April 15, 2017, Employee E10 was by herself with the sit to stand lift, I entered the room and saw the resident on the floor with the employee, I called for the nurse and assisted getting the resident back in bed after she was assessed by the nurse. The resident was crying. An interview with Employee E11, a nurse, on May 17, 2017, at 5:00 p.m. stated, I was called to the room, the resident was halfway in the sit to stand lift, the nursing assistant was by herself. The resident was crying, while assessing the resident she complained of bilateral shoulder pain and left hip pain. Employee E10 stated that she never transferred this resident before and did not check the care card. The facility failed to provide adequate supervision during a transfer and failed to use the appropriate type of lift which resulted in fractures to Resident CL1's femur and pelvis resulting in actual harm to the resident. A review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with dementia and contractures (a condition of shorting and hardening of muscle, tendons or other tissues, often leading to deformity and rigidity of joints) of the knees. A review of Resident R1's annual MDS dated [DATE], revealed that the resident was moderately impaired in decision making skills. Further review of the MDS revealed that the resident required extensive assistance for all activities of daily living (dressing, eating, hygiene etc.). The resident did not ambulate. A review of nurse's notes dated April 20, 2017, at 2:18 p.m. revealed that the resident was dragged out of bed by another resident (Resident R2), who was confused and thought that Resident R1 was in her house and in her bed. Resident R1 complained of pain to her lower extremities and left side of her head and was medicated for the pain. The resident's family was notified. The physician was notified and ordered X-rays of the right hip, right leg, and right knee which revealed no fracture. A review of nurse's notes dated April 21, 2017, revealed that the resident continued to complain of right hip and leg pain. The physician was notified and ordered the resident sent to the hospital for evaluation. A review of nurse's note dated April 22, 2017, revealed that the resident was admitted to the hospital for bilateral (both) femur (the long bone of the upper leg) fractures. Subsequently, Resident R1 was admitted on to Hospice services on April 29, 2017. A review of the facility investigation dated April 20, 2017, revealed that when Employee E3, the nursing assistant entered Resident R1 and Resident R2's room to answer a call bell, Resident R1 was on the floor next to her bed. Resident R2 was standing next to Resident R1. Resident R2 stated, I didn't mean for her to fall, my husband paid for this house and this bed, she does not belong here. An interview with Employee E3, nursing assistant on May 17, 2017, at 3:00 p.m. revealed that I went into the resident room to answer a call bell and found (Resident R1) on the floor next to her bed, I immediately call the nurse. Employee E3 observed Resident R2 standing next to Resident R1 and stated, why you people in my house, I tried to move her and dropped her. Employee E3 indicated that a nurse entered the room and Employee E3 took Resident R2 out of the room. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident R2's MDS dated [DATE], revealed that the resident was severely impaired in decision making skills. Further review revealed that the resident needed limited assistance with dressing, hygiene and toileting. The resident could ambulate with supervision. A review of psychiatric consultation notes dated April 11, 2017, revealed that Resident R2 was examined due to her dementia. The psychiatric consultation noted that the resident was not competent and had no acute behavioral symptoms. Further review of a nurse's note dated April 20, 2017, revealed that at the supervisor's request that Resident R2 be placed on 15 minute checks as a safety precaution. A Nurse's note dated April 20, 2017, revealed that Resident R2 was moved to another room and continues to say, my husband bought this place. A review of psychiatric consultation notes dated April 25, 2017, revealed that Resident R2 was examined again and the psychiatric consultation noted that the resident had Sundowning (also known as late day confusion, can occur in people with dementia) as an acute behavioral symptom. Review of nurse's notes dated April 29, 2017, revealed that Resident R2 continues to be confused about shared residency, believes her new room is her home and Resident CL1 is in her house. Resident CL1 was at the hospital due to new on-set seizures and was not able to be interviewed. A review of Resident R2's care plan dated April 20, 2017, revealed that the resident has a behavioral problem with potential for physical aggression related to dementia/confusion/hallucination thinking that other residents are in her and her spouse's space. Interventions: anticipate and meet resident's needs, provide 15-minute watch to determine resident's position and behavior, stop and talk to resident as she passes by, explain all procedures to the resident, encourage activity participation, encourage rest, escort the resident to her new room so she can become comfortable in her new surroundings. An interview with Employee E4, a nurse, on May 17, 2017, at 3:15 p.m. revealed that Resident R2 had stated about her new roommate that she has to go. Interviews with the Nursing Home Administrator and the Director of Nursing on May 17, 2017, at 10:00 a.m. confirmed that in between those 15 minute checks that Resident R2 could cause harm to her new roommate. The facility failed to adequately monitor and continuously supervise Resident R2, by placing her in another room with another resident and putting other residents at risk for harm after Resident R2 pulled Resident R1 out of bed causing bilateral femur fractures. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 07/01/16 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 08/27/15, 09/10/15, 07/01/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/27/15, 05/05/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 08/27/15, 09/10/15, 05/05/16, 07/01/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 08/27/15, 09/10/15, 07/01/16

Based on a review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to follow physician's orders [REDACTED]. Findings include: Review of the clinical record for Resident CL2 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record revealed that the resident was actively receiving [MEDICAL CONDITION] treatments for [MEDICAL CONDITION] and that the resident was a full code (resident expressed desire to have a full resuscitation or CPR performed in the event of an emergency). Further review of the clinical record revealed that on [DATE] at 11:30 a.m., Resident CL2 was noted by the nursing staff with a new change in the resident's medical condition. The change was noted as the resident was not eating which was documented as a new symptom and noted that the symptom was worsening in severity. Further documentation in the clinical record indicated that the nursing staff was concerned that the resident may be dehydrated (dehydration-lack of sufficient body fluid) and that the staff called the resident's physician who came to the floor to assess the resident. Nursing documentation revealed that the physician came to the floor and examined the resident on [DATE] at 1:30 p.m. An undated and untimed physician's progress note indicated that the physician visited and examined the resident. The physician identified the resident with dehydration and cachexia (cachexia-malnourished and extremely thin). The physician's progress note further reflected that the physician's treatment plan included starting intravenous fluids. In addition, it was noted that if the resident didn't respond to the administration of intravenous fluids, the resident would need to be sent to the hospital. The physician's orders [REDACTED]. One [MEDICATION NAME] (a small bottle of medicine) of multivits (vitamin supplement) was ordered to be added to the first bag. It was also noted in the physician's orders [REDACTED]. Nursing documentation on [DATE] at 2:44 p.m., indicated that the nursing staff had inserted an intravenous line for the delivery of the intravenous fluids. Further nursing documentation indicated that the intravenous fluids had been ordered from the pharmacy and that the staff were awaiting delivery. Nursing notes dated [DATE] at 11:16 p.m., revealed that, [MEDICATION NAME] not available from the pharmacy, fluids encouraged, .will monitor. At 2:10 a.m., [DATE], the resident was noted with a temperature elevation of 100.8 degrees Fahrenheit and was medicated with Tylenol (medication used to reduce fever) 650 milligrams (mgs). Further nursing documentation indicated that the resident's intravenous fluids were initiated at 5:30 a.m., approximately sixteen hours after they were ordered. Further review of the nurses' notes dated [DATE] at 7:00 a.m., revealed that the resident was noted as unresponsive (unable to be aroused) and that the resident was transferred to the hospital via [DATE] at 7:30 a.m. The resident was admitted to the hospital on [DATE], with the a [DIAGNOSES REDACTED]. The resident subsequently died five days later on [DATE]. Facility staff failed to follow the physician's orders [REDACTED]. In addition, the staff failed to follow an explicit physician's orders [REDACTED]. The facility delayed the administration of intravenous fluids to a resident diagnosed with [REDACTED]. Review of the clinical record for Resident R41 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The nurses' notes dated [DATE] at 9:00 a.m., revealed that the resident was noted with a new change in medical condition. Further documentation indicated that the resident had experienced a change in mental status and the mental status of the resident was now described as non-responsive to touch or verbal prompts. In addition, the resident's blood pressure was noted as ,[DATE]. Further review of the nurses' notes revealed that the resident's physician was notified of the change in condition on [DATE] at 10:00 a.m., approximately one hour after it was noted. A physician's orders [REDACTED]. Facility staff contacted their routine ambulance transport company who stated that they would arrive in approximately thirty minutes to transport the resident to the hospital. The nurses' notes further revealed that the resident was transferred to the hospital at 11:35 a.m., approximately two and one half hours after being found unresponsive by staff with elevated blood pressures. Interview with Employee E3, Registered Nurse, on [DATE] at approximately 12:10 p.m., revealed that given the condition of Resident R41 on [DATE], (unresponsive and elevated blood pressure) the employee would have expected staff to transfer the resident emergently via [DATE] to the hospital for further evaluation and treatment. Further interview with Employee E3 confirmed that there is some variability among staff in response to physician notification of changes in resident condition. emergency room documentation dated [DATE] at 2:30 p.m., revealed that the resident had been seen and examined. Further review of the emergency room documentation indicated that the resident was comatose (coma-state in which one can't be aroused) and required intubation (insertion of a tube into the airway to assist in breathing) to protect the resident's airway. The resident was subsequently admitted to the hospital with [REDACTED]. Facility staff failed to notify the physician in a timely manner of an acute change in the resident's medical condition, failed to ensure that the resident was transported emergently to the hospital resulting in delay in treatment which caused actual harm to this resident. Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of nurses' progress notes dated [DATE] at 2:45 p.m., revealed that while the resident was being assisted to bed, she became unresponsive with right hand weakness and right sided facial drooping. The nurses' note also stated, at that time, Resident CL1's blood pressure was ,[DATE], pulse was 96 and blood sugar was 200. Further review of the nurses's notes revealed that resident CL1's physician was in the facility and was notified of the resident's change in condition at 2:50 p.m At that time, the physician ordered the resident to be transferred to the hospital for further evaluation to rule out [MEDICAL CONDITION] (stroke, brain hemorrhage). Further review of Resident CL1's clinical record revealed that the resident left the facility at 3:40 p.m., approximately one hour after the noted change in condition. Interview with Employee E4, registered nurse/unit manager, on [DATE] at approximately 2:00 p.m., confirmed that resident CL1 did experience a change in condition and became unresponsive on [DATE] at 2:45 p.m. Further interview with Employee E4, registered nurse/unit manager, confirmed that resident CL1 left the facility at 3:30 p.m., approximately one hour after developing an acute change in condition, by the facilities routine ambulance transport. Employee E4 further indicated during the interview that residents with known changes in condition should be transported via [DATE] (emergency transport) to the hospital for further evaluation and treatment. Additional review of resident CL1's clinical record revealed that the resident had been admitted to the hospital with [REDACTED]. The facility failed to respond to acute changes in medical conditions of three residents in a timely manner resulting in a delay in treatment and causing actual harm to these three residents. 28 Pa. Code 211.12(d)(1)(2) (5) Nursing services. Previously cited [DATE]. 28 Pa. Code 210.18(b)(1) Management. Previously cited [DATE].