Independence Rehab And Nursing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, review of facility policy and information of alcohol-based hand sanitizer, it was determined the facility failed to adequately supervise and monitor Resident R1. This failure resulted in Resident R1 obtaining and ingesting alcohol-based hand sanitizer on three separate dates resulting in an Immediate jeopardy situation for one out of three residents reviewed (Resident R1).
Findings include:
Review of the facility's policy, Accident & Injury Prevention and Response Policy dated January 1, 2026, indicated that the purpose of the policy was to ensure that all residents of the facility are protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response.
Review of the Safety Data Sheet for the ProCure Alcohol Gel Hand Sanitizer 70% indicated the chemical name as Ethyl Alcohol with 70-75% concentration. The first aide measure to follow if ingested stated to contact a physician or a poison control center immediately, do not induce vomiting, and to never give anything by mouth to an unconscious person.
Review of Resident R1's MDS (Minimum Data Set - periodic assessment of resident's abilities) assessment dated [DATE], revealed Resident R1 was assessed with a BIMS score of 10, indicating the resident had moderate impaired cognition.
During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on March 10, 2026 at 10:45 a.m. it was discussed Resident R1 drank and/or was observed with hand sanitizer in a cup on 3 separate occasions, has a history of alcohol abuse, and continued to have access to hand sanitizer at the facility.
Review of Resident R1's March 2026 physician orders revealed the diagnoses of alcohol abuse (medical condition characterized by impaired ability to control alcohol consumption despite negative consequences); Bipolar Disorder (condition of periods of depression and periods of extreme happiness), Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform), Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and Dementia (group of symptoms affecting memory, thinking and social abilities).
Review of Resident R1's hospital records dated May 24, 2025, revealed the resident was brought to the local hospital by (her/his) son on May 24, 2025. The resident had been staying with (her/his) son due to (her/him) being discharged from another long term care facility the prior week for alcohol abuse, issues with (her/his) insurance and behavioral issues.
Review of Resident R1's nursing note dated January 23, 2026, at 2:15 p.m. by Licensed nurse, Employee E3 revealed While rounding, this nurse observed the resident drinking hand sanitizer. Nurse informed and educated resident that the substance was hand sanitizer, not water. The hand sanitizer was immediately removed from residents possession. A full assessment was completed, and vitals 128/76 (normal blood pressure 120/80); 87 (normal pulse 60-100); 97% (normal oxygen saturation 95%-100 %), 97.4 (normal temperature 97.5 degrees Fahrenheit) are stable. This nurse will continue to monitor residents, reassess as indicated, and follow up throughout the shift. Resident paired care.
Continued review of Resident R1's clinical record failed to reveal documented evidence the physician was notified of Resident R1 drinking hand -sanitizer on January 23, 2026, and failed to reveal documentation of interventions to monitor and supervise the resident in relation to the consumption of hand- sanitizer.
Review of a nursing note by Unit manager, Employee E4 dated February 28, 2026, at 9:04 a.m. revealed Resident found drinking a cup of hand sanitizer. Cup thrown away. Residents educated on why she should not drink hand sanitizer and the dangers of ingestion of the product. MD (physician) and RP (resident's responsible party) made aware.
Review of Resident R1's person-centered plan of care included a care plan dated February 28, 2026 indicating Resident drinks hand -sanitizer, with interventions including: administering medications as ordered, analyzing key times, places, circumstances, triggers and what deescalates behavior and document, assess resident's coping skills and support system, continue to provide reeducation and discuss risks/benefits of refusals, and encourage resident to discuss feelings and allow resident to vent.
Review of a nursing note on March 1, 2026, at 12:42 p.m. confirmed that Resident R1 was observed by Licensed nurse, Employee E3 in her room with a bottle of hand- sanitizer and a cup with hand sanitizer inside of it. Upon helping resident put on shoes this nurse observed a bottle of hand sanitizer and a cup with hand sanitizer in it, in resident room. Bottle and cup were removed.
Review Psychologist's notes on March 2, 2026, at 12:00 p.m. stated: Resident was observed drinking hand sanitizer from a cup There was no other documentation that this was further addressed with the resident or interventions to prevent reoccurrence.
Review of Psychologist's notes from October 2025 to March 2026 including the following dates: 3/2/26; 2/21/26; 2/9/26; 1/25/26; 1/14/26; 12/28/25; 12/10/25; 11/30/25; 11/16/25; 11/2/25; 10/26/25 included resident's alcohol and cocaine abuse history, in addition to documentation of the resident reporting to the psychologist that (she/he) currently drinks, does not plan to stop and that (she/he) drank at (her/his) previous nursing home.
Interview conducted with Unit manager, Employee E4 on March 9, 2026, at 1:55 p.m. the unit manager revealed she notified the physician once she observed the resident with the half-filled medication cup of hand sanitizer in (her/his) room, and the physician ordered labs (bloodwork) for the resident and to monitor the resident for diarrhea. Unit manager, Employee E4 revealed she took the 4-ounce medication cup from the resident, [Resident R1] walks throughout the building unrestricted, explaining this statement revealed the resident could get more on (her/his) own without anyone knowing. Unit manager, Employee E4 further revealed resident replied, sorry, when confronted with the hand filled cup. Unit manager, Employee E4 revealed she did not ask the resident where the resident got the cup of hand sanitizer from because I don't think (she/him) would have told me anyway. Employee E4 stated that she updated Resident R1's plan of care and referred the resident to psych (psychologist) as intervention. Employee E4 reported that she was unaware of the previous occurrence when Resident R1 drank hand sanitizer on January 23, 2026.
Continued interview with the Unit manager, Employee E4 revealed on, March 1, 2026, she was notified by Licensed nurse, Employee E3 that Resident R1 had bottle of hand sanitizer and a cup filled with hand sanitizer with ice, which was taken from the resident by the Licensed nurse, Employee E3.
Interview conducted with Licensed nurse, Employee E3 on March 10, 2026, at 11:47 a.m. regarding her nursing notes from January 23, 2026. It was discussed with Licensed nurse, Employee E3 the clinical record failed to evidence in nursing notes that Employee E3 notified the physician regarding the incident or notified any other clinical staff.
During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on March 10, 2026 at 10:45 a.m. it was discussed Resident R1 drank and/or was observed with hand sanitizer in a cup on 3 separate occasions, has a history of alcohol abuse, and continued to have access to hand sanitizer at the facility.
Based on the above findings an Immediate Jeopardy to the safety of Resident R1 was identified to the Nursing Home Administrator on March10, 2026 at 1:08 p.m. for failure to ensure Resident R1 was provided with an environment free of hazardous substances and adequate supervision. This failure placed Resident R1 in an Immediate Jeopardy situation, who had access to alcohol-based hand sanitizer and ingested the hand- sanitizer in three different instances. The Immediate Jeopardy template was provided to the Administrator, and an immediate action plan was requested.
On March 10, 2026, at 4:09 p.m. the facility provided the following corrective action plan:
1. Resident R1's personal environment audited to ensure no hazardous substances are in possession or in reach.
2. Resident R1 CP (care plan) updated to include hx (history) of alcohol and substance.
3. Entire staff in-service initiated on sign and symptoms of alcohol and substance consumption. As well as need to report to direct supervisor. Supervisor will notify MD (physician) and family in the event of consumption. All staff in building at this time were in -serviced. This is a 97 or our 155 (62%) current staff. In -service will continue until every staff member in-serviced. Every staff member will be contacted by tomorrow morning.
4. Staff notified/in-serviced of residents behaviors and educated to monitor when Resident R1 comes in view. In-service completed for all staff currently in building.
5. All sanitizers that potentially can be accessible to resident were removed from units, (all refills from wall dispensers removed at this time, actual dispensers are being removed as well), this includes wall dispensers as well as other self-standing bottles.
6. All staff in building received and will continue to be provided will be provided with pocket sanitizers going forward. No Hand sanitizer will be available in the facility aside from these.
7. Staff educated to keep sanitizers on person only at all times.
8. Audit report of all residents with hx (history) of alcohol and substance abuse conducted. All residents identified. Care Plans are now being updated to include this history and appropriate interventions.
9. Facility will continue to audit units on every shift (7-3, 3-11, 11-7) x 4 weeks.
10. Followed by monthly x 3 months. Results of both will be reported to QAPI (Quality Assurance Improvement Plan)
Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on March 11, 2026, at 4:54 p.m.
The Immediate Jeopardy identified for Resident R1 occurred from March 23, 2026, to March 11, 2026
28 Pa. Code 201.18(b)(3)(e)(1) Management
28 PA. Code 211.10(d) Patient care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, and interviews with staff, it was determined the facility failed to implement interventions following prior elopement behavior and failed to revise the care plan to reflect newly identified elopement risk and escalating behavioral for one of one resident reviewed. (Resident R1) Findings include: Review of the facility's undated Leave of Absence (LOA) Policy indicated that a Leave of Absence is a temporary period when a resident leaves the facility with the expectation of returning. The policy requires staff to ensure the resident is clinically stable prior to departure, obtain a signed LOA form, document the date and time of departure, and provide any necessary instructions. Upon the resident's return, staff are required to document the time of return, complete a nursing assessment, and update the care plan if indicated. The policy also states that if a resident does not return as expected, staff must attempt to contact the responsible party and take additional steps, including notifying authorities if the resident's safety cannot be confirmed. Review of Resident R1's Minimum Data Set (MDS- a federally required assessment) dated January 10, 2026, revealed the resident was admitted on [DATE]. The resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment indicated the resident required partial to moderate assistance with sit-to-stand, chair-to-bed transfers, toilet transfers, and ambulation of 10 and 50 feet with turns, and was totally dependent for car transfers. Resident R1's diagnoses included coronary artery disease (narrowing of the arteries that supply blood to the heart), hypertension (high blood pressure), diabetes mellitus (a disorder affecting blood sugar regulation), cerebrovascular accident (CVA), also known as a stroke caused by interrupted blood flow to the brain, malnutrition (inadequate intake of nutrients needed for health), generalized weakness (reduced muscle strength affecting mobility), and a history of falls. The resident's medication regimen included antiplatelet medications (to prevent blood clots), hypoglycemic agents including insulin (to control blood glucose), and anticoagulant therapy (blood thinners used to prevent clot formation). Review of Resident R1's nursing notes revealed that on January 12, 2026 at 3:27 PM, Resident R1 was involved in a verbal altercation with another resident. During the incident, the other resident ran toward Resident R1 and punched the resident. No visible injuries were noted for either resident. The Director of Nursing (DON), physician, police, and the responsible party were notified of the incident. Continue review of nursing notes revealed that on January 13, 2026 at 9:52 AM, Resident R1 was transferred to room to another room. Within five minutes, the resident was involved in a verbal altercation with his new roommate. As a result, the resident was subsequently transferred to a different nursing unit. Nursing note dated January 20, 2026, at 9:23 AM, state that the facility contacted the emergency room (ER) and was informed that Resident had left the ER without being seen at 7:00 AM. The resident returned to the facility at 9:00 AM. A new elopement assessment was completed, and the resident was identified as a flight risk. The physician, Social Services, and Administration were notified, and a full body assessment was completed with no skin issues noted. Review of Resident R1's elopement risk evaluation dated January 20, 2026, revealed that the resident is at risk for elopement, with a score of 2.0. The evaluation was based on several factors, including a history of attempting to leave the facility without informing staff, wandering behavior, and behavior that could compromise the safety or well-being of self or others. Additionally, the resident had been recently admitted within the past 30 days and had not fully adjusted to the facility. According to facility protocol, a score greater than 1 indicates that the resident is considered at risk for elopement. Review of nursing note dated January 30, 2026 at 2:25 PM, revealed the resident was found smoking in his room. Social Services was notified, and the resident verbally threatened another resident , stating he would beat him up. Continued review of nursing notes revealed a note dated February 4/2026 at 11:36 PM, the resident remained on a Leave of Absence (LOA). A phone call was placed to follow up, but there was no answer. A message was left for the responsible party. Review of Resident R1's care plan revealed multiple identified risk areas beginning December 17, 2025, including risk for impaired skin integrity, self-care deficits with expected ADL decline, risk for adverse medication reactions related to medication use, and discharge planning needs. Discharge planning was initiated upon admission, with goals to provide community resource information and ensure appropriate support systems are in place prior to discharge. The care plan further identifies diabetes management goals to prevent complications, continued monitoring for medication-related adverse effects, and fall risk with interventions to anticipate and meet resident needs. Additional problem areas include potential oral/dental health issues and nutritional concerns related to abnormal labs, heart disease, diabetes, and a history of high added-sugar dietary patterns. Behavioral concerns were added to the care plan on January 12, 2026, following an incident in which the resident punched another resident. The care plan reflects potential for physical and verbal aggression, as well as smoking-related behaviors. On February 4, 2026, a self-determination focus was added addressing the resident's choice not to follow facility smoking rules, with a goal for the resident to discuss and understand the potential negative consequences of noncompliance. Continue review of Resident R1's care plan revealed that there was no care plan developed for wandering behaviors or elopement risk. Interview with Social Worker, Employee E3 on February 26, 2026 at 08:58 a.m. confirmed she was familiar with the resident and spoke with the resident on January 20, 2026 regarding the facility's Leave of Absence (LOA) policy. She informed the resident that he could not go out that day because the physician was not available to provide consent. Employee E3 described the resident as someone who frequently expressed a desire to leave the facility. At the time of that discussion, she stated she was unaware that the resident had been identified as an elopement risk. She further indicated she was not aware that the care plan had been updated to reflect elopement risk status. 28 Pa. Code 201.18(b) Management 28 Pa. Code 211.12(c)(d)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, review of clinical records, and interviews with staff it was determined that the facility failed to provide adequate supervision for 1 of 1 sampled resident identified as being at risk for elopement and failed to implement interventions following prior elopement behavior. (Resident R1) Findings include: Review of the facility's admission Agreement indicated that residents may temporarily leave the facility on a Leave of Absence or pass in accordance with facility policies and procedures. The agreement states that the resident or legal representative assumes responsibility for the resident while the resident is away from the facility and releases the facility, its owners, directors, officers, and employees from liability for injury, illness, or decline in condition that may occur during the absence. The agreement also indicates that residents leaving on pass must follow facility requirements, which may include obtaining a physician's order for medications and medical information, meeting escort requirements if applicable, and providing advance notice of the planned leave in accordance with facility policy. Review of the facility's 'Elopement Prevention Policy' undated indicated residents are to be assessed for elopement risk upon admission, routinely, and with any significant change in condition. The policy states that residents identified as an elopement risk will have individualized care plan interventions implemented to promote safety and monitoring. Staff are required to document exit-seeking behaviors, promptly report attempts to leave the premises, and remain with the resident while notifying the charge nurse and obtaining assistance if a resident attempts to leave the facility. Review of the facility's Leave of Absence (LOA) Policy undated, indicated that a Leave of Absence is a temporary period when a resident leaves the facility with the expectation of returning. The policy requires staff to ensure the resident is clinically stable prior to departure, obtain a signed LOA form, document the date and time of departure, and provide any necessary instructions. Upon the resident's return, staff are required to document the time of return, complete a nursing assessment, and update the care plan if indicated. The policy also states that if a resident does not return as expected, staff must attempt to contact the responsible party and take additional steps, including notifying authorities if the resident's safety cannot be confirmed. Review of Resident R1's Minimum Data Set (MDS- a federally required assessment) dated January 10, 2026, revealed the resident was admitted on [DATE]. The resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment indicated the resident required partial to moderate assistance with sit-to-stand, chair-to-bed transfers, toilet transfers, and ambulation of 10 and 50 feet with turns, and was totally dependent for car transfers. Resident R1's diagnoses included coronary artery disease (narrowing of the arteries that supply blood to the heart), hypertension (high blood pressure), diabetes mellitus (a disorder affecting blood sugar regulation), cerebrovascular accident (CVA), also known as a stroke caused by interrupted blood flow to the brain, malnutrition (inadequate intake of nutrients needed for health), generalized weakness (reduced muscle strength affecting mobility), and a history of falls. The resident's medication regimen included antiplatelet medications (to prevent blood clots), hypoglycemic agents including insulin (to control blood glucose), and anticoagulant therapy (blood thinners used to prevent clot formation). Review of resident R1's elopement risk evaluation dated December 17, 2025 (upon admission) revealed a score of 0, indicating no identified risk for elopement at the time of admission. There were no findings suggesting the resident was at risk for leaving the facility unsafely. Review of Resident R1's elopement risk evaluation dated January 20, 2026, revealed that the resident is at risk for elopement, with a score of 2.0. The evaluation was based on several factors, including a history of attempting to leave the facility without informing staff, wandering behavior, and behavior that could compromise the safety or well-being of self or others. Additionally, the resident had been recently admitted within the past 30 days and had not fully adjusted to the facility. According to facility protocol, a score greater than 1 indicates that the resident is considered at risk for elopement. Review of Resident R1's nursing notes dated February 3, 2026, revealed that Resident R1 was picked up for a leave of absent (LOA) and returned to the facility the same evening without incident. Further review of Resident R1's clinical record revealed social service notes dated February 4, 2026, which revealed that the resident left the faciity on leave of absence at approximately 11:00 AM. Resident did not return as expected social service director attempted to contact resident via phone with no response. Social service director contacted the shelter were resident previously resided but was not located. Review of the Leave of Absence log maintained at the front desk, where residents and family sign out when leaving the facility, revealed the following:On February 3, 2026, Resident R1 left the facility at 10:20 AM and returned at 3:20 PM, accompanied by (his/her) brother.On February 4, 2026, Resident R1 again left the facility at 11:05 AM, also accompanied by (his/her) brother. Resident did not return Interview with Medical Director Employee E4 on February 26, 2025, at 10:50 a.m. stated that he does not write blanket orders for Leave of Absence (LOA). He indicated that it would be highly irregular to issue an LOA order on the same day a resident was admitted to the facility. He explained that an order should be written each time a resident leaves the facility. The Medical Director further confirmed that if a resident is identified as an elopement risk, the resident should not leave the facility without staff supervision. He stated that he would not give an order permitting a resident identified as an elopement risk to leave the facility independently. Interview with the Director of Nursing (DON)on February 26, 2026, at 11:30 a.m. Employee E2 stated that when residents leave the facility, it is considered a day pass. The DON, Employee E2 reported that documentation for LOA/day passes is limited to the resident signing out. She stated that for one-day passes, there is no requirement for formal documentation, education, or medication reconciliation. While nurses may verbally speak with the resident or escort prior to departure, she indicated that this communication does not require documentation. Interview with Social Worker, Employee E3 on February 26, 2026, at 8:55 a.m., confirmed she was familiar with Resident R1 and had spoken with him on January 20, 2026, regarding the facility's Leave of Absence policy. She stated that on that date, the resident was not allowed to leave because the physician was unavailable to provide consent. Employee E3 stated not being aware that the resident had been identified as an elopement risk. Employee E3 further reported that she was unfamiliar with the facility's policies regarding elopement and Leave of Absence procedures. 28 Pa Code 201.14 (a)(c) Responsibility of Licensee 28 Pa. Code (b)(1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on review of facility policies, documentation and clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure all allegations of suspected abuse were reported immediately, as required, to the Department of Health for two of three allegations reviewed (Resident R2 and R10). Findings include: Review of undated facility policy, Abuse, Neglect and Exploitation revealed that the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the grievance for Resident R10 submitted on February 7, 2026, for an ongoing alleged incident of verbal abuse happening most recently on February 6, 2026, by Employee E10. Employee E10 allegedly threatened Resident R10 to get him kicked out of the facility because he was accusing her of telling people about his mental health diagnosis. A review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS) revealed no reported events by the facility for Resident R10. Interview with the Administrator and Director of Nursing (DON) on February 18, 2026, at 1:30 p.m. confirmed that the February 7, 2026, allegation of an alleged incident of verbal abuse involving Employee E10 and Resident R10 which occurred on February 6, 2026, was not reported to DOH or entered into the ERS. Interview with the DON on February 18, 2026, at 1:20 p.m. revealed that she recalled a discussion with Resident R2 and her daughter about an allegation of verbal abuse that had happened on February 3, 2026. The DON recalled that Resident R2 alleged that a nurse aide who was wearing black scrubs had threatened her to stop ringing her call bell or she would end up dead. The DON recalled that she told the resident and her daughter that the black scrubs meant that the aide was likely from an agency. When asked if this allegation of verbal abuse was reported to the DOH or entered into the ERS she indicated that it was not. A review of the Pennsylvania DOH ERS revealed no reported events by the facility for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide residents with their requested foods of preferences for five of seven residents interviewed (Residents R3, R4, R5, R6 and R9). Findings include: Interview with Resident R3 on February 18, 2026, at 12:05 p.m. revealed that she often receives foods that she told them she does not like. Interview with Resident R4 on February 18, 2026, at 12:08 p.m. revealed that she often receives foods that she told them she does not like, but that she eats them because she is so hungry. Observation of her plate from lunch revealed that she had eaten everything on the plate. When asked if she got the ham, broccoli and mashed potatoes, she said that the did and that she really does not like ham. She said that she spoke to the dietitian and is supposed to be getting double portions but never does. She is concerned about losing weight. Further observation of her meal ticket revealed no items were listed as double portions. Interview with Resident R4 on February 18, 2026, at 12:11 p.m. revealed that she does not like the food served and is not eating well. She said that she had a recent diagnosis of cancer and is worried about losing weight. She said she is supposed to be getting a nutritional supplement with her meals but only got this once over a week ago. Interview with Resident R5 on February 18, 2026, at 12:15 p.m. revealed that he often receives foods that he cannot eat and showed a picture on his phone of a black square item on a plate. When asked, he said it was a burnt piece of pizza that was not edible, he said he sent it back and never got a replacement item. When he asked, he was told that the did not send anything, and he said he had to order out again. He said he has also received chicken that had blood in it and he refused to eat the rest fearing of getting worms. Again he said that the did not give him a substitution. Interview with Resident R9 on February 18, 2026, at 12:20 p.m. revealed that she is not getting enough to eat and is often hungry. She said she receives foods that she told them she does not eat, like scrambled eggs and they still send it. 28 Pa. Code 211.6(a) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a safe, clean and homelike condition on two of four nursing units (1st floor [NAME] Unit and 4rth floor nursing unit). Findings:
A review of the facility policy titled Policy Number: RR1.01 revised 09/2025 stated under bulletin 3. gg. Section p.8 F584 Safe/Clean/Comfortable/Homelike Environment- 1. Right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. 2. Housekeeping and maintenance services that maintain a sanitary, orderly, and comfortable interior 3. Clean bed and bath linens that are in good condition 4. Private closet space in each resident room [ROOM NUMBER]. Adequate and comfortable lighting levels in all areas, comfortable and safe temperatures levels (71F-81F), and maintenance of comfortable sound levels.
On January 21, 2026, at 9:30 a.m., an observation on the first-floor [NAME] unit revealed that room [ROOM NUMBER] had a temperature of 52 degrees F, and the restroom light was not functioning. The sink water was turned off at the valve, and the Maintenance Director, Employee E7, had to turn it back on by opening the valves beneath the sink. Resident R7 was lying in bed wrapped in multiple blankets and reported that he/she was cold and that it had been cold for the past three months. Resident R7 refused a room change.
room [ROOM NUMBER] had a temperature of 69 degrees F. The restroom showed rusted metal edges on the wall, with rust flaking off. [NAME] rust discoloration was observed around the toilet and toilet valves. The floor tile behind the toilet also had brown rust discoloration.
On January 21, 2026, at approximately 9:40 a.m., an interview with Resident R8, who resided in room [ROOM NUMBER], revealed that he/she reported feeling cold in the room.
Further observations during the same time screening revealed that room [ROOM NUMBER] had a temperature of 57 degrees F. Resident R9 reported feeling cold in the room. The [NAME] hallway unit had a total of two sanitizer dispensers, both of which were empty.
It was further discovered that the left side of the first-floor [NAME] nursing unit heating system was not functioning. The following room temperatures were recorded:
room [ROOM NUMBER] – 61 degrees F room [ROOM NUMBER] – 62 degrees F room [ROOM NUMBER] – 66.5 degrees F room [ROOM NUMBER] – 57 degrees F room [ROOM NUMBER] – 52 degrees F
All rooms from 111-116 had a restroom light that was not functioning. These observation were confirmed by the maintenance director, Employee E7.
On January 21, 2026, at 9:58 a.m., an observation in room [ROOM NUMBER] revealed a strong smell of cigarette smoke near Bed A. Resident R10 was interviewed and denied smoking; however, the Unit Manager, Employee E40, confirmed the strong smoking odor in the room and reported that the resident is a smoker who has a contract with the facility not to smoke but is noncompliant. They conducted a search and found a lighter.
On January 21, 2026, at 10:18 a.m., an interview with Resident R10 revealed, It's freezing, but they did something and it got better.
On January 21, 2026, at 11:27 a.m., an interview with the Administrator, Employee E1, and the Director of Nursing, Employee E2, revealed that there were heating issues on the left side of the first-floor [NAME] nursing unit. An invoice from a vendor indicated that on January 20, 2026, the vendor worked on the HVAC units and reported the following: We replaced the inducer motor on a rooftop unit, diagnosed another rooftop unit, and cleaned the limit switch. The unit also needs a rollout switch. In addition, the thermostat on one of the units needs to be replaced. Admin confirmed that thermostat was replaced and rollout switch was obtained by vendor. Everything was fixed as of January 20. 2026.
The Administrator further reported that the facility would offer room changes and provide blankets to residents in room [ROOM NUMBER]-116. Frequent monitoring of room temperatures would be conducted if residents refused to change rooms. The Medical Director would be contacted to determine whether the room temperatures could affect residents' medical status. Residents' body temperatures would be checked every four hours for signs of hypothermia. A vendor was scheduled to return that day. The inducer motor was fixed the previous day. The facility had blankets on hand and placed an additional order for blankets the previous day in anticipation of worsening weather the following weekend.
On January 21, 2026, at 1:26 p.m., the Maintenance Director, Employee E7, reported that the vendor shut down and reset the rooftop unit, after which the heat began functioning. All six rooms were back in compliance, with temperatures ranging from 72 degrees F to 79 degrees F. The Administrator reported that heat checks would be conducted every two hours for the next week to monitor room temperatures on the first-floor [NAME] unit.
During a tour with the Nursing Home Administrator on January 5, 2026, at 1:20 p.m. room [ROOM NUMBER] where Resident R2 residents did not have any working cold water when the faucet in the bathroom was turned on. During an observation in room [ROOM NUMBER] during the above referenced time period, no working cold water was found when the faucet in the bathroom for room [ROOM NUMBER] was turned on. Resident R4 reported that she told them, about it, but could not recall who she told when she was asked.
During an interview with the Director of Maintenance (Employee E7) on January 5, 2026, at 2:00 p.m. the Director of Maintenance reported that he was aware that room [ROOM NUMBER] did not have any working cold water when he went to fix the toilet in that room on December 10, 2025. The Director of Maintenance reported that he had known since this time and had not had time to fix it. In regard to room [ROOM NUMBER] not having any working cold water, the Director of Maintenance stated that he was notified of that after the above referenced observation in room [ROOM NUMBER].
28 Pa. Code 201.18(e)(2.1) Management

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that one resident (Resident R2) was properly assessed by nursing staff and failed to ensure that 2 residents received medications according to physician orders (Resident R5 and R6). Findings include:Review of the January 2026 physician orders for Resident R2 included the following diagnosis: epilepsy (a brain condition that causes recurring seizures); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); post-traumatic stress disorder (PTSD- a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it); adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior); anxiety (frequent intense, excessive and persistent worry and fear about everyday situations, hypertension (high blood pressure), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high).During an interview with Resident R2 on January 4, 2025, at 1:15 p.m. the resident reported concerns that a drawer fell my right shoulder.my arm and reported that no one at the facility who spoke to her about it believed her. Resident R2 reported during the above referenced interview that her arm hurt. Review of the clinical record did not show any documentation that the alleged event occurred and/or that a nursing assessment was completed on the resident regarding the incident that she reported to ensure that the resident was properly assessed for any possible additional care, the physician was notified of her reported incident and could provide any necessary instructions and/or orders to the nursing staff, and that such assessment was complete and accurately documented in the clinical record. (e.g. no documentation in the clinical record that the resident's arm/shoulder area was assessed over a period of time, or that any vital signs.During an interview with Employee E10 (licensed nurse) on January 6, 2026 at 12:44 p.m. reported that the resident notified him that a dresser fell on her shoulder while she was sitting on her bed. Discussed with the licensed nurse that there was no documentation of the reported incident, no documentation of any assessment done on the resident to include assessment of the area where the dresser reportedly fell on, vital signs, . in the clinical record. The licensed nurse reported that he was told by the manger on duty, Human Resources Manager (Employee E9) to not document anything regarding event in the clinical record. Review of the January 2025 physician orders for Resident R5 included the following diagnosis: kidney failure (a condition in which one or both of your kidneys no longer work on their own); osteoporosis; psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it). Continued review of the resident's January 2025 physician orders included an order for the resident to be administered 1-2 milligram tablet of the medication Haloperidol in the morning for the treatment of psychosis and schizophrenia.During the medication administration observation, on January 6, 2026 at 10:11 a.m. Employee E11 (licensed nurse) could not locate the medication haloperidol on the medication cart, or in the medication room when she looked. During the above date and time, the license nurse reported that resident's above referenced medication could not be administered because the resident had no more left, and it had to be reordered from the pharmacy.Review of the January 2026 physician orders for Resident R6 included the following diagnosis: lumbago with sciatica (characterized by pain radiating from the lower back and into the legs and feet); hypertension (high blood pressure), and epilepsy (a brain disorder that causes repeated seizures).Continued review of the resident's January 2026 physician orders included a physician's order for the administration of 1-15 milligram tablet of the pain medication, oxycodone to be administered by mount every 10 hours. oxycodone HCI Oral Tablet 15mg (Oxycodone HCI) Give 1 tablet by mouth every 10 hours related to LUMBAGO WITH SCIATICA, LEFT SIDE.During a medication administration observation on January 6, 2026 at 10:38 a.m. Employee E12 (licensed nurse)went in to administer the medication for Resident R6 when R6 asked the licensed nurse do you have my pain medication? Licensed nurse reported that the oxycodone was not available for the resident to take because it had not been delivered by the pharmacy because a prescription from the physician is needed. During an interview with the resident during the above reference date and time, the resident reported I am in a lot of pain and I need my pain medication. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and interviews, it was determined that the facility failed to ensure complete and accurate clinical record regarding the consumption of a meal for 1 out of 3 residents observed (Resident R5).Findings include:Review of the January 2025 physician orders for Resident R5 included the following diagnosis: kidney failure (a condition in which one or both of your kidneys no longer work on their own); osteoporosis; psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).Review of a physician's order for Resident R5 with an order date of August 25, 2022 and monthly thereafter included an order for the resident to have a fortified cereal one time a day during her breakfast meal for the additional calories and protein intake. Fortified Cereal one time a day for additional kcal and protein intake. With breakfast. During the medication administration observation, on January 6, 2026 at 10:11 a.m. Employee E11 was observed documenting in the clinical record with her initial indicating that the resident had at least received the fortified cereal/and or consumed it. When asked if she observed the resident with the cereal on her breakfast tray and/or if she consumed it, Employee E11 confirmed that she did not see her with it, and stated, they (referring to dietary) usually send it up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of information submitted by the facility, review of facility documents, and staff interview, it was determined the facility failed to ensure a resident was free of abuse for one of two residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1. Resident R1 was involved in a physical altercation with a staff member, during which the staff member punched Resident R1 in the face. A reasonable person would determine that a staff member striking a resident with moderate cognitive impairment caused actual harm. Due to the resident's cognitive limitations and dependence on staff for care and protection, the impact of the incident is magnified and places the resident at risk for ongoing psychological trauma. This deficiency was cited as past non-compliance. Findings include:
Review of the facility policy, Freedom from Abuse Neglect and Exploitation, with a revision date of September 2025, indicated the facility must provide a safe resident environment and protect residents from abuse, and not use verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion.
Review of Resident R1's clinical record revealed January 2026 physician orders included the following diagnosis: Epilepsy (brain condition that causes recurring seizures); Hypertension (high blood pressure); Chronic Obstructive Pulmonary Disease (COPD- a term for lung and airway diseases that restrict your breathing); Dementia (group of symptoms affecting memory, thinking and social abilities and interfere with a person's daily life), and unspecified Psychosis (term used for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).
Review of Resident R1's Comprehensive Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated November 19, 2025, indicated the resident had moderate cognitive impairment.
Review of information dated November 23, 2025, at approximately 7:00 p.m. submitted by the facility on November 23, 2025, it was reported that [Resident R1] was being physically aggressive towards staff and attacked and hit an employee. According to the report another employee attempted to de-escalate the situation by speaking to [Resident R1]. [Resident R1] attacked that employee and the employee allegedly took a swing at [Resident R1]. The facility substantiated the incident as resident abuse.
Review of the facility investigation revealed dietary worker (Employee E3) reported being approached and punched in the face by the resident while they were in the elevator. Continued review of the facility investigation documentation revealed Employee E4, dietary supervisor (alleged perpetrator) was interviewed and stated he was notified the resident hit an employee in his department while the employee and the resident were both in the elevator. Employee E4 reported that he went to find out what happened and attempt to calm the resident down. Dietary supervisor reported the resident started to get aggressive with him and he asked (him/her) to stop multiple times. Dietary supervisor reported that he attempted to exit the situation, then the resident took a swing at him. The dietary supervisor reported that he swung back and hit the resident.
Review of written statement by the dietary aide dated November 23, 2025, indicated the dietary aide was hit by the resident. Review of a second written statement by the dietary aide indicated the dietary aide was walking to get the truck and that a resident asked him to walk with them to see something. The dietary aide reported that when the lady came out, the resident grabbed a plate and then put it back. Dietary aide reported the resident asked him if he (the dietary aide) could hear (him/her) and he (dietary aide) stated that he could. The dietary aide reported the resident then started to approach him, so he (dietary aide) backed up and the resident swung at him and hit him in the face.
During an interview with the dietary aide on January 7, 2026, at 3:23 p.m. the dietary aide reported, he was on the first floor, west wing getting the food truck. He stated a nurse was about to put a tray on the cart when (the resident) asked to check the tray. The dietary aide stated the resident asked him (dietary aide) if he could hear (him/her), he replied yes, then the resident started to approach him and hit him in the face. Dietary aide reported that he told the dietary supervisor what happened and called his mother. Dietary aide reported he wrote a statement about what occurred with the above-referenced resident. The dietary aide reported he saw the resident knocking on the double doors that lead to the kitchen but did not witness the dietary supervisor get hit by the resident and only heard about the incident.
Review of statement obtained from the dietary supervisor dated November 23, 2025, revealed the dietary aide came to the dietary supervisor and told him what happened with Resident R1. The dietary supervisor reported he went to find out where resident was and went to the hallway where he found Resident R1. Dietary supervisor reported he saw the resident and told the resident that he needed to stop, and he said this a couple of times. Continued review of the dietary supervisor's statement indicated Resident R1 tried to swing at him and he (dietary supervisor) swung back and hit him.
Review of a witness statement by a resident witness (Resident R3) dated November 23, 2025, revealed Resident R3 was sitting in front of the nursing office and saw Resident R1 walk towards the kitchen. Resident R3 witness statement revealed the dietary staff opened the doors and Resident R1 was trying to go by them. Resident witness reported that Resident R1 put (his/her) hands up to fight the staff and the dietary supervisor tried to talk with Resident R1 to find out what was wrong. Resident R3 witnessed Resident R1 hit the dietary supervisor and the dietary supervisor hit Resident R1 back. Resident witness (Resident R3) has been discharged from the facility since the incident on November 23, 2025, and was not interviewed regarding (his/her) statement that (he/she) provided to the facility.
Review of witness statement by activity aide (Employee E5) dated November 23, 2025, revealed that around 7:00 p.m. on the date of the incident the dietary aide notified her that he was hit by Resident R1. The activity aide reported she notified the nursing supervisor (Employee E6). The activity aide reported, she was with the dietary aide and the dietary supervisor near the kitchen door where the resident was also. Activity aide reported Resident R1 was shaking and wobbling while throwing (his/her) hands up at the dietary supervisor and that the dietary supervisor reacted and hit the resident on the right side of the face.
During interview with the activity aide on January 8, 2026, at 11:39 a.m. the activity aide reported that during the time of the incident on November 23, 2025, she was working as the front desk receptionist. The activity aide reported during the interview the dietary aide notified her that Resident R1 hit him on the elevator. Activity aide indicated that she notified the nursing supervisor who came down to speak with the dietary aide. The activity aide stated both she and the nursing supervisor went around to the kitchen area (the area near the double doors that lead to the kitchen area) and they notified the dietary supervisor about the incident. Activity aide revealed that Resident R1 walked around to the area where they were all standing and had his fist balled up. Activity aide reported the dietary supervisor was standing near the resident who had (his/her) fist balled up, and the dietary supervisor hit the resident on the side of (his/her) face. The activity aide reported that she did not witness the resident hit the dietary supervisor. Activity aide reported that she moved the resident out of the way and the nursing supervisor called someone and she (activity aide) went back to the front desk.
Review of written statement from nursing supervisor (Employee E6) dated November 23, 2025, revealed that the nursing supervisor was called to the dietary department because it was reported to her that Resident R1 hit the dietary aide. Nursing supervisor reported that when she arrived at the kitchen she was met by Resident R1 who stated to the nursing supervisor, where is he? Nursing supervisor reported that she did not respond, and that she went into the kitchen and asked the dietary aide if the resident hit him. The nursing supervisor indicated in the statement that the dietary aide told her that the resident punched him. Nursing supervisor indicated that dietary supervisor then came from the kitchen, and the resident had his hands up as if (he/she) was going to fight. Nursing supervisor indicated the dietary supervisor asked the resident what happened, and what could he do for (him/her) since he was notified by the dietary aide that the resident hit him. Nursing supervisor reported that as the dietary supervisor approached the resident, the resident punched the dietary supervisor. Nursing supervisor indicated that the dietary supervisor then began hitting the resident, and stated to the resident, you messing with the wrong one, and then punched the resident in the face.
Based on review of facility documents and interview with staff, a reasonable person would determine that a staff member striking a resident with moderate cognitive impairment caused actual harm. Due to the resident's cognitive limitations and dependence on staff for care and protection, the impact of the incident is magnified and places the resident at risk for ongoing psychological trauma. This action compromised the resident's right to be free from abuse and undermined the resident's sense of safety.
This deficiency was cited as past non-compliance.
Review of facility Action plan/Follow up documentation revealed the following information.
Resident R1 was immediately removed from the area and assessed by the charge nurse. There were no signs of bruising or redness. Resident R1 was transferred to the hospital on 302 for psychiatric evaluation. The staff member involved immediately suspended immediately pending investigation. Staff member was terminated 11/24/2025.
On 11/23/2025 the nursing supervisor and NHA interviewed residents and facility staff to [NAME] that there were no other incidents.
On 11/23/2025 the nursing supervisor started education for Facility Staff regarding Abuse and de-escalation. The NHA, DON and/or designee continue De-escalation training for facility staff. An ad-hoc QAPI was held on 11/24/2025. The facility has engaged vendor provider to provide de-escalation training. Training will be conducted on February 2, 2026.
NHA, DON and /or designee will conduct audits of allegation of staff-to-resident abuse allegations. Results of the audits will be reviewed at the QAPI meeting held monthly.
The facility alleged a date of compliance with this plan of correction as November 24, 2025.
Facility education records and subsequent audits were verified as complete. Staff were interviewed to confirm education on the facility's de-escalation policy for all staff. Staff interviews were also conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interviews, or observation.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record review, and interviews with resident and staff, it was determined that the facility failed to assist and initiate a discharge plan for a resident who requested to be discharge from the facility for one of three residents reviewed. (Resident R1) Findings include:Review of the facility policy title Discharges dated October 1, 2025, revealed that the residents may not be discharged unless specific criteria are met and at the facility must provide written notice, physician documentation, and coordinate discharge planning with social services, nursing, MDS (resident assessment of care needs), and therapy. The policy requires a discharge notice include the reason for discharge, effective date, appeal rights, and discharge location, and that a post discharge plan of care be developed. Review of Resident R1's admission MDS dated [DATE], revealed that this resident was admitted into the facility on October 8, 2025. Resident R1 was assessed with a BIMS (Brief interview for Mental Status score of 14, indicating that the resident was cognitively intact. The assessment documented that she was independent with indoor mobility and required supervision or partial assistance with walking and transfers. Resident R1's diagnosis included cellulitis (skin infection) of the lower limb. Review of Resident R1's admission agreement packet dated October 8, 2025, revealed that Resident R1 signed the admission documents, which included information regarding anticipated care services. The packet indicated that the resident was admitted for short-term rehabilitation, defined by the facility as goal-oriented, comprehensive inpatient care provided to individuals with an acute illness, injury, or exacerbation of a disease process. The admission packet further states that all resident transfers and discharges will be conducted in accordance with applicable state and federal laws. It specifies that a resident may be transferred or discharged if their condition has improved sufficiently so that facility-level services are no longer required, or if the resident voluntarily chooses to be transferred or discharged . In all cases, the facility is required to collaborate with the resident or legal representative to develop and implement a safe, timely, and appropriate discharge plan.The admission documents also included the Resident Rights section, affirming the resident's right to be informed of and participate in their treatment, care planning process, expected goals and outcomes, and the duration and effectiveness of the plan of care.Resident R1 signed and acknowledged receipt of all documents included in the admission agreement. Interview with Resident R1 completed November 18, 2025, at 9:50 a.m. revealed that (she/he) stated (she/he) was at the facility only for rehabilitation and is eager to go home. Resident R1 expressed this desire for several weeks to the former social worker, but no action has been taken. The resident stated that (she/he) has discussed plans with her family and intends to stay with (her/his) daughter upon discharge. Interview with the social worker on November 18, 2025, at 11:35 a.m. revealed that she was aware the resident wished to leave the facility, but she was not confident about the resident's planned living arrangement. The social worker confirmed that Resident R1 is (her/his) own representative and is cognitively capable of making her own decisions. Review of the resident's care plan revealed that there was no documentation or mention of a discharge plan.Review of the resident's nursing notes revealed that on November 12, the social worker documented an attempt to contact the resident's daughter. No other documentation was found indicating that the resident or facility had initiated discharge planning.Review of the resident's physical therapy notes revealed that the resident is expected to return to living at home with family, with home assistance and support provided as needed. The notes identified potential barriers to discharge, including multiple medication management requirements, the need for physical assistance to function safely at home, and likely caregiver support in the next setting. Therapy notes dated November 13, 2025, indicated that the resident was compliant and actively participated in skilled interventions.Interview with the nursing home administrator on November 19, 2024, at approximately 2:30 PM revealed that he was aware the resident had requested a discharge. He stated that the request had been discussed at a recent meeting and confirmed that there was no documentation indicating that a discharge plan had been initiated or that any steps had been taken to facilitate the resident's discharge.25 Pa Code 201.14(a) Responsibility of licensee

Based on observations of the physical environment of the building on the first floor, reviews of the pest control operators reports and interviews with staff, it was determined that the facility was not maintaining an effective pest control program. Findings include:Observations of the physical environment of the facility revealed that the food and nutrition department was located on the first floor (ground floor) of the building. Further observations revealed that the trash and refuse area for the entire building was located through the double doorway in the back hallway that was adjacent to the main kitchen and dry food storage area. Observations of the double doors leading directly outside the building and into a driveway where the trash and garbage disposal system (dumpster unit) was held, revealed that these doors did not seal upon closing. A two-inch void was visible between the doors. The gap provided easy access for common household pests and rodents (mice, flies, roaches) to enter the building on the first floor. A review of the pest control operator's reports for September 3, 2025, revealed that the main kitchen and food storage area was being treated for mice activity. The pest control operator identified areas of the building that structural voids needed to be sealed. A review of the pest control operator's reports for August 4, 2025, revealed that the pest control operator treated the kitchen for common household pests (roaches and flies). The pest control operator advised the kitchen staff to practice deep cleaning and floor power washing throughout the kitchen to maintain a clean and sanitary food service department. A review of the pest control operator's report dated July 28, 2025, revealed that the dumpster area was treated for fly infestation. The pest control operator indicated that there was food debris and liquid food spillage surrounding the dumpster unit that was attracting the pests to the trash and refuse area of the facility. A review of the pest control operator's report dated July 28, 2025, revealed that the kitchen was treated for common household pest activity (roaches and flies). The pest control operator said that the main kitchen flooring needed to be power washed and grease spills and food debris needed to be removed from the hot food preparation area to maintain the main kitchen in a clean and sanitary manner and prevent the feeding and breeding of pests and rodents. 28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code201.18(b)(1)(3)(e)(1)(2.1)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to provide timely pressure ulcer treatment for one of nine residents reviewed (Resident R13). Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], with diagnoses of but not limited to Hypertension (high blood pressure), Rheumatoid Arthritis (isa chronic autoimmune disease that primarily affects the joints), Hypothyroidism (condition due to deficiency in the thyroid hormone resulting in decreased body metabolism).Review of Resident R13's MDS (minimum data set a federally required resident assessment completed at a specific interval) dated June 26, 2025, revealed that section GG0130. Self-Care C. Toileting hygiene: was coded has dependentant.Review of nurse's aide task revealed that for toileting and hygiene Resident R13 was dependent to maximum assist.Review of Resident R13's nursing note dated July 25, 2025, reveal that Nurse's Aide reported that resident complained of pain on her right heel. On assessment resident observed with deep tissue injury to right heel. Skin prep applied, message left for MD (physican).Review of Resident R13's skin assessment dated [DATE], performed by a licensed nurse revealed that resident was at risk for skin breakdown. Further section G (Additional observation) of Resident R13's skin assessment revealed a note that Resident R13 had DTI (deep tissue injury) to left heel and had a right buttocks skin alteration.Review of July 2025 physician's order revealed an order to Cleanse Right buttock with NSS (normal saline solution) apply Adaptec and cover with clean drydressingevery evening shift for skin alteration -Start Date-07/27/2025 -D/C (discontinued) Date-07/28/2025-Santyl Ointment 250 UNIT/GM (Collagenase)Apply to per additional directions topically every evening shift for wound care -Start Date-07/28/2025 -D/C Date-08/10/2025-Cleanse Right buttock with NSS apply Santyl calcium alginate cover with clean dry dressing. every evening shift for skin alteration-Start Date-07/29/2025-D/C Date-09/13/2025 Further review of Resident R13's clinical record revealed no documented evidence that the physician and addressed the DTI to left heel and right buttocks skin alteration which were identified on July 25, 2025, until July 27, 2025, and wound treatment was not started until July 27, 2025. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to ensure that hot beverages were served at a safe temperature during a resident activity in one of four floors. (Second floor dining room) Findings include:The FDA, Consumer Product Safety Commission, and the American Burn Association all warn against serving beverages at temperatures above 150 F, as liquids at or above this level can cause severe burns within seconds. According to these organizations, a serious burn can occur in just one second when a beverage is served at 160 F. To minimize the risk of scalding injuries, best practices recommend that hot beverages be served at temperatures between 130 F and 160 F.Review of The American Burn Association https://ameriburn.org, revealed at 140 degrees Fahrenheit, serious burns can occur in about five seconds and a 160 degrees Fahrenheit it can happen in just one second, this underscores how quickly severe burns can occur from hot liquidsObservation on n September 15, 2025, at approximately 11:00 AM, during a scheduled coffee hour in the second-floor dining and activity room, approximately 20 residents were observed consuming coffee served in paper cups with lids. Activity assistant Employee E10, was observed pouring and distributing the coffee. During preparation, steam was visibly rising from the cups, indicating that the beverage was very hot. When a surveyor requested a cup and sampled the coffee, it was found to be hot. Upon being asked about the beverage temperature, Employee E10 stated they did not know the temperature. The employee then left the activity room to find a kitchen staff member to assist in measuring it.Observation of kitchen staff, Employee E26 on September 15, 2025, at approximately 11:20 AM, revealed that Employee E14 entered the room and used a thermometer to check the coffee temperature, which registered at 167 F. When asked about the acceptable temperature range for serving hot beverages, Employee E14 was unable to provide a definitive answer and guessed that around 160 F was appropriate.Interview with Dietary Supervisor, Employee E7on September 15, 2025, at 11:35 a.m., in the kitchen the Dietary Supervisor, employee E7 explained that it is not the kitchen's responsibility to monitor beverage temperatures for activities. Instead, she stated that the activity staff are expected to ensure the beverages are served at a safe temperature. When asked to provide a written temperature policy for hot liquids, Employee E7 was unable to do so. She indicated that there was no formal policy in place and noted that kitchen staff generally believe that 160 F is an acceptable serving temperature.Further observation in the kitchen at approximately 11:50 AM revealed coffee being poured for lunch tray distribution. A thermometer reading showed the coffee temperature at 170 F and the hot water temperature at 185 F. A review of the kitchen's temperature logbook for the month of September indicated that, on multiple days, coffee temperatures were not recorded. Notably, on September 12, 2025 the coffee was documented as having left the kitchen at a temperature of 180 F.On September 16, 2025, at 2:50 PM, an interview was conducted with the Nursing Home Administrator, Employee E1. During the interview, the administrator confirmed that the facility does not have a written policy outlining the acceptable temperature range for serving hot liquids. Employee E1 acknowledged the potential safety risk this poses to residents and recognized that serving improperly monitored hot beverages could result in serious burns. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1) Staff development

Based on clinical record review and staff interview, the facility did not ensure that nurse aides received annual performance evaluations to assess competency and performance, as required. Findings Include: An interview was held on September 17, 2025 at 2:45 p.m. with Employee E1 the Nursing Home Administrator. Employee E1 when asked to provide evidence nurse aides were evaluated at least every 12 months. Employee E1 stated, we don't have any nurse aide evaluations. I thought that they needed the required trainings only. Based on the information above, the facility could not provide any nurse aide evaluations during the past 12 months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(c) Nursing services

Based on observation, review of facility documentation and staff interview, it was determined that the facility failed to ensure that dietary equipment to maintain hot foods remain in functional capacity. Findings include: Observations of the food and nutrition services department on September 15, 2025 at 11:30 a.m., in the presence of the food service director, Employee E7, revealed that the plate warmer was not equipped with a lid/cover that was necessary to contain heat. This piece of foodservice equipment was designed to warm/heat the ceramic plates that were used for plating and serving meals to the residents. The ceramic plates were not hot to touch. Additional observations of the food and nutrition services department on September 15, 2025, revealed that the dietary operation was not using a complete thermal system for maintaining hot foods (meals) during transportation and delivery to the nursing units from the main kitchen. Interview with the Director of Dietary Services at 11:30 a.m., on September 15, 2025, revealed that the thermal pellet base charger and thermal pellet base under liners had been non-functional for several months and that a request had been placed by the food and nutrition services department for administration to purchase new equipment (thermal pellet base charger and thermal pellet base under liners). A review of the undated facility policy titled resident tray assessment revealed that the service temperature standards for the hot entree, starch and vegetables at mealtimes, for the residents were established at 130 degrees Fahrenheit. A review of the food committee meeting minutes dated May 21, 2025, revealed that the residents were voicing concerns about the palatability and temperature of the foods being served to them, from the dietary services department. The residents were reporting that foods were unappetizing and not served at proper temperatures. A review of the food committee meeting minutes dated August 13, 2025, revealed that the residents were complaining that the hot foods from the main kitchen were being served cold. Observations of the meal delivery for the residents on the second-floor nursing unit, during the noon meal on September 16, 2025, confirmed that the temperature of the hot foods were not appetizing at point of service for the residents. Foods evaluated were the beef soft tacos sauteed peppers and onions and Mexican corn. The hot food entree, starch and vegetables tested at 109 degrees Fahrenheit. 28 Pa. Code 201.14(a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review of facility documents, job descriptions and interview with staff it was determined that the facility failed to ensure that a qualified staff performs a wound assessment for one of nine residents reviewed (Resident R13)Review facility job description for licensed nursing staff revealed Job summary qualifications responsibilities duties and tasks of a charged nurse. Further review of the facility's job description for a charged nurse revealed that there was no specific job description for a registered nurse and there was no specific job description for a licensed practical nurse.Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], with diagnoses of but not limited to Hypertension, Rheumatoid Arthritis, HypothyroidismReview of Resident R13's skin assessment dated [DATE], revealed that resident was at risk for skin breakdown with a score of 17.Further section G (Additional observation) of Resident R13's skin assessment revealed DTI (deep tissue injury) to left heel and right buttocks skin alteration. Further, skin assessment dated [DATE], was performed by a licensed practical nurse. Further review of Resident R13's clinical record revealed no documented evidence that a wound assessment was performed by a Registered Nurse or other licensed medical professionals who are allowed by to perform an assessment, upon identification of the DTI on the left heel and skin alteration of right buttocks. Interview with Employee E2 conducted on September 19, 2025, confirmed that Licensed Practical N'urses are not allowed to assess and that only a Registered Nurse can perform an assessment. Further Employee E 2 revealed that she will conduct an inservice to all nurses related to their functions. 28 Pa. Code 201.1 Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to develop and maintain an accurate, comprehensive facility-wide assessment. Findings include:Review of the facility's policy titled Facility Assessment (dated 2025) revealed that the facility is required to complete and document a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. The policy identifies that the facility assessment must include, at a minimum:- The resident population, including number, facility capacity, and care needs using data-driven methods that reflect disease types, physical and behavioral health needs, cognitive impairments, and acuity levels;- Physical environment, equipment, services, and cultural/religious factors that may affect care.- Facility resources including staffing, equipment, therapy, pharmacy, behavioral health services, and all contracted services.- Responsibility for completion assigned to the Administrator; and- Annual updates or as necessary. Review of the facility's most recent Facility assessment dated [DATE], and reviewed by the QAPI (Quality Assessment Improvement Plan) Committee on July 30, 2024, revealed that the document was outdated and lacked several required components:- The description of the resident population was incomplete. Disease types and acuity levels were not accurately listed. Psychiatric and mood disorders were addressed only through third-party contracts with no analysis of prevalence or impact on care delivery.- Under intellectual disabilities and other complex needs, vague statements were provided, such as follow-up with specialists or as directed by Medical Director, without defining specific staff competencies or resources.- The evaluation of staff competencies was absent. The document stated only that staffing meets or exceeds minimum ratios, without analysis of specific training or skill sets required to meet the care needs of the resident population.- The resource and service evaluation lacked detail. Statements such as CNA staff assist with ADLs, behavioral health monitored through documentation, and infection control monitored by program were too general and did not demonstrate an analysis of resources necessary to meet actual resident needs.Interview with the Nursing Home Administrator (NHA) on September 18, 2025 at approximately 10:00 a.m. revealed that he considered the assessment to be complete.During a follow-up interview on 9/19/2025 at approximately 9:00 a.m. the NHA acknowledged that the original Facility Assessment was missing required information and confirmed that a revised assessment had been created after surveyor inquiry. The updated document included more detailed information that had previously been omitted. The NHA confirmed that the added content was completed only after the initial surveyor interview.28 Pa. Code (a)(j) Responsibility of Licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the Nursing Home Administrator and Director of Nursing effectively and efficiently implemented resources to management incidents of resident abuse and failed to ensure that behavior management resources were implemented for one of seven sampled residents (Residents R148) Findings include:A review of the facility policy titled accident and incident-investigation, and reporting dated July 2017 revealed that all accidents and incidents involving residents occurring on the premises were to be investigated and reported to administration. The nursing supervisor was required to document and investigate the accident and incident. The report was to contain the circumstances surrounding the accident and incident, names of all parties involved such as witnesses and their accounts of the accident or incident, residents' statements of the event, the physician's response to the event was to be documented, vital signs and nursing measures instituted, any corrective action taken to prevent the accident or incident in the future and any follow-up action to prevent and accident and incident from happening again. The documented accident and incident report was to be submitted to the director of nursing and the administrator. The director of nursing and the administrator were responsible for reviewing the accident and incident for safety hazards and individual resident vulnerabilities to ensure the residents' environment was safe. Review of Resident R148's MDS quarterly assessment (MDS-an assessment of care needs) dated July 23, 2025, indicated this resident had adequate vision and hearing. The resident was assessed with disorganized thinking (rambling, irrelevant conversation, unclear ideas, unpredictable switching from subject to subject). Continued review of the MDS revealed the resident was independent with functional abilities and activities of daily living that included ambulation. The assessment indicated that this resident had diagnoses of anxiety disorder, depression and schizophrenia (disease characterized by loss of reality contact). Review of Resident R101 MDS quarterly assessment dated [DATE], revealed that the resident was able to express ideas and wants and understood verbal content. Review of nurse practitioner's notes dated April 4, 2025, indicated that Resident R101 was awake alert and oriented. Review of psychiatrist notes dated March 24, 2025, indicated that Resident R101 was alert and oriented. Review for Resident R148 revealed that the resident left the first-floor nursing unit ambulating without supervision at 6:00 a.m., on April 6, 2025. On April 6, 2025, the nursing staff documented that Resident R148 was found in room [ROOM NUMBER] standing over Resident R101 while the resident was sleeping. A nursing staff member reported that Resident R148 was shaking resident R101 to wake him up. Interview with Resident R101 at 11:00 a.m., on September 18, 2025, revealed that Resident R148 was trying to grab his private area, when he entered his room on April 6, 2025. The clinical record indicated that as the nurse went over to Resident R148 to stop him from shaking Resident R101, Resident R148 turned and spit on the nurse then with a closed fist punched the same nurse in the face. The nursing staff documented that Resident R148 continued to wander away from the first-floor nursing unit. The nurse also documented that the resident was unable to be redirected. There was no statement available for review from Resident R101, who was cognitively intact and able to make his needs known to staff. Interview with the director of nursing and the administrator at 10:00 a.m., on September 17, 2025, confirmed no safety measures were instituted to protect Resident R101 after incident on April 6, 2025.Review of Resident R76 revealed an admission MDS comprehensive assessment dated [DATE], that indicated this resident was cognitively intact. The assessment also indicated that this resident had no upper or lower body functional limitations with range of motion. Resident R76 was assessed as able to ambulate ten feet with supervision and that no assistive device needed for walking. Review of Resident R148 revealed and incident on August 8, 2025, that indicated this resident walked into the rehabilitation gym on the first floor of the facility and without being provoked began screaming, cursing and lunging at Resident R76. Resident R148 told Resident R76 that he was going to kill him. Interview with Resident R76 at 1:00 p.m., on September 17, 2025, revealed that he thinks Resident R148 should be closely monitored and not walking freely throughout the entire facility. Resident R76 said that he was capable of defending himself; however, some other residents that live here were not as physically able and were more vulnerable to his verbal threats and aggressive behaviors.There was no documented accident or incident report available for review for the incident that took place in a common area of the facility with staff working on August 8, 2025, between Resident R148 and Resident R76. There were witness statements recorded (staff or residents). There was no documentation to indicate what the preventative action or corrective action taken by the facility to prevent further occurrences of verbal threats and aggressive behaviors by Resident R148 with Resident R76 and other residents living at this facility.Interview with the Director of Nursing Home Administrator at 1:15 p.m., on September 17, 2025, confirmed the lack of documented investigation and preventative measures following the incident that took place on August 8, 2025, between Resident R148, the aggressor and Resident R76 the victim.Clinical record review revealed that Resident R148 was exhibiting aggressive, combative and sexually inappropriate behavior on August 29, 2025, on the first-floor nursing unit. Resident R148 was observed with his pants lowered engaging in inappropriate self-stimulation while rubbing his genital area as he watched the nursing staff at the medication cart in the hallway. Upon redirection the resident became agitated, raising his voice and displaying combative gestures. Interview with the Director of Nursing and the Nursing Home Administrator at 1:20 p.m., on September 17, 2025, confirmed the lack of documentation and investigation related to the above mentioned incident that took place on August 29, 2025, Clinical record review for September 11, 2025, revealed that Resident R148 was pacing the hallways and lobby of the facility located on the first floor of the building all during the night. The nursing staff indicated that on September 11, 2025, Resident R148 was observed blowing smoke in the face of a nurse staff member. The nursing staff member also noted that resident R148 was using profane and racially derogatory language toward the nursing staff. Interview with the Director of Nursing and the Nursing Home Administrator at 1:30 p.m., on September 17, 2025, revealed that there was no documented accident and incident report for the incidents documented by the nursing staff on September 11, 2025. The administrator reported being unaware of Resident R148 having smoking materials inside the facility. The administrator reported that Resident R148 does leave the facility with his brother at times, during approved leaves. The administrator reported that smoking or vaping was not allowed in the building. The Director of Nursing and Nursing Home Administrator reported that there were no corrective actions or follow-up actions to prevent the following incidents that occurred on September 11, 2025, involving Resident R148.Clinical record review on September 12, 2025, for Resident R148 revealed that this resident came out of his room naked, went to the residents' dining area and began masturbating all over the place. The nursing staff documented that Resident R148 was not able to be redirected. Interview with the Director of Nursing and the Nursing Home Administrator at 1:45 p.m., on September 17, 2025, revealed that there was no documented accident or incident report, in accordance with the facility's policies for the incident that took place on September 12, 2025, for Resident R148. The Director of Nursing and Nursing Home Administrator were unaware if there were other residents in the dining/activities area during Resident R148's demonstration of inappropriate sexual behavior. The Director of Nursing and Nursing Home Administrator reported that there were no corrective actions or follow-up care planning measures documented for the sexually inappropriate behavior that occurred on September 12, 2025, involving Resident R148; because they were unaware that this incident had happened or the surrounding circumstances that took place. Refer to R740Refer to F610 28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18(b)(1) Management28 PA. Code 211.10(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of facility policies, it was determined that the facility failed to ensure that residents are treated with dignity and respect for one of 35 residents reviewed. (Resident R183)Findings include: Review of Resident R 183's quarterly Minimum Data Set (MDS-a federally mandated assessment tool for all residents) dated September 4, 2025, revealed that Resident R183 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), asthma (condition that causes the airways to swell, narrow and fill with mucus), and bipolar disorder (mental condition that causes extreme mood swings). The residents' cognitive status, as measured by the Brief Interview for Mental Status (BIMS), yielded a score of 10, indicating moderate cognitive impairment. Observation on September 16, 2025, at 08:30 a.m. on the second-floor nursing unit revealed Licensed Nurse, Employee E12 administering medications to Resident R183. Licensed nurse, Employee E12 asked the resident to remove her bracelets, stating she could not take her blood pressure otherwise, Resident R183 refused. The nurse responded by stating she could not reach the resident's upper arm and asked her to move. The resident verbally expressed dissatisfaction, saying, Stop flipping your hair and rolling your eyes at me. The nurse later returned with the medication and stated, Here you go, [NAME], I got your meds. The resident became visibly agitated and responded, Don't call me '[NAME].' My name is xxxx The nurse then exited the room without further communication. Interview with Resident R183 at time of the observation revealed that this resident felt disrespected by the nurses demeaner, including flipping her hair and rolling her eyes, and using patronizing language ([NAME]). She reported that she did not appreciate the attitude and stated, I will not take that from nurses.Interview with Licensed nurse, Employee E12, following the above interaction, confirmed that the interaction and described the resident as difficult. 28 Pa. Code 211.12 (d)(1) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, staff interview, and review of facility policies, it was determined that the facility failed to ensure that one of 33 residents reviewed was assessed to self-administered medications. (Resident R77)Findings Include: Review of the facility's policy titled Medication Self-Administration revealed that residents are not permitted to retain or self-administer medications in their rooms unless the primary physician writes an order authorizing self-administration and the interdisciplinary team determines the resident is capable of doing so safely. An evaluation of the resident's ability to self-administer must be conducted and documented. The physician's order must be signed and dated prior to self-administration. Self-administration must be reflected in the resident's care plan and reviewed at least quarterly or upon any clinical change in the resident's status.Review of Resident R 77's Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated June 20, 2025, revealed the resident was admitted on [DATE], with the diagnoses of hypertension (high blood pressure), diabetes (the body cannot regulate glucose), cerebrovascular accident (CVA-stroke), seizure disorder (uncontrolled jerking, loss of consciousness, blank stare caused by abnormal electrical activity in the brain), and asthma (chronic condition that effects the airways in the lungs, causing wheezing, shortness of breath and coughing). The resident's Brief Interview for Mental Status (BIMS) score was 15, indicating intact cognition.Review of Resident R77's care plan dated June 20, 2025, revealed that the resident is care planned for behaviors including resisting care, combativeness, hoarding, and frequent refusal of lab work, ACCU (blood sugar) checks, and medications. There is no indication that this resident is able to self-administer medications.Observation on September 16, 2025, at 12:30 PM revealed two medication inhalers on the resident's bedside table. Licensed nurse Employee E 25 removed the inhalers from the resident's possession. Interview with the resident at time of the observation confirmed the inhalers were hers and that she self-administers them.Interview with licensed nurse Employee E25 at time of the observation confirmed the inhalers were on the bedside table and stated that the resident does not allow nurses to administer them. Licensed nurse employee E25 further stated she was unaware of any physician's order for self-administration, saying, I guess not. 28 Pa. Code 211.10 (c)Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on observations, review of facility policy, and interview with residents and staff it was determined that the facility failed to ensure that residents were explained their resident rights for four of eleven residents reviewed. (R1, R76, R120, and R178). Findings Include:Review of the facility policy titled Resident Rights undated, reads Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Further review of the Resident Rights policy revealed, Policy Explanation and Compliance Guidelines: A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility.During resident council group meeting held on September 17, 2025 there were five of eleven residents that stated they did not know what their resident rights were or how they would call the Department of Health to file a complaint. Review of resident council minutes from the months of April, May, June, July, and August, 2025 revealed there were no indication that any of the resident rights were reviewed during resident council. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(d) Resident Rights

Based on observation, review of facility policy and interview with residents and staff, it was determined that the facility failed to ensure to maintain privacy for resident's clinical records during medication administration and incontinence care for two of thirty-one residents observed (Resident R168 and R207). Findings include:Review of undated facility policy title HIPAA Security Measures revealed that under section Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality integrity and availability of resident's identifiable information and or records that are in electronic format. Under section Policy Explanation and Compliance Guidance #1. Facility leadership will ensure the implementation of policies and procedures to prevent detect contain and correct any security violations. #3. Only appropriate employees will have access to electronic protected health information. #8. Physical safeguards will be implemented that limit physical access to its electronic information systems and the facility of facilities in which their housed, while insuring their properly authorized access is allowed. Observation of the fourth floor East Side Medication Cart conducted on September 16, 2025, at 11:18AM revealed that the medication cart was parked against the wall outside the medication room unattended. Further, the laptop on top of the medication cart was open. Further observation revealed that Resident R207's clinical information was visible to passersby. Review of the facility policy titled, Promoting/Maintaining Resident Dignity undated states, policy-It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Continued review of the procedure revealed. 12. Maintain resident privacy. On September 15, 2025 at 10:53 a.m. an interview was held with Resident R168. Resident R168 talked about how he has made complaints about his roommates being changed while he is in the room and not pulling the curtain and nothing it ever done. A re-visit was completed for Resident R168 on September 15, 2025, at 1:28p.m. and all the residents in the room had just been served their lunch in their room. Observation while exiting Resident R168 room revealed nurse aide Employee E16 going to pull closed Resident R168 curtain and one other roommate's curtain. Observation while outside of Resident R168 room after exiting the room revealed Employee E16 going to change Resident R168's roommate and Employee E16 did not pull the roommates curtain closed. Employee E16 stated, Keep your curtain closed like that Resident R168 and you won't see anything. Interview with Unit clerk, Employee E26 conducted at the time of observation confirmed that the laptop was opened. Further Employee E26 went to look for the nurse who was in-charge of the cart. Follow-up interview with Unit Manager Employee E27 conducted on September 17, 2025, at 11:43AM confirmed that the medication nurse, Employee E28 left the laptop open and unattended on September 16, 2025. 28 Pa. Code 201. 211.5 Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and staff interview, it was determined that the facility failed to maintain a safe, clean, and comfortable environment in a manner that promotes a homelike atmosphere for residents for one of 33 residents reviewed (Resident R1 and Resident R62) and on one of four nursing floors. (Third floor)Findings Include:Review of facility policy titled, Resident Rights undated states that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further review of the policy states that residents have the right to a 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Observations conducted during a tour of the Third Floor on September 15, 2025 at 9:40 a.m. revealed the following: At 10:01 a.m. the Third-floor high side had foul odors of urine and feces. At 10:53 a.m. room [ROOM NUMBER] was observed with a ceiling tile by the window that had two broken corner pieces. The resident's closet doors had a lot of dirt build up. At 10:58 a.m. room [ROOM NUMBER] was observed with several towels that appeared to have been saturated and since have dried. Interview with the Director of Maintenance At 1:07 p.m. room [ROOM NUMBER] was observed with two stained ceiling tiles and the over the bed light for bed B flickering. The third-floor pantry area also had food particles and paper trash between the cabinets and the refrigerator. Observations of Resident R62 at 11:30 a.m., on September 15, 2025, revealed that this resident was in bed looking out the window. Clinical record review for the speech therapy department revealed an assessment dated [DATE], that indicated that this resident had a diagnosis of cerebral vascular accident (stroke) and difficulty communicating. The speech therapist indicated that if questions are phrased for a yes/no response that Resident R62 was able to respond appropriately. Observations of Resident R62's room revealed that her roommate had a television, and it was angled toward the roommate so that she could visualize it. Resident R62 was asked if she could see the only television in the room. The resident shook her head no. Observations of Resident R62's bedroom revealed that this resident had no personal effects or memories as decoration. The recreational therapist reported that Resident R62 had no family visiting or contacting her that the facility staff were aware of. The recreational therapist reported that she would also look into Hispanic music for Resident R62, since this resident was of Hispanic origin. Observations of Resident R1 revealed that this resident was in bed in her room during all days of the survey (September 15 through September 19, 2025). There were no personal effects (pictures of family, places or things) that this resident enjoyed in her room. Clinical record review revealed a psychiatrist progress note dated August 18, 2025, that indicated this resident was awake and alert with fair concentration, judgement and memory. The nursing note dated July 14, 2025, indicated that Resident R1 was alert and oriented. The activities assessment dated [DATE], indicated that it was important for Resident R1 to take care of her personal belongings. The resident was also reporting that it was important to her to have her family involved in her care. The resident said that religious services and her favorite activities were things she wanted to do while living at the facility. Interview with Resident R1 and the licensed nurse, Employee E27, at 10:30 a.m., on September 16, 2025, revealed that the resident would like her daughter, who was her responsible party, to bring in some pictures of the family for her to have in her room as decoration and fond memories. The licensed practical nurse, Employee E27 also said that she was ask Resident R1's daughter for any religious statues or bible for her mother to use for reading and prayer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on observations, facility policy review, and staff interview, it was determined that the facility failed to provide residents with the ability to file grievances anonymously for four out of four nursing units reviewed.Findings Include: Review of the facility policy titled, Grievance Policy dated November 2016 states, The facilities established grievance policy includes: Notifying the resident individually or through posting of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of the grievance official, a reasonable expected time frame for completing review of the grievance, the right to obtain a written decision, the contact of independent entities to whom grievances may be filed (state agency, quality improvement or, state survey agency, state LTC ombudsman). Further review of the facility policy states, The facility Grievance Office is the Social Worker, and is responsible for: Overseeing the grievance process, receiving and tracking grievances to conclusion, leading any necessary investigations, maintaining the confidentially of all information associated with grievances, issuing written grievance decisions, coordinating with state and federal agencies as necessary in light of specific allegations.Observations conducted of the First, Second, Third, and Fourth floor nursing units with the Social Services Director, Employee E16, on September 16, 2025 at 1:49 p.m. revealed that there were no grievance forms accessible to residents, caregivers, or family members to have the ability to form anonymous grievances. When Employee E16 was asked where grievance forms were, she stated, I have the forms in the office, the nurses have them in their office, but residents usually come to if they have a concern. Further observation of the grievance process in the facility revealed there were two grievance mailboxes where residents could turn in their grievance, but the boxes were not locked for privacy. Further observation during the tour revealed that it did not have any posting on the second, third of fourth floor in a prominent location about the right to file grievances in writing anonymously. The posting also did not include the reasons why you would file a grievance at the facility. Review of the facility grievance form provided revealed there was no space to indicate that the grievance was being formed anonymously. Further review of the grievance form revealed there was also no space to check off regarding the right to obtain a copy of the written decision regarding his or her grievance. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(i) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of care and services, reviews of facility policies and procedures, interview with residents and staff, reviews of facility documentation and clinical records, it was determined that the facility failed to ensure that allegations of verbal abuse, mental abuse and physical abuse were reported promptly and thoroughly investigated for three of thirty-one residents reviewed. (Resident R2, Resident R148, Resident R211 and Resident R45) Findings include:A review of the undated policy titled abuse, neglect and exploitation revealed that it was the responsibility of the facility to provide protection for each resident to prohibit and prevent abuse, neglect, exploitation and misappropriation of property.The policy indicated that alleged allegations of abuse (psychological, neglect for the provision of safe care for residents, verbal abuse, misappropriation of property and sudden changes in behaviors such as fear of a person) would be thoroughly investigated immediately. All alleged violations of abuse would be reported to the administrator, state agency, adult protective services and all other required agencies (law enforcement) within specific time frames. An immediate investigation into the possible or alleged abuse would be conducted by the staff responsible for the investigation. The investigation was to include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others. The focus of the investigation was to determine if abuse occurred, to what extent and the cause of the possible abuse. The facility policy indicated that a complete and thorough documentation of the investigation was to be kept on file. A review of the policy titled accident and incidents investigating and reporting dated July 2017 revealed that it was the responsibility of the administrator to ensure that all accidents and incidents involving residents occurring on the premises be investigated and reported.The policy said that the nurse supervisor was responsible to promptly initiate and document the investigation of the incident or accident involving the resident(s). The incident and accident investigation was to include circumstances surrounding the event, names of witnesses and their accounts of the event, the injured persons account of event, response by the attending physician to the event, the condition of the injured person including vital signs, any corrective action taken to prevent the incident from reoccurring and other pertinent data as required. Review of Resident R45's quarterly Minimum Data Set (MDS-an assessment of care needs) dated March 4, 2025, indicated this resident was cognitively impaired. This assessment revealed that this resident had no problems with vision or hearing. The assessment also indicated that Resident R45 required staff assistance to roll side to side, moderate assistance of staff for transfers from bed to chair and chair to bed. Resident R45 had a diagnosis of aphasia (difficulty communicating), cerebral vascular accident (stroke) and anxiety disorder. Review of Resident R148's annual comprehensive MDS dated [DATE], revealed that this resident was confused with disorganized thinking. This resident had no functional upper and lower extremity impairments. Resident R148 was documented as independent with all activities of daily living including ambulation. Review of a psychiatrist note dated July 1, 2025, indicated Resident R148 had a diagnosis of schizophrenia (disease characterized by loss of reality contact) and on-going behavioral health issues of aggressive and threatening behavior toward others, masturbation in public areas, screaming and yelling throughout the day that was anxiety provoking for the other residents. Clinical record review revealed a nursing note dated February 22, 2025, that indicated a nursing assistant, Employee E30, observed Resident R148 proceed to get on top of Resident R45, while Resident R45 was supine in bed. The licensed nurse, Employee E29, noted that Resident R45 had a frightened look on his face about Resident R148 attempting to get on top of him. Clinical record review revealed a psychiatrist evaluation dated March 3, 2025, that indicated Resident R148 made an effort to get on top of Resident R45. Resident R45 was in bed in a supine position. The psychiatrist documented that Resident R45 was fearful and confused because of Resident R148's behavior of trying to get on top of him, while he was lying on his back in bed. Interview with Registered nurse, Employee E28, at 10:00 a.m., on September 18, 2025, revealed that she was working on the seven to three shift during the occurrence of the incident on February 22, 2025; where Resident R148 proceeded to get on top of Resident R45. Registered nurse, Employee E28 reported that although she was working when the incident happened; she was not asked to give a statement related to the circumstances of the event. Employee E28 reported that Resident R45 was afraid and fearful of Resident R148. Registered nurse, Employee E28 stated that Resident R45 was not capable of physically defending himself or speaking to staff about Resident R148, since he had a diagnosis of dysphagia (difficulty swallowing). Registered nurse, Employee E28, reported that her assessment of Resident R45 on February 22, 2025, was that this resident was scared and fearful of Resident R148. Employee E28 reported that a room change for Resident R45 took place after the incident with the roommate Resident R148, so that Resident R45 was not a victim of sexually inappropriate behavior or physical injury by the roommate Resident R148. The registered nurse, Employee E28 confirmed at 10:15 a.m., on September18, 2025 that the nursing assistant, Employee E30, found Resident R148 climbing into bed with Resident R45. The licensed nurse, Employee E29 documented on February 22, that when she asked Resident R148 why he was getting into bed with Resident R45, he replied Leave me alone! Get out of my face!''The possible emotional or psychological abuse of Resident R45 by Resident R148 was not reported to the State Survey Agency as required. Written statements were not taken from all staff responsible for the care of these residents on February 22, 2025. Resident statements were not recorded about the possible emotional or psychological abuse exhibited by the aggressor, Resident R148 on February 22, 2025. Review for Resident R211's quarterly MDS assessment dated [DATE], indicated that this resident had no functional limitations with upper or lower extremity range of motion. The assessment also indicated that this resident was independent with ambulation and transfers bed to chair/ chair to bed. The assessment indicated that Resident R211 was alert and oriented with diagnoses of seizure disorder and attention deficit hyperactivity disorder. Review of Resident R148's annual comprehensive MDS dated [DATE], that indicated this resident had no functional impairments of the upper or lower extremities. The assessment indicated that the resident was independent with activity of daily living, including ambulation. The assessment said that this resident had a diagnosis of anxiety disorder, depression and schizophrenia (mental disease of the brain characterized by lost of reality).Review of nursing documentation revealed that on May 18, 2025, Resident R148 was found in a physical altercation with Resident R211. The residents were in the hallway, and the nursing assistant was yelling, no wait, don't do that. Resident R148 was seen using his hand and forcefully hitting Resident R211 in his face multiple times. The licensed nurse documented that she observed Resident R211 fall to the floor; after being punched and during the fall the resident hit his head on the handrailing wall. The licensed nurse assessed Resident R211 post fall and on May 18, 2025. The licensed nurse documented that she gave advice to Resident R211 post fall with hitting his head on May 18, 2025. The licensed nurse's recommendation to Resident R211 was that he would consent to be evaluated further at the hospital. The nurse documented that the resident refused to go to the hospital. The possible physical abuse for Resident R211 was not completely investigated and reported to the State Survey Agency as required. Written statements were not available for review from residents living on the west wing (A, B, C) nursing unit where the incident on May 18, 2025, took place. The administrative staff failed to determine the causative factor of the incident that occurred on May18, 2025 and put care plan measures in place to prevent further occurrences of physical aggression and injury for Resident R211. Clinical record review revealed a psychiatrist progress note on May 19, 2025, that indicated Resident R211 reported that he does not like the way Resident R148 speaks to the nurse. Interview with the registered nurse, Employee E28, at 11:00 a.m., on September 18, 2025, revealed that Resident R148 speaks disrespectful to the nursing staff frequently. The registered nurse also said that Resident R148 makes derogatory sexual comments to the nursing staff as well. Interview held with Resident R2 after holding resident council on September 17, 2025 at 10:49 p.m. The resident want to talk privately about a resident (R148) that on Monday night September 15 she had been verbally attacked and threatened by Resident R148. Resident R2 stated that on Monday, he threatened me saying, B****, m***** f*****, I'll punch you in your face, I'm going to kick your a**, if I catch you on the first floor I will punch you in the face. Resident R2 stated that this happened on the first floor by the lunchroom. When asked if anyone else witnessed what happened she stated the man who handles the money came out. Resident R2 reported that she filled out a grievance with a male staff, but when she asked for a copy of the grievance she got upset because he did not write everything down that she stated. She stated that since then no one has come to talk with her.Interview held with Employee E18 who stated he was the nursing supervisor on shift from 3 p.m.-11p.m. shift on September 15, 2025. Employee E18 stated that Resident R2 did come to him and complained something about Resident R148. When asked about specifics, he stated he could not remember. When shown the incomplete grievance form, Employee E18 stated that was the grievance form he filled out for Resident R2. When asked where he got the grievance form, he stated from my office. When asked where he took the form after filling it out, Employee E18 stated he slid it under the social service office door.On September 17, 2025 at 2:33 p.m. an interview was held with the Director of Social Services Employee E19 was interviewed and stated there was no grievance form found or submitted on or after September 15, 2025 for Resident R1. When asked where the original grievance form was, Employee E19 stated, we don't know, we do have a copy of the grievance form from Resident R1 and nursing is completing the form and starting the investigation now.On September 17, 2025 at 3:10 p.m. an interview was held with business office worker Employee E20. Employee E20 did confirm that he was a witness to Resident R148 verbally attacking Resident R2. He stated I hear some loud noise, but didn't think anything of it at first then I heard R2 yelling. I came out and Resident R148 was cursing at Resident R2. When Employee E20 was asked if he could remember anything specific he stated, yes, Don't let me catch you down here again. When asked if he told anyone Employee E20 stated yes Employee E18. 28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18(b)(1) Management28 PA. Code 211.10(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documentation, and interview with staff it was determined that the facility did not notify the state mental health authority or state intellectual disability authority, promptly after a significant change in the mental condition for three of thirty-three residents reviewed. (R4, R53, R56).Findings Include: Review of Resident R4's psychiatry note from September 2, 2025 stated, [Resident R4] with noted history of schizoaffective disorder in electronic health records system and past psychology note. Resident R4 does not answer appropriately assessment questions and is a poor historian. [Resident R4] was previously prescribed Haldol, but medication was discontinued in 2024, after discontinuation, pt displayed no signs of psychosis. [Resident R4's] medical record includes no documentation confirming schizoaffective diagnosis. This patient does not meet DSM-5 criteria for schizoaffective please remove diagnosis. Continued review of the resident's record revealed no further communication with the state mental health authority. Review of Resident R53's psychiatry progress note from August 19, 2025 stated, attempted to evaluate to confirm Schizoaffective diagnosis due to limited background information being available in medical records. Resident does not answer appropriately assessment questions and is a poor historian, unable to give an accurate diagnostic history. Unable to locate history information in chart or medical records to confirm diagnosis. Resident does have a history of mood swings, anger and irritability per past evaluation. Discussed with RNAC (Registered Nurse Assessment Coordinator), will remove diagnosis. Continued review of the resident's record revealed no further communication with the state mental health authority. Review of Resident R56's progress note from September 2, 2025 stated, Resident seen today for a follow up visit related to previous Schizophrenia diagnosis. Resident received today in room, seated in wheelchair watching television. Resident currently denies feeling depressed or anxious. He denies history of Schizophrenia. The resident was admitted with a diagnosis of Schizophrenia but currently denies diagnosis, also denies ever utilizing psychotropic medications. This resident does not meet DSM-5 criteria for Schizophrenia, please remove diagnosis. Interview with the Director of Social Services Employee E19 on September 18, 2025 at 1:33 p.m. revealed the facility did have an audit and has been working on completing new PASSAR ( Pre-admission Screening and Resident Review ) forms and contacting the state mental health authority. 28 Pa Code 201.14 Responsibly of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that a person-centered care plan was developed related to oxygen and PTSD (post-traumatic stress disorder) for two of 33 residents reviewed (Resident R11 and Resident R19) Review of facility's undated policy on Comprehensive Care Plan revealed that under section Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Section Policy Explanation and Compliance Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed.2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Observation conducted on September 16, 2025, at 10:32 AM revealed that an oxygen concentrator was on Resident R11's bedside. Further observation revealed that the oxygen concentrator was not on. Interview with Resident R11 conducted at the time of the observation revealed that he only uses it at night for apnea. Review of Resident R11's clinical record revealed that Resident R11 was admitted to the facility on [DATE]. Further, Resident R11's diagnoses were but not limited to COPD (chronic obstructive pulmonary disease- a group of lung diseases that block airflow and make it difficult to breath). Review of physician's orders revealed an order for Apply oxygen (continuously) at 1liters/minute via NC (nasal canula) every shift for SUPPLEMENTAL -ordered 8.20.25 Review of Resident R11's Quarterly MDS (Minimum data set a federally required resident assessment completed at a specific interval) dated August 27, 2025, section O0110 (Special Treatments, Procedures, and Programs), C1. revealed that Oxygen therapy was coded yes. Further review of Resident R11's clinical record revealed that no person-centered care plan for oxygen was developed and implemented. Review of Resident R19's clinical record revealed the residents diagnoses of diagnosis of Post Traumatic Stress Disorder (PTSD- a mental condition that can developed after experiencing and/or witnessing a traumatic event)).Review of Resident R19's Quarterly MDS dated [DATE], section I0020 revealed that Resident R19 had a diagnosis of Post Traumatic Stress Disorder (PTSD).Review of Resident R19's care plan revealed that no person-centered care plan for PTSD was not developed and implemented. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing service

Based on observation, staff interview, and clinical record review, it was determined that the facility failed to ensure that a medication label was accurate for one of (Resident R3).
Findings include:
Review of Resident R3's April 2026 physican orders revealed an order dated March 19, 2025, for Potassium Chloride Liquid 20 MEQ/15ML (10%), Give 20 mEq via PEG-Tube one time a day for Hypokalemia (low Potassium Levels)
Observation conducted of the label on the medication for Potassium Chloride revealed Potassium Chloride Liquid 20 MEQ/7.5 ML.
On April 28, 2025, at 10:31 a.m., interview with the Director of Nursing revealed that the Pharmacy wrongly labelled the dose of Potassium Chloride Liquid 20 MEQ/15ML (10%), for R3 as to administer 7.5 ML, instead of 15 ML.
28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of clinical records, interviews with staff, and facility policy, it was determined the facility failed to provide treatment and services in accordance with professional standards of practice related to a failure to conduct routine testing to verify therapeudic levels of a seizure medication. The facility failed to clarify the orders when a medication for epilepsy was decreased in error, and failed to inform the physician of a recommended psychotropic dose increase for one of 33 resident records reviewed. (Resident R46 )
Findings included:
Review of the facility's policy, Medication and Treatment Orders revised October 2016 states, Orders for medications and treatments will be consistent with principles of safe and effective order writing .
Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented capable of making independent decisions, diagnosed with epilepsy, (a chronic brain disorder that causes seizures) and hemiplegia (one sided weakness) affecting the right dominate side. The resident was assessed as independent in all activities of daily living (ADL), including walking, and transferring and was continent of bowel and bladder.
On admission, dated October 23, 2024, Resident R46 was ordered Depakote (used to prevent seizures and for certain psychiatric conditions) instructed to give three, 125 milligrams (mg) tablets of Depakote (equally 375 mg), twice a day (daily total of 750 mg ) for the resident's diagnosis of Epilepsy.
Review of Resident R46's care plan dated October 24, 2024, for the resident's diagnosis of seizures stated seizure medications will be maintained at therapeutic levels with interventions that include to obtain and monitor labs/diagnostics work.
Review of Resident R46's nursing note dated June 3, 2024, stated the resident was seen by psychology and the resident's Depakote increased from 125mg to 250mg twice a day. This order was not clarified, instead the dose was decreased, now receiving 250 mg twice a day to equal 500 mg daily. The new order was administered from June 4, 2024, to June 17, 1014. On June 18, 2024, the Depakote was increased back to the original dose of 750 mg a day.
On December 18 and 19, 2024 the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked what the facility's policy/protocol was for testing residents' Depakote levels. The NHA and DON failed to answer nor provide documentation. During the same time the NHA and DON were questioned as to why Resident R46's Depakote was lowered by psychiatry, when the resident was taking the medication for epilepsy not for a mental illness. The NHA and DON failed to answer, nor provide supporting documentation.
Further review of Resident R46's clinical records revealed Depakote levels were tested on admission, dated, October 23, 2023, no further documented evidence therapeutic levels were tested prior to lowering the dose on June 4, 2024.
On October 22, 2024, psychiatric note indicated Resident R46's order for Risperdal (an antipsychotic medication) be increased to 1 mg due to the resident's increased paranoia and aggression. Surveyor requested and the NHA confirmed there was no documented evidence the physician was made aware of this recommendation and the dose was not increased.
During an interview with the psychiatrist on December 19, 2024, at 12:00 p.m. confirmed the dose of Depakote should not have changed. The psychiatrist explained it was to simplify the number of pills given to the resident at one time, from three-125 mg of Depakote twice a day to one 250 mg pill in the morning and 2- 250 mg pill in the evening. The psychiatrist indicated Depakote levels should be done every six months to ensure they are at the therapeutic levels for residents taking the medication for seizures. During the same interview it was also confirmed the recommended increase in Risperdal to 1 mg was not completed.
28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for two of 36 residents reviewed for limited range of motion (Resident R7 and Resident R37).
Findings include:
Observation conducted during the tour of the second-floor unit on December 16, 2024, at 9:34 am revealed that Resident R7 was in bed with his left arm in a fixed position on his chest.
Review of Resident R7's clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of but not limited to Paraplegia, Multiple Sclerosis, Acquired Absence of Right and Left Leg, Muscle Weakness, Contractures of Muscles Multiple Sites.
Review of Resident R7's quarterly MDS (Minimum Data Set, a federally required assessment completed at a specific interval) dated October 7, 2024 section GG0115 (Functional Limitation in Range of Motion), revealed that A. Upper extremity (shoulder, elbow, wrist, hand) was coded 1 indicating that resident R7 had impairment on one side, B. Lower extremity (hip, knee, ankle, foot) was coded 2, indicating that Resident R7 had impairment on both sides
Review of occupational therapy notes revealed that resident was receiving occupational therapy services from November 25, 2024, through October 11, 2024, with discharge recommendations to continue with previously established splinting.
Review of Resident R7's clinical record revealed the following previously established restorative nursing program:
Nursing Maintenance Program- Passive ROM (range of motion) in all planes 2 x15 as tolerated to prevent further joint stiffness daily dated 12/19/23
Nursing Maintenance Program-Don bilateral resting hand splint 2 hour/day with skin checks pre/post, and hygiene performed before and after as tolerated-dated 8/9/24
Nursing Maintenance Program-Resident will wear left hand palm protector with finger separators for 3 hours/day. assess [NAME] at donning/doffing and provide hygiene daily as tolerated dated 12/3/23
Nursing Maintenance Program-Splinting- Patient to tolerate left elbow extension splint for 2 hours/day with skin checks pre/post as tolerate-dated 8/12/24
Further review of Resident R7's clinical record revealed no documented evidence that restorative nursing program/splinting was provided to Resident R7.
Interview with ADON (assistant director of nursing) Employee E9 conducted on December 19, 2024, at 10:57 a.m. confirmed that there was no documentation indicating that that restorative nursing program/splinting was provided to Resident R7.
Review of Resident R37's clinical record revealed that Resident R37 was originally admitted to the facility on [DATE], with the most recent readmission date of November 19, 2023. with diagnoses of CVA (Cerebrovascular Accident-stroke) Hemiplegia/Hemiparesis (paralysis/weakness of one side of the body), Muscle weakness, Contracture of unspecified joint.
Review of OT (Occupational Therapy) Discharge summary dated [DATE], revealed a recommendation for: Restorative Splint and Brace Program. Resume prior RNP (Restorative Nursing Program) for daily management with skin checks pre and post.
Review of Resident R37's clinical record revealed the following previously established restorative nursing program:
Nursing Maintenance Program Ambulation with Hemi walker with +1 contact guard assistance/min for 20-30 feet with wheelchair follow as tolerated to be completed daily. Ensure resident wears appropriate footwear or nonskid sock, allow to take time or breaks as needed. Dated November 30, 2023
Nursing Maintenance Program-Apply left hand splint during the nighttime hours as tolerated to decrease stiffness. Inspect skin before and after application.
Review of Resident R37's care plan initiated on November 20, 2023, revealed the following: Resident R37 will wear a left-hand splint for 6 hours a day, Splint to be applied at 10 p.m. and removed at 4 a.m, Nursing to assess residents' skin at the time of application and removal of the brace for alterations in skin integrity and provide hygiene-Dated December 3, 2023
Nursing Maintenance Program-Left resting hand splint don in am and doff in pm (at least 4 hours) with skin checks before and after application. refer to PT/OT as needed-Dated December 3, 2024
Further review of Resident R37's clinical record revealed that there was no documented evidence that the previously established Restorative Nursing Program or Nursing Maintenance Program was reinstated and provided to Resident R37.
Interview with ADON (Assistant Director of Nursing) conducted on December 29, 2024, at 10:58 am confirmed that there was no documented evidence that Restorative nursing/splinting was provided to Resident R37
Observation conducted during the tour of the second-floor unit on December 17, 2024, at 11:05 am revealed that Resident R37 was in bed with her left arm on her side.
Follow-up observation on Resident R37 conducted with Director of Rehab, Employee E10 on December 18, 2024, at 1:36 pm revealed that Resident R37 was in the hall way of the second floor unit, sitting on a wheelchair. Further, Resident R37's left upper and lower extremities were limp.
Interview with Employee E10 confirmed that Resident R7 had a left sided hemiplegia.
Interview with Resident R37 in the presence of Employee E10 conducted at the time of the observation revealed that no one puts her and that she is not able to put it in on on her own. Upon further interview with Resident R37, she revealed that sometimes one of the staff will put it on her at night.
Observation of Resident R37's room together with Employee E10 revealed that there were no splints in her drawers, bed side table or anywhere in her room. Employee E10 stated that she will get Resident R37 a new pair of splints.
28 Pa Code 211.10(d) Resident care policies
28 Pa. Code 211.12 (d)(1)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policy,and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to Resident R46's diagnosis of physical aggression, paranoia, insomnia and Resident R170 needing oxygen therapy for two of 33 resident records reviewed
Findings include:
Review of the facility policy titled, Comprehensive Care Plan, dated November 2019, states, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented capable of making independent decisions, diagnosed with epilepsy, (a chronic brain disorder that causes seizures) and hemiplegia (one sided weakness) affecting the right dominate side. The resident was assessed as independent in all activities of daily living (ADL), including walking, and transferring and was continent of bowel and bladder.
Review of Resident R46's nurses' notes dated, May 2, 2024, indicated a verbal altercation between both residents. Resident R46 was heard yelling from bathroom door to Resident R112, cursing and threatening the resident, saying he would, 'Beat you the f-k up,' and 'You don't know me'. Resident R46 was asked to close the door and calm down.
Weekly nursing note dated June 3, 2024, states, Resident R46 frequently screams and curses at roommate related to shared bathroom.
Review of facility documentation and resident's witness statement revealed on October 12, 2024 Resident R46 was seen to push Resident R112 and hit him/her with his/her cane. This caused Resident R112 a hematoma to the back of his head, a laceration to the front, and a fractured finger.
Review of Resident R46's psychiatric note dated October 22, 2024, noted the physical aggression towards another resident. The note further stated that the resident was paranoid and suspicious, and that the resident stated, People been watching my moments too much and I don't like it. The same note, listed medications Trazadone and Melatonin given for insomnia and Risperdal an antipsychotic given for unspecified psychosis.
Further review of Resident R46's clinical record revealed no evidence a care plan was developed for the resident's physical aggression, paranoia and suspicious behaviors, including the May 2, 2024, and October 12, 2024 altercation with Resident R112. Furthermore, the facility failed to develop a care plan for Resident R46 for the diagnosis of insomnia and taking an antipsychotic medication for his diagnosis of psychosis.
Observation conducted on December 16, 2024, at 11:15 am during tour of the second-floor unit revealed that Resident R170 was in bed awake. Further observation revealed that Resident R170 was on oxygen concentrator via nasal cannula running at 2 liters per minute.
Interview with Resident R 170 at the time of the observation revealed that she did not know when her oxygen was started. Further Resident R170 did not provide any more information during the interview.
Review of Resident R170's clinical record revealed that Resident R170 was admitted to the facility on [DATE], with diagnoses of Anemia and Acute Myeloblastic Leukemia (cancer of the blood and bone marrow).
Further review of Resident R170's clinical record revealed a physician's order for 2 liters of oxygen as needed for SOB (shortness of breath) - ordered December 15, 2024.
Further review of Resident R170's clinical record revealed that there was no care plan develop to address Resident R170's shortness of breath and the need for oxygen use.
Interview with ADON (Assistant Director of Nursing) Employee E9 conducted on December 18, 2024, at 2:43 pm confirmed that there was no care plan for respiratory or oxygen use developed for Resident R170.
Refer to F600
28 Pa. Code 211.10 (c) Resident care policies.
28 Pa. Code 211.10 (d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, observation, facility documentation and interviews with staff, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards, and failed to ensure that hazardous material were not accessible to a resident in one nursing unit of one of three nursing units. (Third floor)
Findings include:
Review of Resident R575's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis' including opioid dependence with withdraw, other psychoactive substance dependence, homicidal ideations, nicotine dependence with withdrawal, homelessness, and suicide attempt.
Review of MDS (minimum data set, assessment of resident care needs) for Resident R575 dated December 11, 2024, revealed that the Resident R 575 had a BIMS (brief interview for mental status) score of 15 which indicated the cognitive status of the resident was intact.
Review of hospital record for Resident R 575 dated November 7, 2024, revealed the Resident reports that he had head injury in 1995 and report significant anger issues. The resident has a history of suicide ideation, homicide ideation, opioid use disorder spent most of his life in prison.
Review of care plan for Resident R 575 dated December 5, 2024, revealed the resident was noted with a history of suicide attempt. Interventions included to allow the resident to express feelings and offer support, consult psychology, the door to residence room to be left open, items with resident could harm self to be removed from resident's room, residents be maintained on every hour check, and resident will use plastic utensils during meals. Also included in the intervention is a tap bell (no cords attached) given in place of call bell light for safety.
Observation of Resident R575 on December 18, 2024, at 11:50 a.m. revealed Resident R575 standing in the doorway of the resident's room with 2 razors in hand.
Interview with Resident R575 at time of above observation revealed that razors were found in the bathroom, set on the sick, they were left by Employee E4 nursing assistant.
Interview with Employee E4, nursing assistant on December 18, 2024 confirmed that this employee accidently left the razors in the bathroom.
Interview with Director of Nursing (DON), Employee E2 and administrator and Employee E1 on December 18, 2024, at 2:10 p.m. confirmed Resident 575 has history of behaviors and has care intervention in place for prevention of harm. DON confirmed that the resident should not have had access to razors.
28 Pa. Code 211.10(d) resident care policies
28 Pa. Code 201.14(a) responsibility of licensee
28 Pa. Code 211.18(b)(1) management

Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined the facility failed to ensure a medication were administered with adequate indications for use and monitoring for two of 33 resident clinical records reviewed (Resident R46 and R83).
Findings include:
A review of the policy titled antipsychotic medication use dated December 2016 revealed that the antipsychotic medications would be prescribed by the physican at the lowest possible dosage for the shorest period of time. The policy also indicated that psychotropic medications were to be evaluated by the physician for gradual dose reduction routinely. The policy said that residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated. The policy indicated that the need to continue as needed orders for psychotropic medications beyond 14 days required that the physician document the rationale for the extended order.
Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented capable of making independent decisions, diagnosed with epilepsy, (a chronic brain disorder that causes seizures) and hemiplegia (one sided weakness) affecting the right dominate side. The resident was assessed as independent in all activities of daily living (ADL), including walking, and transferring and was continent of bowel and bladder.
Review of Resident R46's physician orders instructed to give 3 milligrams (mg) of Melatonin dated August 13, 2024, and 50 mg of Trazodone dated October 24, 2023, to be given at night for insomnia.
Further review of Resident R46's clinical record revealed the resident did not have a diagnosis of insomnia.
Clinical record review revealed a quarterly MDS assessement dated September 22, 2024 that indicated Resident R83 had severe cognitive impairment and diagnoses of anxiety disorder, psychotic disorder and schizophrenia. The assessment also indicated that this resident was receiving antianxiety medication and antipsychotic medication.
Clinical record review for Resident R83 revealed a psychiatrist's note dated December 5, 2024 that indicated that Resident R83 had diagnoses of schizophrenia, anxiety disorder and psychosis.
Clinical record review revealed the physician had an order dated May 2, 2024 for Lorazepam (antianxiety agent) .5 mg orally every four hours as needed for anxiety disorder.
Clinical record review revealed that there was no documentation to indicate the rationale for the continued use of an as needed psychotropic medication, Lorazepam, beyond 14 days for Resident R83. There was no clinical record documentation to indicate the duration that the antianxiety medication was to be used.
Interview with Licensed nurse, Employee E17, at 9:30 a.m., on December 19, 2024 confirmed that there was no clinical record documentation, as required for the rationale and extended use of the psychotropic medication, Lorazepam for Resident R83.
Clinical record review for Resident R83 revealed that the physician had an order dated Setember 4, 2024 for Depakote sprinkles (anticonvulsant medication) 125 mg twice a day for behavior for Resident R83. Clinical record review also revealed that a valporic acid blood level (used to determine that effectiveness of therapy of the drug depakote) had been obtained and documented as below normal range of 50 to 100 micrograms per milliliter at 16.2 micrograms per milliliter for Resident R83 on October 29, 2024. There was no clinical record documentation to indicate that the laboratory study had been reviewed with the physician to ensure adequate monitoring of the drug use and that an acceptable blood range was acheived for Resident R83.
Clinical record review for Resident R83 revealed that the physician had an order dated Setember 4, 2024 for depakote sprinkles (anticonvulsant medication) 125 mg twice a day for behavior for Resident R83. There was no clinical record documentation to indicate the physican had prescribed the medication depakote with adequate indication for its' use. The drug depakote was used pharmacologically for the treatment of bipolar polar disorder, epilepsey or migraine headaches.
Interview with licensed practical nurse, Employee E17, at 9:45 a.m., on December 19, 2024 confirmed that there was no clinical record documentation to indicate that depakote (an anticonvulsant medication) was being used with adequate monitoring or with an adequate indication for use for Resident R83.
28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interview, it was determined that the facility failed to obtain a laboratory study as ordered by the physician for one of 33 clinical records reviewed. (Resident R158)
Findings include:
Clinical record review for Resident R158 revealed a diagnosis of obesity (overweight with excess body fat). Resident R158 was 68 inches in height and weighed 231 pounds indicating a weight of 25% above the ideal body weight of 154 +/- 10%.
Clinical record review for Resident R158 revealed a quarterly MDS dated [DATE] that indicated that this resident was at high risk for pressure sore development and had moisture associated skin damage.
Clinical record review for November 13 and 15, 2024 revealed that the physician had ordered laboratory studies of the blood to review the metabolism of albumin (a blood test to determine nutritional deficiencies and measure liver and kidney function) and thyroid (a gland that controls metabolism which effects how your body uses energy, regulates body temperature, blood pressure and heart rate) function for Resident R158. There was no clinical record documentation to indicate that these tests were completed as ordered by the physician for Resident R158.
Interview with the Licensed nurse, Employee E17, at 10:00 a.m., on December 19, 2024 confirmed the lack of following the physician's orders for laboratory testing on November 13 and 15, 2024 for Resident R158.
28 Pa Code 211.12(d)(1) Nursing services

Based on clinical record reviews, interviews with residents and staff, reviews of policies and procedures and food committee meeting minutes, it was determined that for eight of nine residents reviewed, the facility failed to ensure that suitable and nourishing snacks were provided for the residents who wanted to eat at non-traditional times, outside of the scheduled meal service schedule. (Residents R111, R23, R476, R95, R145, R133, R162 and R167).
Findings include:
A review of the facility policy titled the serving of between meal and bedtime snacks dated September, 2010 revealed that it was the facility's responsibility to provide each resident with adequate nutrition. The policy indicated that bedtime snacks were to be placed on the overbed table or serving area for each resident. Nursing staff were responsible for positioning all residents so that the bedtime snack was easily reachable. Each resident was to be placed in upright position. All residents were to receive assistance with eating their bedtime snacks (foods and beverages) as necessary, by the nursing staff.
A group meeting held at 10:30 a.m., on December 17, 2024 with alert and oriented Residents (R111, R23, R476, R95, R145, R133, R162 and R167) revealed that these residents were able to verbally express their nutritional preferences and needs. During the meeting it was the residents consensus that they were not being routinely offered nourishing snacks (foods or beverages) at bedtime.
Clinical record review for Residents (R111, R23, R476, R95, R145, R133, R162 and R167) confirmed that all of these residents were all alert and oriented and able to express their nutritional needs to staff.
Clinical record review for resident R111 revealed an annual comprehensive assessment MDS (an assessment of care needs) dated September 16, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R23 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 28, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R476 revealed an admission comprehensive assessment MDS (an assessment of care needs) dated December 9, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R95 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 15, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R145 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 9, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R133 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated September 6, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R162 revealed an annual comprehensive assessment MDS (an assessment of care needs) dated October 8, 2024 that indicated this resident was cognitively intact.
Clinical record review for Resident R167 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated September 24, 2024 that indicated this resident was moderately cognitively impaired.
Observations at 9:00 a.m., on December 18, 2024 of the medication rooms on the first floor nursing units revealed that the dietary department had provided bulk snacks at 6:00 a.m., for the residents. Licensed nursing staff, Employees E16 and E17 reported at 10:00 a.m., on December 18, 2024 that they would use the bulk snacks in the medication rooms for the residents during the 7-3 shift, if the residents requested a snack. The licensed nurses also reported that they were unaware if the 3-11 nursing staff were offering all the residents a bedtime snack routinely.
Clinical record review for Residents (R111, R23, R476, R95, R145, R133, R162 and R167) revealed a lack on consistent and complete documentation to indicate that staff members responsible for offering and assisting residents with bedtime snacks (food and beverages) were completing this task.
A review of the food committee meeting minutes for November 14, 2024 revealed that a resident that was in attendance at this meeting had voiced concerns about the between meals and bedtime snacks. The resident said that she was not offered between meals and bedtime snacks frequently, as care planned.
28 Pa. Code 201.18(b)(3) Management

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Findings include:
Review of facility policy, Ware washing, revised February 2023 indicated that the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.
An initial tour of the main kitchen was conducted on December 16, 2024, at 9:38 a.m. with the Food Service Director (FSD), Employee E11. Interview with Employee E11, revealed that the facility dish machine is operating as a low temperature machine, primarily relying on chemical sanitation.
Observations at 8:45 a.m. revealed dietary staff, Employee E13 and Employee E14, were starting the dishwasher to clean dirty dishware. Employee 13 and Employee 14 completed two loads of dirty dishes and stored them to dry. Further observations revealed that a test load of dishes was not conducted and the sanitizer testing strip to test the concentration of the final rinse waster was not utilized.
Review of facility documentation, Dish machine log for the month of December 2024 revealed that the machine was tested at breakfast, lunch, and dinner on December 13th through the 15th by the Dietary Assistant, Employee E12.
Observations of Dietary Assistant, Employee E12 testing the chemical dish machine revealed that Employee E12 utilized incorrect test strips, QAC QR test strip, which are used to measure the concentration of Quaternary Ammonium Compounds in a solution. Observations revealed that the strip did not change color and remained light green, indicating 0 parts per million (ppm).
Follow up interview with Dietary Assistant, Employee E12 revealed that Employee E12 utilized the QAC QR test strips each time when completing the Dish Machine Log, and that she is unsure if this is the proper sanitation procedure.
Interview with the FSD at 10:00 a.m. revealed that chlorine test strips are to be used to measure the concentration of chlorine in the sanitizing dishwasher solution and confirmed that Employee E12 did not use the correct test strips during observations. Further interview confirmed that proper sanitation practices for food safety were not followed.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, staff interviews, and review of clinical records, it was determined this facility failed to establish and maintain enhanced barrier precautions for one resident of eight resident reviewed (Resident R15).
Findings include:
Review of the CDC Center for Disease Control and Prevention title enhanced barrier precaution and skilled nursing facilities dated November of 2022, revealed that enhanced barrier precautions (EBPS) in addition to standard precautions, are utilized to prevent the spread of multi drug resistant organisms to residents. Enhanced barrier precautions employees targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity as opposed to before entering the room. All protective equipment is changed before caring for another resident. Example of high contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions include dressing, bathing, transferring, providing hygiene, changing linen, changing briefs, device care (urinary catheter, feeding tube, ventilator, tracheotomy), and wound care.
Signs are posted on the door or wall outside the resident's room indicating high contact resident care activities that require the use of gowns and gloves.
Review of quarterly MDS (minimum data set assessment of resident care needs) for Resident R15 revealed Resident R15 was admitted into the facility November 13, 2012, then again readmitted [DATE] with diagnoses including Parkinson's disease (progressive disease of the central nervous system), dyskinesia (difficulty with voluntary movement), anxiety, bipolar disorder (condition in which a person has periods of depression and period of being extremely happy), muscle wasting, and dysphasia (difficulty swallowing). Further review of this MDS revealed that Resident R15 require enteral nutrition (food delivered through tube feeding).
Review of Resident R15's care plan dated November 4, 2024, revealed Resident R15 requires tube feeding related to gastrostomy status with goals including tube insertion site will be free of signs and symptoms of an infection. Further review of the care plan revealed interventions that include to monitor, document, and report any signs or symptoms of aspiration or fever.
Observation of Resident R15, door entering the resident room revealed a sign that stated, STOP, Enhanced Barrier Precautions, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and gown for the following high contact resident care activities dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, to voice care such as central line urinary catheter, feeding tube, tracheotomy, and wound care.
Observation of Resident R15 on December 18, 2024, at 11:51 a.m. revealed that nurse aide, Employee E6 was providing incontinence care to Resident R15. Employee E6 was viewed as only wearing gloves, no gown was seen.
Interview with nursing aide, Employee E6 on December 18, 2024, at 12:00 p.m. confirmed that this employee was aware of the enhanced barrier precaution instructed and did not follow the proper procedure of wearing a gown.
28. Pa Code 211.12(d)(1)(5) Nursing services
28 Pa. Code 201.14(a) Responsibility of licensee

Based on interviews with staff, review of clinical records, and facility documentation, it was determined the facility failed to protect Resident R112 from Resident R46 who had a history of verbal aggression towards Resident R112. This failure resulted in actual harm to Resident R112 who sustained a closed head injury and a fractured right finger when Resident R46 became physically violent towards Resident R112 for two of 33 resident records reviewed. (Resident R112 and Resident R46)
Findings include:
Review of Resident R46's quarterly MDS assessment (Minimum Data Set, assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented, capable of making independent decisions, diagnosed with Epilepsy, (chronic brain disorder that causes seizures) and Hemiplegia (one sided weakness) affecting the right dominate side. The resident was assessed as independent in all activities of daily living (ADL), including walking, and transferring and was continent of bowel and bladder.
Review of Resident R112's quarterly MDS assessment, dated August 15, 2024, assessed the resident with severe cognitive impairment, diagnosed with Schizophrenia (chronic mental disorder) and Dementia (progressive degenerative disease of the brain). The resident was occasionally incontinent of urine and frequently incontinent of bowel, used a walker for ambulating and needed supervision with activities of daily needs.
Review of Resident R112 care plan dated May 11, 2021, revealed a care plan developed for incontinence care and Activities of Daily Living. The resident was care planned for requiring staff assistance when needed.
Review of Resident R46's nurses' notes dated, May 2, 2024, indicated a verbal altercation occurred between Residents R46 and R112. Resident R46 was heard yelling from bathroom door to Resident R112, cursing and threatening the resident, saying he would, 'Beat you the f-k up,' and 'You don't know me.' Resident R46 was asked to close the door and calm down, and social services was notified.
Review of written statement taken by Social Services during an interview with Resident R112 and Resident R46 dated May 2, 2024 revealed, Resident R112 said [he/she] called the resident the N word because [Resident 46] kept yelling about the toilet. Resident R46 said [he/she] got into an argument because [he/she] keeps leaving the toilet clogged. When Resident R46 told the resident about it, Resident R46 said [he/she] was called the N word.
Review of weekly nursing note dated June 3, 2024, states, Resident R46 frequently screams and curses at roommate related to shared bathroom.
Review of Resident R112's nursing note dated October 12, 2024 revealed the nurse aide called this nurse around 6:10 a.m. and reported the resident is bleeding from [his/her] head and resident stated that a black guy hit [resident] on [resident] head. This nurse immediately responded and found resident sitting in a chair in front of [his/her] room bleeding from [his/her] head. Nursing supervisor made aware. Upon assessment laceration noted on the top of the head, on the middle of the head and also a laceration noted on the back of [his/her] head with hematoma. Resident also both with a small cut and a swollen and bruised right pinky finger. Resident is alert and awake with some period of confusion, able to make need known with no loss of consciousness. The resident was asked if he/she fell and the resident denied falling. This writer asked resident what happened and resident stated that [he/she] was coming out of the bathroom and a black guy hit [him/her] on [his/her] head with a cane. The physician was notified and order to send resident to the emergency room for evaluation.
Review of information dated October 12, 2024 submitted by the facility on October 12, 2024 to the State Agency, revealed Resident R112 was seen walking to [his/her] bedroom with blood on [his/her] face. Resident R112 was noted to have a hematoma on the back of the head, a laceration on top of head and finger. The resident attending physician was notified and Resident R112 was sent to the hospital for evaluation.
Continue review of information dated and submitted by the facility on October 12, 2024 to the State Agency revealed Resident R112 was treated at the hospital for a closed non displaced fracture of the proximal phalanx of the right little finger and a closed head injury.
Further review of information dated October 12, 2024 and submitted by the facility on October 12, 2024 to the State Agency revealed the Nursing Home Administrator interviewed Resident Resident R107 who was R112's roommate. Resident R107 witnessed next-door-neighbor (Resident R46), who they share a bathroom with, push Resident R112 and hit [Resident R112] with [his/her] cane. The investigation concluded that Resident R46 was identified as the perpetrator and the facility substantiated the resident-to-resident altercation as abuse.
The facility failed to ensure that Resident R112 was free from physical abuse from Resident R46 with a history of verbal aggression towards Resident R112. This failure resulted in actual harm to Resident R112 who sustained a closed head injury and a right fractured finger when Resident R46 became physically violent towards Resident R112.
28 Pa. Code 201.29 (c)(3)(4) Resident rights
28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of one of three residents reviewed.(Resident R1)
Findings include:
Review of the job description for the Nursing Home Administrator (NHA) stated, The Administator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper healthcare services to residents. The Administrator administers, directs and coordinates all activities of the center to assure that the highest degree of quality of care is consistently provided to the residents of the facility.
Review of the job description for the Director of Nursing (DON) stated, The Director of Nursing is responsible for administration of nursing service in the nursing center. He/she directs, plan and coordinates service activities of professional nursing and auxiliary nursing personnel in rendering resident care. The Director of Nursing interprets center policies and regulation to all nursing personnel and ensures compliance, as well as analyzes and evaluates nursing and related service rendered to improve quality of resident care and to better utilize staff time and abilities. The Director of Nursing also ensures the provision of in-service training programs for nursing personnel.
Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior).
Review of an admission note dated March 27, 2024, at 6:37 p.m. written by Employee E3 (licensed nurse) indicated that the resident was admitted to the facility on the above referenced date from the local hospital after suffering a heart attack.
Review of the resident's person-centered plan of care included a plan of care dated March 28, 2024, that indicated that the resident was at risk for injury related to elopement and wandering.
Review of information submitted to the State Survey Agency on April 24, 2024, indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement.
Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024, 8:42 p.m. on the third floor walking to his room.
Review of an interview conducted by the facility dated April 23, 2024, with nurse aide (Employee E8) who was assigned to Resident R1 on April 23, 2024 from 7:00 a.m. through 3:00 p.m. reported that she saw the resident at approximately 8:17 a.m. She reported that he was dressed and heading to the elevator. During an interview with the state surveyor on April 30, 2024, at 12:28 p.m. Employee E8 reported that she thought she saw the resident get on the elevator at 8:17 a.m. in the morning. Employee E8 also stated that she placed the resident's breakfast tray in his room and that the resident was not present at the time that she delivered the breakfast tray to him. Employee E8 reported that she came back around 12:00 p.m. and noticed that he did not eat it. Employee E8 reported that she contacted the unit manager to let her know that he did not eat his breakfast and that the name Dr. Walker was called throughout the facility, which is a code word used to notify staff that there was a resident whose presence in the facility cannot be accounted for.
Review of an interview conducted by the facility with Resident R2 (Resident R1's roommate) on April 24, 2024, revealed that Resident R2 notified the facility that he did notice that the window was open because he felt a breeze. Resident R2 stated that when he felt the breeze he walked over to the window and noticed that the window was pulled out of its frame and was lying on the floor. Resident R2 stated that he picked the window up, and put the window back in the frame. During an interview with Resident R2 on April 30, 2024 at 10:27 a.m. Resident R2 reiterated his account of seeing the window on the floor, picking it up and inserting it back into the window frame.
Review of an account from the Social Services Director (SSD, Employee E10) dated April 23, 2024 at 1:00 p.m. the SSD that both he and Employee E11 (Social services assistant) drove to the resident's old apartment, called the resident Guardian to see if she had working cell phone number for him. The Social services director reported that he was able to make contact with the resident at approximately 1:30 p.m. when the resident told the SSD that he was in the hospital because he climbed out of his window the previous evening an attempt to go home.
Continued review of the investigation completed by the facility revealed that Resident R1 was last seen entering his bedroom at 8:42 p.m. on April 22, 2024 on facility surveillance footage, however nursing staff assigned to Resident R1 did not noticed that the resident was missing from the facility until the next day, April 23, 2024 at approximately 12:00 p.m. 15 hours after the resident was last seen entering his room.
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 F689.
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
28 Pa. Code 201.18(e)(1) Management

Based on staff interviews, review of clinical records and review of facility policy, it was determined that the facility failed to ensure professional standards of practice related to medication administration for one out 3 residents reviewed (Resident R1).
Findings include:
Review of the policy Medication Administration, dated 05/16 indicated that for residents who are not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged. After completion of the medication pass, the nurse returns to the missed resident to administer the medication. The policy also indicated that the resident is always observed after administration to ensure that the does was completely ingested. Continued review of the policy indicated that topical medications used in treatments are listed on the treatment administration record (TAR).
Review of the April 2024 physician orders for Resident R1 included the diagnoses of St. Elevation myocardial infarction (a type of heart attack); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior.
Review of a facility reportable incident received from the State survey agency on April 24, 2024 indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement.
Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024 8:42 p.m. on the third floor walking to his room.
A summary of interviews conducted with facility staff (licensed nurses and nursing assistants) who worked on the 3:00 p.m. through 11:00 p.m. shift revealed that the resident was last seen on the third floor where his room was located between 8:00 p.m. through 9:00 p.m.
Review of the investigation did not show evidence of the facility conducting an interview yet with Employee E7 (licensed nurse), who was assigned to Resident R1 on April 22, 2024, on the 11:00 p.m. through the 7:00 p.m. nursing shift. During a telephone interview with Employee E7 (licensed nurse) on April 30, 2024 at 1:32 p.m. Employee E7 confirmed with this state surveyor that she was assigned to the resident on the above referenced shift. Employee E7 also reported that she did not remember seeing the resident at all during her shift. She stated, He is always out. I work on the floor 3-4 times a week, so I always see him out in the hallway asking if he can get on the elevator or asking if he can have a shower. Employee E7 continued her statement and reported, He's always nice, polite, and easily directed, and paces the floor. I didn't bother him that night because I figured since I didn't see him like I usually do on the unit, then he is finally sleep for once, so I'll just let him sleep.
Review of the resident's Medication Administration Record (MAR) and the resident's Treatment Administration Record (TAR) for the month of April indicated that although it was determined through the investigation that Resident R1 was not in the building during the 11:00 p.m. through the 7:00 a.m. nursing shift, in addition to Employee E7 statement about not seeing the resident at anytime during her shift, Employee E7 documented on the MAR/TAR that during her shift on April 22, 2004 she provided the resident with treatment and services, as outlined in his physician orders, which included, checking placement of the resident's pressure reducing mattress in his bedroom; checking the placement, function of the wanderguard, in addition to checking the resident's skin integrity on the area and surrounding area where the resident wears the wanderguard. Other treatment and services that Employee E7 documented on the MAR/TAR on April 22, 20024 during her shift as being provided included assessing the resident for pain every shift, and documenting that the resident exhibited no pain, by marking 0, in addition to documenting that Resident R1 was not exhibiting any signs of respiratory infections and documenting his temperature as 97.7 and his oxygen saturation as 97. Review of the MAR/TAR also revealed that Employee E7 documented that she administered barrier cream to the resident during her 11:00 p.m. through 7:00 a.m. nursing shift, in addition to documenting that she provided Resident R1 with 120 cubic centimeters (4 ounces) of fluids on her shift during his medication pass. Review of the resident's April 2024 physician orders did not show evidence that Resident R1 was ordered to have any medication administered to him on that shift.
During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) April 30, 2024 at 2:34 p.m. Discussed that Employee E7 documented on the MAR/TAR that she provided treatment and services to the resident, despite Resident R1 not being present in the building, and Employee E7 stating that she did not see him at all during her shift.
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement and failed to ensure that windows were secure on the unit. This failure resulted in an Immediate Jeopardy situation for Resident R1, who exited the building through a third floor window and sustained serious injuries, including bilateral lower extremity fractures and a fracture of the third lumbar spine vertebra for one of three residents. (Resident R1)
Findings include:
Review of the facility policy, Elopements and Wandering Residents, with a revision date of April 23, 2024, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.
Continued review of the policy indicated that residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The policy also indicated that adequate supervision will be provided to help prevent accidents or elopements.
Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior).
Review of an admission note dated March 27, 2024, at 6:37 p.m. written by Employee E3 (licensed nurse) indicated that the resident was admitted to the facility on the above referenced date from the local hospital after suffering a heart attack.
Continued review of the above referenced admission note indicated resident is at risk of elopement, wandering or exit seeking behaviors.
Review of the resident's discharge hospital records dated March 27, 2024, indicated that the resident did not have the capacity to make his medical decisions. Review of a court order dated March 19, 2024 stated that the resident was adjudicated on the above referenced date as a totally incapacitated person, and had an appointed Guardian (someone appointed by the court to manage the personal and financial affairs an individual who the court has determined lacks the capacity to make his/her own decisions).
Review of the resident's Elopement Assessment dated March 27, 2024, indicated that the resident was at risk for elopement. The assessment indicated that resident Expresses desire to leave, Independently mobile, Adjustment difficulties, Desire to return home, in addition to a Psychiatric history.
Review of Resident R1's March 2024 physician orders indicated a physician order dated March 28, 2024, and monthly thereafter, for the resident to have a wanderguard (an electronic device that is typically applied on an individual's ankle or wrist to alert his/her caregivers (with an alarm) when that individual is near an exit location (e.g. doors, elevators) applied to his left ankle. The order also indicated that on every nursing shift, staff is to ensure to check the placement and function of the wanderguard.
Continued review of the March 28, 2024, physician orders also included a physician's order for the 11:00 p.m. -7:00 a.m. supervisor to check the function of the resident's wanderguard during his/her shift.
Review of the resident's person-centered plan of care included a plan of care dated March 28, 2024, that indicated that the resident was at risk for injury related to elopement and wandering. The resident expressed intent to leave facility. The plan of care also included the resident's diagnosis of Schizophrenia. The interventions related to this care area included involving the resident in activities, reporting changes in behavior, provide activities of interest, in addition to the application of a wanderguard.
Review of a nursing note dated March 28, 2024, at 6:17 a.m. indicated .wander guard placed to left ankle due to reports of wandering.
Review of a nursing note on March 28, 2024, at 1:10 p.m. documented that the resident was at the nursing station asking, how do I get out of here?
Review of a nursing note dated March 30, 2024, at 6:46 p.m. revealed Resident came to the nursing office asking if I could give him a day pass to go to 7-11 mini market. Resident is an elopement risk, but no attempts to leave out of the facility. Resident does have wanderguard applied to his left ankle. Plan of care is ongoing.
Review of a nursing note on April 5, 2024, at 6:56 a.m. indicated that the resident was not wearing his wanderguard and that another one was placed on his ankle.
Review of a nursing note dated April 11, 2024, at 5:06 p.m. indicated that the resident's wanderguard bracelet was found in his bedside drawer, and that the resident stated that he did not want to wear it. Continued review of the note indicated that the resident did not want the wanderguard on his ankle so nursing staff applied the wanderguard to his left wrist.
Review of a nursing note dated April 12, 2024, at 2:37 a.m. the resident was found with the wanderguard bracelet inside the dresser next to his bed. The note documented that the resident reported that he did not want the wanderguard on him.
Review of a nursing note dated April 13, 2024, at 3:10 p.m. documented Resident is alert and oriented x 3 Confusion noted. Exhibits anxiety, wanders
Review of a nursing note on April 14, 2024, at 5:19 p.m. documented that the resident is an elopement risk and that he continues to remove his wanderguard.
Review of a nursing note dated April 14, 2024, at 2:15 p.m. indicated that the resident was pacing back and forth throughout shift and needed to be redirected.
Review of a nursing note dated April 15, 2024, indicated . resident continues refusing wanderguard.
Review of a nursing note dated April 18, 2024, at 11:58 a.m. indicated that resident informed the social services director that he wanted to discharge home to his apartment.
Review of a nursing not dated April 18, 2024, at 2:59 p.m. documented Resident received at front desk. Resident was assisted back upstairs by charge nurse.
Review of information submitted to the State Survey Agency on April 24, 2024, indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement.
Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024, 8:42 p.m. on the third floor walking to his room.
A summary of interviews conducted with facility staff (licensed nurses and nursing assistants) who worked on the 3:00 p.m. through 11:00 p.m. shift that the resident was last seen on, indicated that the general time period that staff reported last seeing the resident on the third floor where his room was located between 8:00 p.m. through 9:00 p.m.
Review of a statement from Employee E4 (licensed nurse assigned to Resident R1) dated April 23, 2024, reported that she last saw Resident R1 out of bed walking in the hallway around 9:00 p.m. on April 22, 2024. Employee E4 reported that she administered the resident his medication at approximately 8:30 p.m., asked him if he was ok, and reported that the resident nodded yes.
Review of an interview conducted by the facility dated April 23, 2024, with the nurse aide, Employee E5 assigned to the resident on April 22, 2024 during the 3:00 p.m. through the 11:00 p.m. nursing shift indicated that she saw Resident R1 between 8:00 p.m. and 9:00 p.m. in his room. During an interview with Employee E5 on April 30, 2024 at 12:18 p.m. the employee confirmed the statement provided to the facility. Employee E5 reported that she went in to check on the resident during the above referenced time to see if he needed anything (e.g. wash towels, socks). Employee E5 reported that Resident R1 told her that he did not need anything. Employee E5 reported that the resident was sitting on the edge of his bed during her encounter with him.
Review of an interview conducted by the facility dated April 23, 2024 with the nurse aide, Employee E6 assigned to Resident R1 on April 22, 2024 during the 11:00 p.m. through the 7:00 a.m. shift stated, I really didn't see [Resident R1] on 11-7 shift because I know he walks around the building. I know he usually does his own thing.
During an interview on April 30, 2024 at 1:28 p.m. via telephone with Employee E6, confirmed that he was assigned to Resident R1 on the above referenced shift, and reported that he did not see the resident that he was assigned to at all during his 8 hour shift.
Review of the investigation did not show evidence of the facility conducting an interview yet with Employee E7 (licensed nurse), who was assigned to Resident R1 on April 22, 2024, on the 11:00 p.m. through the 7:00 p.m. nursing shift. During a telephone interview with Employee E7 (licensed nurse) on April 30, 2024 at 1:32 p.m. Employee E7 confirmed that she was assigned to the resident on the above referenced shift. Employee E7 also reported that she did not remember seeing the resident at all during her shift. She stated, that the resident was always out. I work on the floor 3-4 times a week, so I always see him out in the hallway asking if he can get on the elevator or asking if he can have a shower. Employee E7 continued her statement and reported, He's always nice, polite, and easily directed, and paces the floor. I didn't bother him that night because I figured since I didn't see him like I usually do on the unit, then he is finally sleep for once, so I'll just let him sleep.
Review of an interview conducted by the facility dated April 23, 2024, with nurse aide (Employee E8) who was assigned to Resident R1 on April 23, 2024 from 7:00 a.m. through 3:00 p.m. reported that she saw the resident at approximately 8:17 a.m. She reported that he was dressed and heading to the elevator. During an interview with the state surveyor on April 30, 2024, at 12:28 p.m. Employee E8 reported that she thought she saw the resident get on the elevator at 8:17 a.m. in the morning. Employee E8 also stated that she placed the resident's breakfast tray in his room and that the resident was not present at the time that she delivered the breakfast tray to him. Employee E8 reported that she came back around 12:00 p.m. and noticed that he did not eat it. Employee E8 reported that she contacted the unit manager to let her know that he did not eat his breakfast and that the name Dr. Walker was called throughout the facility, which is a code word used to notify staff that there was a resident whose presence in the facility cannot be accounted for.
Review of an interview conducted by the facility with Resident R2 (Resident R1's roommate) on April 24, 2024, revealed that Resident R2 notified the facility that he did notice that the window was open because he felt a breeze. Resident R2 stated that when he felt the breeze he walked over to the window and noticed that the window was pulled out of its frame and was lying on the floor. Resident R2 stated that he picked the window up, and put the window back in the frame. During an interview with Resident R2 on April 30, 2024 at 10:27 a.m. Resident R2 reiterated his account of seeing the window on the floor, picking it up and inserting it back into the window frame.
Review of an interview conducted by the facility dated April 23, 2024, with licensed nurse (Employee E9) assigned to Resident R1 on April 23, 2024, from 7:00 a.m. through 3:00 p.m. indicated that the employee stated that she attempted to provide the resident with his medications in the morning but was told by staff that the resident wanders in the building, and that it was his baseline behavior. Employee E9 reported that she looked for the resident in his room while administering medication to other residents, but she still did not see the resident.
Review of the investigation indicated that when it was noted that the resident had not eaten his breakfast, and not had his medication administered to him, the Unit Manager was notified, and the facility initiated their elopement protocol to locate Resident R1.
Review of an account from the Social Services Director (SSD, Employee E10) dated April 23, 2024 at 1:00 p.m. the SSD that both he and Employee E11 (Social services assistant) drove to the resident's old apartment, called the resident Guardian to see if she had working cell phone number for him. The Social services director reported that he was able to make contact with the resident at approximately 1:30 p.m. when the resident told the SSD that he was in the hospital because he climbed out of his window the previous evening an attempt to go home.
Continued review of the investigation completed by the facility indicated that when the resident exited out of his third-floor window, he sustained injuries that caused him to call 911 (Emergency Medical services) for transportation to the hospital.
During an interview with Resident R1 on May 2, 2024, at 9:15 a.m. Resident R1 reported that he wanted to leave the facility, so he jumped out of a window. Resident R1 reported that he lifted the window out of its frame. When asked if he used any tools (knife, pen, etc), Resident R1 stated, I only used my hands. I was surprised it came out that easy. Resident R1 reported that he moved a short distance of where he landed when he jumped and called 911 to pick him up because he could not walk.
Review of the resident's History and Physical report dated April 23, 2024 at 3:39 p.m. indicated that the resident fractured both his right and left legs. Continued review of the report indicated that the resident also had a fracture of the third lumbar spine vertebra (L3).
Review of the resident's clinical record and the facility investigation did not show evidence of any supervision or monitoring that were put in place for Resident R1 who was identified as an elopement risk upon admission and refused to wear his wanderguard. Resident R1 was last seen entering his room at 8:42 p.m. on April 22, 2024, and not noticed missing from the building until April 23, 2024, at approximately 12:00 p.m. 15 hours later.
During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on April 30, 2024, at 12:45 p.m. the facility determined that Resident R1 exited the facility through his window that the room rounds, and bed checks were not completed properly by nursing staff.
The facility failed to adequately supervise a resident who was at risk for elopement and failed to secure windows on the unit. This failure to adequately supervise a resident at risk for elopement resulted in the resident exiting the building by jumping from his 3rd floor bedroom window and sustaining serious injuries resulting in an immediate jeopardy situation.
Based on the above findings an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on April 30, 2024, at 2:34 p.m., for failure to adequately supervise a resident at risk for elopement, and failure to secure windows on the unit. The Immediate Jeopardy template was provided to the Administrator and an immediate action plan was requested.
On April 30, 2024, at 8:59 p.m. the facility provided the following corrective action plan:
1. On April 23, 2024, an audit of all resident room windows were completed by the maintenance director. The maintenance director installed an additional bracket to all resident rooms to prevent the windows from being removed from the frame.
2. On April 23, 2024, the DON (Director of Nursing)/designee reviewed all resident care plans and reviewed and revised them to reflect elopement risk assessment findings.
3. On April 23, 2024, the DON/designee(s)re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool.
4. DON, designee(s) will complete elopement risk assessments that will assess residents on admission, quarterly, and in the event of a significant change.
5. On April 23, 2024, the DON/designee also in-serviced nurse aide staff on completing checks on the residents that they are assigned to every two hours during their shift to account for the resident's whereabouts. Licensed nurses were also serviced to ensure that head counts of residents are completed on their nursing shift.
Interviews were conducted with facility staff on May 1, 2024, between 1:30 p.m.- 3:35 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the proper procedure for alerting management. Review was conducted of the education provided to facility staff related to resident elopement and the Immediate Jeopardy was lifted on May 1, 2024, at 4:16 p.m.
28 Pa. Code 201.18(a) Management
28 Pa. Code 201.18(b)(1)Management
28 Pa. Code 201.18 (b)(3)Management
28 Pa. Code 201.18(d) Management
28 Pa. Code 211.10(b) Resident care policies
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
28 Pa. Code 211.11(a) Resident care plan

Based on staff interviews, review of clinical record and review of facility policy, it was determined that the facility failed maintain complete and accurate clinical records regarding an elopement event for one out of three residents reviewed (Resident R1).
Findings include:
Review of the facility policy, Documentation in Medical Record dated April 23, 2024 indicated that resident medical records shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation.
Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior).
Review of an incident reported to the State Survey Agency on April 24, 2024 indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement, which included two broken legs, when the resident jumped out of his third floor window
Review of the resident's clinical record revealed no documentation related to the resident's elopement incident, his current hospitalization, injuries, and any documentation in the clinical record that the facility provided notification to the resident's court-appointed Guardian about the incident.
28 Pa. Code 211.5 (f)(ii) Medical records
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documentation, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of five residents reviewed (Resident R1).
Findings Include:
Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 29, 2924, revealed the resident was cognitively intact and had diagnoses of anxiety and depression.
Interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the resident recently missed doses of Trazodone, a medication used to help the resident sleep. Resident R1 reported that nursing staff told him the medication was discontinued by the physician but was unable to explain why. Further interview with Resident R1 revealed poor sleep during the days Trazodone was not provided.
Continued interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the physician did not inform the resident of the medication changes or review alternative treatment options to help him sleep.
Review of Resident R1's physician orders revealed the resident was prescribed Trazodone 150 milligrams (mg) at bedtime for insomnia (the inability to sleep adequately) started 2/20/2024 and discontinued 04/08/2024. Review of the discontinued ordered revealed it was marked as completed by the physician. There was no documented evidence by the physician why the medication was completed.
Review of Resident R1's medication administration record confirmed the resident did not receive Trazodone on April 8, April 9, and April 10, 2024.
Continued review of Resident R1's physician orders revealed the Trazodone 150mg every night was re-started for insomnia on April 11, 2024.
Review of Resident R1's entire clinical record revealed no documented evidence that Resident R1 was informed by the physician of the medication change, was allowed to participate in decisions regarding his care and treatment, or that the physician reviewed alternative treatment options to help him sleep.
28 Pa Code 201.18(b)(2) Management
28 Pa Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of four dialysis residents reviewed (Resident R148).
Findings include:
Review of Resident R148's clinical record revealed that the resident was admitted to the facility on [DATE], and that Resident R148 had diagnoses of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life).
Review of Resident R148's physician order, dated February 15, 2024, revealed Revealed that Resident R148 receive dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays.
Review of Resident R148's Hemodialysis Communication Record revealed that on, March 1, 2024 and March 4, 2024 it was lacking information on Pre-Weight, Post- Weight, Pre-Blood Pressure, Post-Blood Pressure, and Temperature. On March 6, 2024; it was lacking information on access site, bruit, thrill (the rumbling or swooshing sound of a dialysis fistula bruit is caused by the high-pressure flow of blood through the fistula; although the bruit is usually heard with a stethoscope, it also can be felt on the overlying skin as a vibration, also referred to as a thrill), acute problem since last appointment, medication changes, and new orders/significant social change in condition during dialysis.
Interview with the Unit Manager of First Floor, a Registered Nurse, Employee E17, on March 27, 2024, at 11:10 a.m., confirmed lack of communication with dialysis center.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa Code 211.5(g)(h) Clinical records
28 Pa Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa.Code 211.12(d)(1)(5) Nursing services

Based on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen washing and processing, in one of one laundry room in the facility. (laundry room)
Findings include:
Observation at the laundry room of the facility, on March 28, 2024, at 12:14 p.m., revealed that two Laundry Aides, Employees E15 and E16, were processing and folding clean linens for the use of residents by holding the linens letting it to touch the Laundry Aides' personal clothing.
It was also observed that while folding the washed and dried linens for the use of residents, the clean linens were in close contact with Employee E15's beard.
At the time of the finding interviewed with Employees E15 and E16, confirmed that the linen should have been folded without letting it touch the employee's clothing to prevent contamination and to maintain infection control.
28 Pa Code 211.12 (d)(1)(5) Nursing services
28 Pa Code 201.14(a) Responsibility of licensee

Based on clinical record review and interviews with staff, it was determined that the failed to ensure complete and accurate documentation related to tuberculosis testing for three of three residents reviewed (Resident R480, R479, R134).
Findings include:
Clinical record review for Resident R480 revealed an admitting diagnosis of chronic kidney disease on March 8, 2024.
Continued review of clinical record revealed an order for TB skin test per protocol. Screening #1 to be administered within the first 24 hours of admission on March 8, 2024. Review of Resident R480's March 2024 Medication Administration Record (MAR) revealed code 1 indicated for this administration. When looking at the key it was revealed that code 1 is absent from home without medication. Continued review of clinical record revealed an order for TB skin test per protocol. Step #2 per protocol on March 15, 2024. MAR revealed code 1 indicated for this administration. When looking at the key it was revealed that code 1 is absent from home without medication. Further review of MAR revealed an order for TB skin test per protocol. Read result of step #2 on March 17, 2024. MAR revealed a notation of negative mm.
Interview with Director of Nursing (DON) on March 26, 204 at 2:18 p.m. confirmed that code 1 does correspond to 'absent at home without medication'. It was also confirmed that resident was newly to the facility and not at home during those times. Further interview, revealed DON was 'unsure' how staff read the step #2 given on March 17, 2024 when the medication was not administered.
Clinical record review for Resident R479 revealed an admitting diagnosis of chronic subdural hemorrhage on March 8, 2024.
Continued review of clinical record revealed an order for TB skin test per protocol. Step #2 per protocol on March 15, 2024. Review of Resident R479's MAR revealed code 2 indicated for this administration. When looking at the key it was revealed that code 2 is refused. Further review of MAR revealed an order for TB skin test per protocol. Read result of step #2 on March 17, 2024. MAR revealed a notation of negative mm.
Interview with Director of Nursing on March 26, 204 at 2:18 p.m. confirmed that code 2 does correspond to 'drug refused'. Further interview, revealed DON was 'unsure' how staff read the step #2 given on March 17, 2024 when the medication was not administered.
Clinical record review for Resident R134 revealed an admitting diagnosis of type 2 diabetes mellitus without complication on November 3, 2023.
Continued review of clinical record revealed an order for TB skin test per protocol. Screening #1 to be administered within the first 24 hours of admission on November 3, 2023. Review of Resident R134's MAR revealed code 1 indicated for this administration. When looking at the key it was revealed that code 1 is absent from home without medication. Continued review of clinical record revealed an order for TB skin test per protocol. Step #2 per protocol on November 10, 2023, 2024. MAR revealed code 2 indicated for this administration. When looking at the key it was revealed that code 2 is refused. Further review of MAR revealed an order for TB skin test per protocol. Read result of step #2 on November 12, 2023. MAR revealed a notation of negative mm.
Interview with Director of Nursing on March 26, 204 at 2:18 p.m. confirmed that code 1 does correspond to 'absent at home without medication'. It was also confirmed that resident was newly to the facility and not at home during those times. Further interview revealed code 2 does correspond to 'drug refused'. Interview, revealed DON was 'unsure' how staff read the step #2 given on November 12 2023, when the medication was not administered.
28 PA Code 211.5(f)(ix) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for four of 36 residents reviewed (Resident R131, R37, R42 and R123).
Findings Include:
Review of the undated Consultant Pharmacist Services Provider Requirements Policy revealed, Medication Regimen Reviews (MRR) for each skilled nursing resident at least monthly, communicate to responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected, and other findings related to medication therapy orders at least monthly, review and follow-up to previous month's pharmacy recommendations with the nursing care center staff.
Review of Resident R131's clinical record revealed that resident was admitted on [DATE], with diagnoses including multiple sclerosis (a chronic autoimmune disease that affects the central nervous system with symptoms including muscle weakness, spasticity and paralysis), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations).
A review of the pharmacy progress notes revealed the following notes:
November 11, 2023, Medical chart reviewed, new recommendation, see report.
December 6, 2023, Medical chart reviewed, recommendations made.
January 6, 2024, Medical chart reviewed, recommendations made.
February 9, 2024, Medical chart reviewed, recommendations made.
Review of Resident R123's clinical record revealed that resident was admitted on [DATE], with diagnoses including other asthma, chronic obstructive pulmonary disease, type 2 diabetes, psychotic disturbance mood disturbance, anxiety disorder, major depressive and unspecified dementia.
A review of the pharmacy progress notes revealed the following notes:
March 7, 2024, Medical chart reviewed, recommendations made.
February 9, 2024, Medical chart reviewed, new recommendations made.
Review of Resident R37's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus with hyperglycemia; repeated falls; anemia; idiopathic peripheralautonomic neuropathy; myocardial ischemia; myocardial infarction; bipolar disorder; colostomy status; dementia without behavioral disturbance; chronic obstructive pulmonary disease; anxiety disorder; osteoarthritis and gastro-esophogeal reflux disease.
Review of pharmacy progress notes revealed the following notes:
November 12, 2023 medical chart reviewed, recommendations made.
December 6, 2023 medical chart reviewed, recommendations made.
January 8, 2024, medical chart reviewed, recommendations made.
No review was available for February 2024.
Review of Resident R42's clinical record revealed that resident was admitted to the facility on [DATE] with diagnoses including cardio-vascular disease, hemiplegia, hemiparesis, chronic obstructive pulmonary disease, diabetes mellitus type II, anxiety, major depressive disorder, spastic diplegic cerebral palsy, hypertension and other pulmonary embolism with acute cor pulmonale.
There were no pharmacy progress notes for review for Resident R42.
Interview with the Director of Nursing on March 28, 2024, at 10:18 a.m. revealed that there was no documentation to review related to the recommendations made by the consultant pharmacist or whether they were acknowledged by the physician and implemented or not and why.
28 Pa. Code 211.9 (k) Pharmacy services.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to maintain sufficient dietary personnel to complete essential job functions, related to meals being served late.
Findings include:
Observations in the main kitchen on March 25, 2024, at 10:50 a.m. revealed the stacks of dirty dishes and tray delivery carts full of trays with dirty dishware that still had to be unloaded, scrapped, stacked, racked, rinsed and run through the dish machine. After the dishes were cleaned, they needed to be stacked in the plate warmers, trays after air drying had to be stacked and preset for the lunch meal, the silverware had to be rinsed, washed, sorted, air dried and set up on the lunch trays.
Interview with on March 25, 2024, at 1:08 p.m. with Licensed nurse, Employee E10, confirmed that the lunch trays were late, that they are usually delivered much earlier.
Interview with on March 25, 2024, at 1:10 p.m. with Resident R82 revealed that she had not received her tray yet, that it very late for lunch.
Interview with on March 25, 2024, at 1:11 p.m. with Resident R131 revealed that she had not received her tray yet, and that it is late again.
Interview with on March 25, 2024, at 1:14 p.m. with Resident R6 revealed that she had not received her tray yet, and that she was waiting.
Interview with on March 25, 2024, at 1:17 p.m. with Resident R18 revealed that she had not received her lunch tray, that it was really late, and that she had been waiting.
Observations on the third floor revealed that the lunch tray cart was not delivered until 1:20 p.m.
Review of the Dietary Meal Truck Delivery schedule revealed that the first cart to the third floor, cart 5, is scheduled to b delivered at 12:30 p.m.
Interview with the Food Service Director (FSD), on March 29, 2024, at 2:15 p.m. revealed that the lunch meal was late and that he had one aide call off and another three hours late which put them behind causing the meal to be late.
Review of the Dietary Department schedule for March 25, 2024, revealed that Employee E13 and Employee E17, AM Dietary Aides, were scheduled at 6:00 a.m. A review of the time clock punch report for March 25, 2024, revealed that Employee E13 did not punch in at all, and that Employee E14 punched in at 9:07 a.m. or about three hours late.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management

Based on observations, interviews with staff, and a review of facility policies and 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.
Findings include:
The Policy: Food Storage: Cold Foods, updated February 2023, states, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
An initial tour of the Food Service Department was conducted on March 25, 2024, at 10:15 a.m. with Employee E3, Food Service Director, FSD, which revealed the following:
Observation in the corridor between the receiving door to the outside and the kitchen was very dusty and dirty with visible dirt and debris on the floor.
Observation in the dry storage room revealed a pan rack with a reddish substance splashed over the rack, and the floor littered with paper, straws, packets and dust, and there was less than the required 18 between boxes (Dart Styrofoam cups, Steamtable Pan Lids, Latex Gloves) on the top shelf and the ceiling and sprinkler heads.
Observation in the walk-in cooler revealed an undated container of garlic, and brown substance on the floor near the door and patches of a light-colored growth on the ceiling.
Observation in the reach-in freezer revealed tilapia filets that were in an open box with the inner plastic liner open to the air.
Observation in the second reach-in freezer revealed an open box of biscuits with the inner plastic liner open to the air, and the outside vent on the top of this freezer had a build-up of dark stick and dusty substance between the louvered vents.
Observation on the prep sink revealed a steady stream of water running even when knobs were shut tight.
Interview with the FSD at 10:30 a.m. on March 25, 2024, confirmed the above findings.
28 PA Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management

Based on the review of employee job description, clinical records and interviews with staff, it was determined that the facility failed to complete a skin assessment according to professional standards of nursing practice. (Employee E4)
Findings Include:
Review of job description for Unit Manager, revealed that Unit Manager will oversee the medical and personal care of residents and supervise the nurses and other caregivers who interact with the residents on a daily basis in accordance with state and federal regulations to promote high quality of care and service.
Responsibilities:
Ensures complete and prompt reporting of incidents with follow-up as necessary to Administrator and Director of Nursing.
Oversee resident care to promote the highest level of physical, mental and psychosocial functioning possible for assigned unit.
Ensures that significant changes in resident condition are communicated to the physician, family or responsible party.
Makes daily rounds on unit to ensure resident care needs and environmental standards are met, this includes monitoring of dining rooms meal times.
Observation of tracheostomy care to Resident R1 on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5, was completed. During the observation a pack of gauze was observed on resident's right side of neck under his trach ties and the right neck area. Both employees did not know why the resident had gauze to the right side of the neck. Resident was observed with his neck towards right ride with his chin bone touching the area of the shoulder bone. A request was made to Employee E4 and E5 to open the gauze.
Further observation after the gauze was removed from Resident R1's neck revealed that there were two new wounds under the gauze. There was a 2 x 2 boarder dressing on one of the wounds without any medications. There was no date on the dressing. The right clavicle wound appeared to be an area where resident's chin touching the clavicle bone and the neck wounds appeared to be an area where the trach tie touched the skin. It was observed that resident's neck tilted towards the right side and right side of the chin was touching the right clavicle bone. No offloading or pressure reducing measures were observed to the area.
Review of physician orders for Resident R1 dated December 27, 2023, revealed an order to complete full body skin assessment three times a week. New skin impairment should be documented; initiate a treatment document in the nurses' notes.
Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated right clavicle's wound measuring 1 cm x 1.5 cm, and left clavicle's wound and left chin. All treatment in place.
Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle, left clavicle and left chin. All treatment in place.
Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound.
Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin.
Review of a skin assessment completed by Licensed nurse, Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment.
Interview with Licensed nurse, Employee E4, on January 5, 2024, at 1:00 p.m. stated she was not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024.
Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. confirmed that the staff did not notify the physician when resident developed right clavicle wound and obtained treatment orders. Employee E2 also stated Licensed nurse, Employee E4 completed an inaccurate skin assessment on January 3, 2024, which resulted in facility not identifying the new pressure ulcers and resident not receiving treatment to the right neck pressure ulcer areas.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on the review of facility policy, interviews with staff, it was determined that the facility failed to ensure that the nursing staff possessed appropriate competencies for tracheostomy care for one of one employee record reviewed. (Employee E5).
Findings Include:
Review of CDC (Centers for Disease Control and Prevention), Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee recommendations revealed that,
Prevention of Person-to-Person Transmission of Bacteria
1. Standard Precautions
a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn. Decontaminate hands as described previously before and after contact with a patient who has an endotracheal or tracheostomy tube in place, and before and after contact with any respiratory device that is used on the patient, whether or not gloves are worn.
b. Gloving
1) Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient.
2) Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient.
c. When soiling with respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient.
2. Care of patients with tracheostomy
a. Perform tracheostomy under aseptic conditions (II).
b. When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection.
During the survey a tracheostomy care observation for Resident R1 was requested by the surveyor on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5. Employee E4 wore a clean glove, touched resident's tracheostomy site, surrounding skin, removed the tracheostomy tube from the resident's stoma, using the same gloves opened the new tracheostomy tube touched the new sterile tube, placed the tube on the table, removed the contaminated gloves, worn another clean glove and placed the new tubing into resident's stoma.
It was observed that Employee E5 did not wash her hand or sanitize the hand after removing tracheostomy tube from the resident and changing the gloves or prior to wearing the new glove. Employee E4 and Employee E5 did not wear a gown, a face mask or a face protection. Staff did not use tracheostomy sterile dressing change kit or sterile gloves.
Interview with Employee E5 on January 5, 2024, at 11.50 a.m. confirmed that she touched the sterile tracheostomy tube prior to changing the contaminated glove. Employee E5 confirmed that she did not use sterile or clean technique while providing tracheostomy care for Resident R1. Employee E5 stated she was not aware of the appropriate steps in tracheostomy care. Employee E5 stated she was an agency staff, and she did not receive any tracheostomy training or competency assessment from the facility.
Facility did not provide any evidence of competency evaluation for tracheostomy care for Employee E4 during the survey.
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observations, review of clinical records, review of facility policy and interviews with staff, it was determined the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for one of four clinical records reviewed (Resident R1).
Findings include:
Review of CDC (Centers for Disease Control and Prevention), Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee recommendations revealed that,
Prevention of Person-to-Person Transmission of Bacteria
1. Standard Precautions
a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn. Decontaminate hands as described previously before and after contact with a patient who has an endotracheal or tracheostomy tube in place, and before and after contact with any respiratory device that is used on the patient, whether or not gloves are worn.
b. Gloving
1) Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient.
2) Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient.
c. When soiling with respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient.
2. Care of patients with tracheostomy
a. Perform tracheostomy under aseptic conditions (II).
b. When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection (IB
Review of an undated facility policy Tracheostomy Care revealed that The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.
Procedure with Use of Disposable Cannula:
a. Verify that the inner cannula is disposable. Verify correct size.
b. Explain the procedure to the resident and screen for privacy.
c. Perform hand hygiene and put on clean gloves.
d. Slowly remove present inner cannula from the tracheostomy tube by squeezing tabs on
connector until both snaps clear the ridged lock on the outer cannula.
e. Dispose of the removed inner cannula.
f. Pick up the new inner cannula, touching only the outer locking portion. Insert and lock the
inner cannula into position
g. Change trach ties/tube holder when soiled or wet. Replace dressing using manufactured split
dressing with flaps pointing upward
h. Discard gloves and perform hand hygiene.
Make sure oxygen is administered as ordered.
Document procedure and report any signs or symptoms of infection to the physician.
Review of an undated facility policy Enhanced Barrier Precaution revealed that Enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for resident known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. An order for enhanced barrier precautions will be obtained for residents with any of the following 1. Wounds and/or indwelling medical devices ( eg. Tracheostomy/ventilator tubes). Implementation of enhanced barrier precautions- a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. c. Position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 4. High contact resident care activities include; g. Device care or use . tracheostomy/ventilator tubes. Enhanced barrier precautions should be used for the duration of the affected residents stay in the facility or until the wound heals or indwelling medical device is removed.
During the survey a tracheostomy care observation for Resident R1 was requested by the surveyor on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5. Employee E5 wore a clean glove, touched resident's tracheostomy site, surrounding skin, removed the tracheostomy tube from the resident's stoma, using the same gloves opened the new tracheostomy tube, touched the new sterile tube, placed the tube on the table, removed the contaminated gloves, worn another clean glove and placed the new tubing into resident's stoma.
It was observed that Employee E5 did not wash her hand or sanitize the hand after removing tracheostomy tube from the resident and changing the gloves or prior to wearing the new glove. Employee E4 and Employee E5 did not wear a gown, a face mask or a face protection. Staff did not use tracheostomy sterile dressing change kit or sterile gloves.
Interview with Employee E5 on January 5, 2024, at 11.50 a.m. confirmed that she touched the sterile tracheostomy tube prior to changing the contaminated glove. Employee E5 confirmed that she did not use sterile or clean technique while providing tracheostomy care for Resident R1. Employee E5 stated she did not receive any tracheostomy training or competency assessment from the facility, and she was not aware that the resident was on enhanced barrier precautions.
Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated facility practice of tracheostomy care and changing of inner cannula was a sterile procedure. There were sterile trays available at the facility for tracheostomy dressing change which the staff was expected to use.
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, review of facility policies, observations and staff interviews, it was determined that the facility failed to timely assess and consistently provide recommended and/or prescribed treatment and services, to prevent new wound development, promote healing and prevent worsening of existing wounds. This failure resulted in actual harm to Resident R1 who developed new and worsening wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. (Resident R1)
Findings include:
Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.
The American College of Physicians [ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair.
Review of an undated facility policy Wound Treatment Management revealed that 1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.
Review of an undated facility document Wound Management Program revealed that Based on the comprehensive assessment of a resident, 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
Review of Resident R1's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 6, 2023, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living to include bed mobility, transfers, and toilet use. The resident's cognition was severely impaired, and the assessment indicated that the resident was unable to complete interview. MDS also indicated that the resident rarely/never makes self-understood and able to understand others.
Review of Resident R1's care plan dated December 30, 2023, revealed that the resident was at risk for skin integrity with interventions included body check weekly and as needed, notify physician and family of changes and provide skin care as needed.
Observation of tracheostomy care to Resident R1 on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5, was completed. During the observation a pack of gauze was observed on resident's right side of neck under his trach ties and the right neck area. Both employees did not know why the resident had gauze to the right side of the neck. Resident was observed with his neck towards right ride with his chin bone touching the area of the shoulder bone. A request was made to Employee E4 and E5 to open the gauze.
Further observation after the gauze was removed from Resident R1's neck revealed that there were two new wounds under the gauze. There was a 2 x 2 boarder dressing on one of the wounds without any medications. There was no date on the dressing. The right clavicle wound appeared to be an area where resident's chin touching the clavicle bone and the neck wounds appeared to be an area where the trach tie touched the skin. It was observed that resident's neck tilted towards the right side and right side of the chin was touching the right clavicle bone. No offloading or pressure reducing measures were observed to the area.
Interview with Licensed Nurse, Employee E5 on January 5, 2023, stated she was not aware of resident's two wounds to the right side of the neck. There was no information provided to the shift-to-shift report. Employee E5 stated there was no physician order to provide treatment or check residents wound to the right neck.
Review of physician orders for Resident R1 dated July 7, 2023, revealed an order to check for skin integrity around the neck related to trach collar.
Review of nursing progress note dated December 21, 2023 revealed that the resident was identified with moisture associated dermatitis to left clavicle which measured 0.5 centimeter (cm) x 1.0 cm. X 0.1 cm.
Review of progress note for Resident R1 dated December 26, 2023, revealed a skin documentation that a new skin impairment was observed on residents left chin area which measured 1.5 centimeter (cm) x 2.0 cm.
Review of physician orders for Resident R1 dated December 27, 2023, revealed an order to complete full body skin assessment three times a week. New skin impairment should be documented; initiate a treatment document in the nurses' notes.
Review of the clinical record revealed that the resident was transfered to the hospital on December 27, 2023, with a repiratory change in condition. The resident was readmitted to the facility on [DATE].
Review of hospital record for Resident R1 dated December 29, 2023, revealed under skin condition that the resident had Stage II pressure ulcer on right and left clavicle, right leg wound and a DTI (Deep Tissue Injury) to the right foot.
Review of facility admission assessment dated [DATE], revealed no evidence that the resident's right clavicle wound was indicated on the assessment, or a treatment plan was initiated.
Review of a readmission assessment of Resident R1 dated December 29, 2023, revealed that there was no negative finding noted on the skin assessment.
Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated right clavicle's wound measuring 1 cm x 1.5 cm, and left clavicle's wound and left chin. All treatment in place.
Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle, left clavicle and left chin. All treatment in place.
Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound.
Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin.
Review of a skin assessment completed by Licensed nurse, Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment.
Interview with Licensed nurse, Employee E4, on January 5, 2024, at 1:00 p.m. stated she was not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024.
Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated Licensed nurse, Employee E4 did not conduct a proper skin assessment. Staff were expected to conduct skin assessment and document the findings in the medical record. Any changes to skin integrity should be addressed with the physician for treatment orders.
Review of clinical record for Resident R1 revealed no documented evidence that the physician or wound care practitioner was notified about Resident R1's right clavicle wound when it was first documented on December 30, 2023, subsequently after. There were no interventions implemented to promote the wound healing or preventing further skin breakdown.
A skin assessment completed on January 5, 2024, at 1:39 p.m., revealed that the right clavicle measured 1.5 cm x 2.3 cm. and right neck wound measured 0.7 cm. x 2 cm.
A wound care consult report dated January 5, 2024, after the surveyor observation of the right clavicle and right neck wound revealed that resident had muscle weakness, reduced mobility and extreme contracture with right clavicle pressure ulcer and right lateral neck pressure ulcer. Right clavicle was an acute Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer and measured 1.3 cm x 2 cm. x 0.2 cm. Right lateral neck was an acute Stage 3 pressure ulcer and measured 0.9 cm. x 1.3 cm x 0.1 cm.
Further review of the wound care consult report dated January 5, 2024, and progress note for Resident R1 dated December 30, 2023, confirmed that the right clavicle wound increased in size and a new wound was developed adjacent to the right clavicle wound.
Review of Medication Administration Record for December 2023 and January 2024 revealed that the nursing staff did not administer any care to the right clavicle and right neck area including, wound treatment, wound prevention, and interventions to promote wound healing.
Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. confirmed that the staff did not notify physician when resident developed right clavicle wound and obtained treatment orders. Employee E2 also confirmed that the staff did not implement interventions for wound prevention and promote wound healing to Resident R1's right neck area. Employee E2 stated staff was expected to initiate an incident report and implement interventions when a new wound was identified which was not completed when Resident R1's wound was first identified with wounds to the right clavicle. Employee E2 also stated Licensed nurse, Employee E4 completed an inaccurate skin assessment on January 3, 2024, which resulted in facility not identifying the new pressure ulcers and resident not receiving treatment to the right neck pressure ulcer areas.
The facility failed to identify, develop and implement interventions to promote wound healing and prevent wound development in accordance to the resident' plan of care, facility polices and professional standards of practice. Facility failed to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who developed new and worsening wounds on his right clavicle and neck.
Immediate jeopardy was called on January 17, 2024 at 9:22 AM and the IJ Template was provided to the facility. Facility developed the following approved action plan:
1. Resident (R1) was assessed by the Nurse Practicioner on 1/5/2024. The area identified on Resident (R1's) right clavicle and right lateral neck were determined to be moisture associated skin dermatitis (MASD). Resident (R1) does not have any pressure-related wounds. Treatment orders were obtained and followed per physician orders.
2. On 1/10/2024 the unit managers assessed all residents in the facility. Treatment orders are in place for all wounds.
3. The facility has implemented additional skin assessments for all residents, a minimum of 2 times per week to identify any new alteration of skin integrity.
4. On 1/17/2024 Nurse management team started education for licensed nursing staff on the facility's pressure ulcer prevention policy and procedure including protocols for skin assessments and treatments for new and existing residents. The facility will have 80% of the staff educated by 1/18/2024. The remaining staff will be educated prior to the start of the shift.
5. The DON, NHA and/or designee will complete weekly audits for residents at risk for developing pressure ulcers. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting.
Review of facility documentation revealed that the corrective action plan was immediately initiated on January 17, 2024.
On January 18, 2024, wound treatment orders were reviewed for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 - treatment orders in place.
Interviewed the following staff regarding PU/PI prevention policy and neglect related to prevention of skin wounds: 12 licensed nurses, employees E9, E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20 and five nurse aides, employees E21, E22, E23, E24, E25.
Reviewed Abuse/Neglect prevention education provided for 96% of all staff. Reviewed Wound Management education provided for nursing staff - completed at 96%.
Immediate Jeopardy was lifted on January 18, 2024 at 4:05 PM.
28 Pa. Code 211.10(a)(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) when practicing enhanced barrier precautions during tracheostomy care and failed to follow enhanced barrier precautions as ordered by the physician. One of four resident records reviewed. (Resident R1)
Findings Include:
Review of an undated facility policy Enhanced Barrier Precaution revealed that Enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for resident known to be colonized or infected with a MDRO (Multidrug-resistant bacteria are bacteria that are resistant to three or more classes of antimicrobial drugs.)as well as those at increased risk of MDRO acquisition. An order for enhanced barrier precautions will be obtained for residents with any of the following 1. Wounds and/or indwelling medical devices ( eg. Tracheostomy/ventilator tubes). Implementation of enhanced barrier precautions- a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. c. Position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 4. High contact resident care activities include; g. Device care or use . tracheostomy/ventilator tubes. Enhanced barrier precautions should be used for the duration of the affected residents stay in the facility or until the wound heals or indwelling medical device is removed.
Review of physician orders for resident R1 dated December 14, 2023 revealed that the resident was ordered for enhanced barrier precaution for Carbapenem-Pseudomonas(A class of drug resistant bacteria)-MDRO.
Review of clinical record dated December 26, 2023, revealed that the resident was on enhanced barrier precaution due to Carbapenem-Pseudomonas.
Observation of the Resident R1's room on January 5, 2024, at 11:30 a.m. revealed that there was no sign placed outside the resident room to alert the staff and visitors of resident's enhanced barrier precaution status. There was no PPE's and trash can available outside or inside resident's room consistent with facility policy.
During the survey a tracheostomy care observation for Resident R1 was requested by the surveyor on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5. It was observed that Employee E4 and Employee E5 did not wear a gown, a face mask or a face protection during the tracheostomy care.
Interview with Employee E5 on January 5, 2024, at 11.50 a.m. confirmed that the resident was ordered for enhanced barrier precaution due to Carbapenem-Pseudomonas.
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, facility documentation and interview with staff, it was determined that the Nursing Home Administrator and the Director of Nursing did not ensure to effectively manage the facility related to prevention of pressure ulcers and pressure injuries (PU/PI) for one of one residents reviewed (Resident R1)
Findings include:
Review of the job description for the Nursing Home Administrator (NHA) revealed The administrator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs and coordinates all activities of the center to assure that the highest degree of quality care is consistently provided to the resident of the facility.
Review of job description for the Director of Nursing (DON) revealed The Director of Nursing is responsible for administration of nursing service in the nursing center. He/she directs plan and coordinates service activities of professional nursing and auxiliary nursing personnel in rendering resident care. The Director of Nursing interprets center policies and regulations to all nursing personnel and ensures compliance as well as analyzes and evaluates nursing and related service rendered to improve quality of resident are and to better utilize staff time and abilities. The Director of Nursing also ensures the provision of in-service trainings programs for nursing personnel.
Review of R1's clinical records revealed a diagnosis of acute and chronic respiratory failure with hypoxia (insufficient amount of oxygen available to tissues), nontraumatic intracranial hemorrhage, functional quadriplegia, obesity, muscle weakness, rhabdomyolysis (occurs when damaged muscle tissue releases its proteins and electrolytes into the blood), dysphagia (difficulty swallowing), tracheostomy status.
A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 6, 2023, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living to include bed mobility, transfers, and toilet use. The resident's cognition was severely impaired, and the assessment indicated that the resident was unable to complete interview. MDS also indicated that the resident rarely/never makes self-understood and able to understand others.
Review of R1's care plan revealed that R1 is at risk for alteration in skin integrity related to anticoagulant therapy, chronic progressive disease, circulation impairment, diabetes, disease process, incontinence of bowel movements, mobility impairment quadriplegia with interventions in place to notify the physician and family of changes as needed and to complete body checks weekly and as needed.
Review of progress note for Resident R1 dated December 26, 2023, revealed a skin documentation that a new skin impairment was observed on residents left chin area which measured 1.5 cm X 2.0 cm.
Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated that the resident had wounds to right clavicle wound which measured 1 cmX1.5 cm, left clavicle wound and left chin. All treatment in place.
Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle wound which measured 1 cmX1.5 cm, left clavicle wound and left chin. All treatment in place.
Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound.
Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin
Review of a skin assessment completed by Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment.
Interview with Employee E4, on January 5, 2024, at 1:00 p.m. stated she was aware not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024.
Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated Employee E4 did not conduct a proper skin assessment. Staff were expected to conduct skin assessment and document the findings in the medical record. Any changes to skin integrity should be addressed with the physician for treatment orders.
Review of clinical record for Resident R1 revealed no documented evidence that the physician or wound care practitioner was notified about Resident R1's right clavicle wound when it was first documented on December 30, 2023, subsequently after on December 31, 2023, and January 2, 2024. There were no interventions implemented to promote the wound healing or preventing further skin breakdown.
A skin assessment completed on January 5, 2024, at 1:39 p.m., revealed that the right clavicle measured 1.5 cm X 2.3 cm. and right neck wound measured 0.7 cm. X 2 cm.
A wound care consult report dated January 5, 2024, after the surveyor observation of the right clavicle and right neck wound revealed that resident had muscle weakness, reduced mobility and extreme contracture with right clavicle pressure ulcer and right lateral neck pressure ulcer. Right clavicle was an acute Stage 3 pressure ulcer and measured 1.3 cm X 2 cm. X 0.2 cm. Right lateral neck was an acute Stage 3 pressure ulcer injury measured 0.9 cm. X 1.3 cm X 0.1 cm.
Further review of the wound care consult report dated January 5, 2024, and progress note for Resident R1 dated December 30, 2023, revealed that the right clavicle wound increased in size and a new wound was developed adjacent to the right clavicle wound.
Review of Medication Administration Record for December 2023 and January 2024 revealed that the staff did not administer any care to the right clavicle and right neck area including, wound treatment, wound prevention, and interventions to promote wound healing.
Interview with facility's DON and Administrator on January 17, 2023 at 11:20 am revealed that facility's physician, employee E7, completed a virtual wound assessment on January 5, 2024 - which resulted to be an inaccurate assessment as supported by in person assessment of facility's nurse practitioner, employee E8 and E7's associate - that areas affected are due to unavoidable prolonged exposure to mucus/moisture from patient's tracheostomy.
Facility administrator and DON did not properly manage and supervise staff to ensure prevention of skin wounds and to ensure prevention of inaccurate assessments and documentation.
Refer to F686 and F600
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 211.10(d) Resident care policies
28 Pa Code 211.12(d)(1)(5)Nursing services

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate notices were provided related to transfer to the hospital/discharge for four of 40 records reviewed (Residents R52, R70, R71, R326).
Findings include:
Review of Resident R52's clinical record revealed that the resident was sent to the hospital on July 17, 2023, due to blockage of his suprapubic catheter (a tube surgically inserted through the skin over the pubic bone in order to drain urine from the bladder).
Review of Resident R70's clinical record revealed that the resident was sent to the hospital on August 8, 2023, due to exacerbation of CHF (congestive heart failure, a condition in which the heart does not pump efficiently, which causes fluid to back up in the system, causing weight gain, edema and difficulty breathing).
Review of Resident R71's clinical record revealed that the resident was sent to the hospital on August 27, 2023, due to elevated temperature and a swollen, discolored right hand.
Review of Resident 32's clinical record revealed that the resident was sent to the hospital on October 3, 2023, for a change in condition including delayed responsiveness and altered mental status.
Interview with Nursing Home Administrator, on October 20, 2023, at 2:30 p.m. revealed that the written notification sent to the family included appropriate bed hold information, and the date of the residents' transfers, but not the reasons for the transfers was inlcuded in the notification.
28 Pa. Code: 211.5 (f) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R92 was free from neglect related to a significant medication error. This failure resulted in an Immediate Jeopardy situation for Resident R92 who received 10 units of a fast-acting insulin that was intended for another resident and without proper monitoring following the administration of the insulin for one of 40 residents reviewed. (Resident 92).
Findings include:
Review of the facility policy entitled, Freedom from Abuse Neglect & Exploitation implementation date November 28, 2017, revealed The purpose of this procedure is to comply with reporting of crimes that may occur at the facility in accordance with section 1150B of the elder Justice Act (EJA). To protect elders with diminished capacity while maximizing their autonomy and help elders recognize the right to be free of abuse, neglect and exploitation.
Review of Resident 92's clinical record revealed an admission date of April 25, 2017, with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit, delusional disorder.
A review of Resident 92's clinical file confirmed that the resident is non-diabetic and does not have a physician order for insulin.
Review of Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severely impaired, and had memory problems.
A review of Resident 92's nursing notes dated September 20, 2023, at 7:23 p. m. revealed that License nurse, Supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u (units) of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime.
Review of facility documentation submitted to the Department of Health on September 20, 2023, revealed a patient/resident neglect report submitted on September 20, 2023, revealed Resident R92 had a licensed charge nurse Employee E24 mistakenly given 10 units of Humalog. Resident R92 does not received insulin. Resident R92 does not have a diagnosis of diabetes. Resident R92 resides in room [ROOM NUMBER]B and was in room [ROOM NUMBER]A sitting in 320A chair. Licensed nurse, Employee E24 believed that Resident R92 was Resident R107. Employee E24 failed to properly identify Resident R92. Resident R92 was assessed by nursing supervisor Employee E23 no distress was noted. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s (signs and symptoms) of hypoglycemia and recheck her Resident R92 at bedtime Nurse Practitioner, Employee E27 evaluated Resided R92 and noted there was no ill effects noted. Facility determined the investigation to be unsubstantiated for neglect.
Review of Resident R92's September 2023's physican orders revealed that on September 20, 2023, order for Accu check, one time only for Glucose (sugar). According to the Medication Administration Report (MAR) on September 20, 2023, at 11:53 p.m. the Accu-check reading was 153. Resident R92 also had a physician order to Monitor resident for s/s of hypoglycemia every shift for 3 days starting on September 20, 2023.
Review of Resident R92's September 2023 Medication Administration Record revealed that Accu-check on September 20, 2023, at 10:53 p.m. reading of 153 blood sugar level and at 11:11 p.m. of 130 blood sugar reading. An attempt was made on September 21, 2023, at 4:20 a.m. and Resident R92 refused. Review of nursing notes revealed no documented evidence of continue monitoring of Resident R92 for signs and symptoms of hypoglycemia, and of what type of sugary drink and food was the resident provided with ordered by the physician.
On October 18, 2023, at 11:31 a.m. an observation was made of Resident R92 sitting in her room without an identifying wristband. An interview was conducted with nursing supervisor, Employee E4 confirming that Resident R92 refused to wear identifying wristband.
Further observation of another resident in the unit (Resident R157) revealed that the resident also did not have an identifying wristband.
On October 18, 2023, at 11:39 a.m. an interview was held with Licensed agency nurse, Employee E22 who reported a resident would be identified based on the name sign in the room, census report or asking the supervisor.
On October 18, 2023, between 3:40 p.m. and 4:03 p.m. about 19 residents were observed and/or interviewed on the 2nd floor and all of them had an identifying wristband on.
On October 18, 2023, at approximately 2:00 p.m. an interview with the Director of Nursing (DON) confirmed that the facility unsubstantiated the neglect investigation related to Resident R92 as it was just a one time occurrence and that the agency nurse made an error. The neglect investigation only included two statements that the Nursing Supervisor, Employee E23 conducted. DON confirmed there was no evidence of proper monitoring following the administration of the insulin. There was no training conducted to all staff on medication administration, and/or identification of residents.
An interview held with Nurse supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. revealed nurse Employee E24 failed to follow the five rights of medication administration which resulted in neglect of Resident R92. It further revealed most likely Licensed nurse, Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency to ensure competencies of medication administration. Nursing Supervisor, Employee E23 confirmed there was no evidence of proper monitoring following the administration of the insulin medication.
Based on the above mentioned findings an immediate jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:47 p.m. The immediate jeopardy template was provided at the time to the Nursing Home Administrator and an immediate action plan was requested.
On October 18, 2023 and 9:57 p.m. the facility provided the following corrective actions:
1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin.
The employee responsible for the medication error no longer works in the facility.
2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON and there were no other occurrences of insulin administration to non-diabetic residents.
3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that the resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system.
In the event of a medication error the facility will notify the physician and follow the physicians' order related to the type of medication error. The resident will be on 24-hour report and monitored based on the physician recommendation.
The facility will obtain parameters for specific monitoring instructions for the medication error. The nurse will document monitoring in nursing notes.
4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Staff will be required to sing off on the training prior to their first shift worked in the facility.
5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting.
The implementation of the action plan was confirmed on October 18, 2023, at 10:12 p.m. Interviews were conducted with facility nursing staff on October 18, and 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration.
On October 19, 2023, at 4:57 p.m. the Immediate Jeopardy was lifted.
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
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free of medication errors for one of 40 residents reviewed (Resident R92). This failure resulted in an Immediate Jeopardy situation for Resident R92 who was administered 10 units of a fast- acting insulin medication that was intended for another resident.
Findings include:
Review of the facility policy entitled, Administering Medications date May 2016, revealed Medication are administered as prescribed in accordance with manufactures' specifications, good nursing principles and practices and only by person legally authorized to do so, Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. It further states under bulletin 10. Resident are identified before medication is administered using at least two resident identifiers. Methods of identification may include a. check identification band 2. Check photograph attached to medication record 3. Verify resident identification with other nursing care center personnel note: the resident's room number or physical location is not used as an identifier.
Review of Resident R92's clinical record revealed an admission date of April 25, 2017, with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit and delusional disorder.
Review of the Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severe cognitive impairment. A BIMS (Brief Interview of Mental Status) score was not documented due to resident being rarely/never understood.
A review of Resident R92's September 2023 physician orders did not list the resident with a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and no orders for insulin.
A review of a nursing note dated September 20, 2023, at 7:23 p.m. revealed that License nurse supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical administration record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime.
Review of facility documentation revealed a witness statement, dated September 20, 2023, by License nurse supervisor, Employee E23 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. noted that she was asked by 3 East charge nurse, Employee E25 to come to the floor and assess an issue. Upon arrival was told by staff that 3 south nurse had accidentally given resident 10 units of Humalog. When asked what happened, 3 south nurse, Employee E24 stated she saw resident sitting in 320 A chair and thought that was her room. Employee E24 stated the resident didn't property answer, aide/CNA (nurse aide), Employee E26 nearby didn't say anything and that the resident in 320 B (Resident 108) just said resident takes meds whole .(Resident R92) noted w/Alzheimer + confusion and wonders and sits in different rooms. When asked did the 3 South charge nurse, Employee E24 check resident's armband or picture on the EMAR, she stated no and was just going by the census sheet. MD made aware and ordered resident be given sugary snacks + drinks, monitor for s/s of hypoglycemia + accu-checks at bedtime. RP made aware and just wants to be updated with any changes. Resident given snacks and drinks.
Review of facility documentation revealed a witness statement, dated September 20, 2023, completed by License nurse supervisor, Employee E23 regarding license nurse, Employee E24 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed charge nurse gave Resident R92 10 units of Humalog accidentally stating that because Resident R92 was sitting in 320A chair & room, she thought it was Resident R107. License nurse, Employee E24 then said that while she was talking to Resident R92, nurse aide, Employee E26, who was nearby did not say she was talking to the wrong resident and that Resident R108 said Resident R92 takes her meds whole. Resident R92 has Alzheimer and confusion and wonders from room and wouldn't be aware enough to say anything. When nursing supervisor, Employee E23 told the charge nurse, Employee E24, she became irritable stating that at other facilities, residents are not allowed to sit in other resident's room. When asked did she check the resident's armband or picture on the EMAR she said no, she was just getting off the census sheet. She then tried to accuse/put blame on Employee E26, nurse aide for not saying anything and of Resident R108. License Nurse, Employee E24 came to the supervisor office and dropped the keys off and stating she wasn't and isn't in the right mental status to work . and then left the facility.
An interview held with Nurse Supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. confirmed the above-mentioned statements. Nursing Supervisor, Employee E23 stated that she received a call approximately at 4:30 p.m. on September 20, 2023, from charge nurse, Employee E25 making her aware that there was issue with Resident R92. Upon arrival Employee E23 learned that Employee E24 who was an agency license nurse assigned to Resident's 92's accidentally administered 10 units of Humalog to Resident R92 who was non-diabetic resident which should have been administered to Resident R107. Resident R92 was sitting in room [ROOM NUMBER]A chair which belong to Resident R107. Employee E24 failed to check resident's armband, Electronic Medical Administration Record (EMAR) or picture and depended on census report to identify the Resident R92.
Nurse Supervisor, Employee E23 further revealed mostly likely was Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency. Nursing Supervisor, Employee E24 told Employee E25 make sugary nourishment to keep Resident R92's sugar elevated and notified the physician. Physician gave an order to give juices, snacks and monitor her blood sugar. Nursing Supervisor, Employee E23 assessed the Resident R92 there was no signs of hyperglycemia or distress. Nurse Practitioner, Employee E27 evaluated Resident R92 this same night at approximately 9:00 p.m. Employee E23 did not write a witness statement nor made herself available after the incident to be part of the investigation. Nursing Supervisor, Employee E23 wrote the above witness statement regarding his encounter with Employee E24.
A telephone interview was held with License nurse, Employee E25 on October 18, 2023, at 6:16 p.m. who worked on September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed that nurse aide, Employee E26 approached her approximately 4:15 p.m. on October 20, 2023, and notified her that license nurse, Employee E24 accidently gave insulin to Resident R92 who is non-diabetic. Licensed nurse, Employee 25 immediately notified supervisor Employee E26 and went to assess the situation. Upon her arrival Resident R92 was as her normal self, sitting with her hands crossed her chest with no distress. Licensed nurse, Employee E24 notified Licensed nurse, Employee E25 that she measures her blood sugar before she gave an insulin, and it was 144. Licensed nurse, Employee E24 further reported that she did not verify Resident's R92 identity per the medication policy but only used her census sheet. Licensed nurse, Employee E25 checked Resident's R92's blood sugar level and to her best memory it was 80. Resident R92 had dinner that night and sugary snacks and drinks were provided such as orange juice and peanut butter sandwich to elevate her sugar level. Resident R92 at any point was not in any distress during the night. At approximately 6:00 p.m. Licensed nurse, Employee E24 left her shift and supervisor was notified.
A telephone interview was held with nurse aide, Employee E26 on October 18, 2023, at 8:56 p.m. who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed she was not in the room when insulin was administered to Resident R92. Employee E26 walked into room [ROOM NUMBER] and observed Resident R92 sitting in a 320A room's chair and License nurse, Employee E24 with a needle in her hand. Nurse aide, Employee E26, questioned if Licensed nurse, Employee E24 gave an insulin to Resident R92. Licensed nurse, Employee E24, responded, no I gave it to Resident 107. Nurse aide, Employee E26, then told Licensed nurse, Employee E24 that was not Resident R107 but Resident R92. Employee E26, immediately went to another nurse, Employee E25 who was covering 3rd floor South Unit and reported that Resident R92 was given insulin and Resident R92 was a non-diabetic resident. Licensed Nurse, Employee E25 immediately notified the nursing supervisor Employee E23 who came to assess the situation.
On October 18, 2023, at 7:25 p.m. an attempt was made to conduct a phone interview with license nurse, Employee E24 whose number was not working. This same time an interview with Director of Nursing revealed that a staffing agency for whom nurse, Employee E24 was employed at was notified and Employee E24 was placed on the do not return list and not permitted at the facility moving forward.
Review of Resident R92's clinical record revealed that physician orders obtained on October 20, 2023 for a one time Accu-Check for glucose level and to monitor the resident for signs and symptoms of hypoglycemia every shift for 3 days starting on September 20, 2023.
Review of Resident R92's September 2022, Medication Administration Record revealed that on September 20, 2023, at 11:53 p.m. the one-time Accu-check reading was 153 blood glucose (sugar) reading.
Based on the above mentioned findings, an Immediate Jeopardy was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:45 p.m. The Immediate Jeopardy template was provided to the Nursing Home Administrator and an immediate action plan was requested at the time noted above.
On October 19, 2023, at 9:57 p.m. the facility provided the following corrective action plan:
1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin.
2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON (Director of Nursing) and there were no other occurrences of insulin administration to non-diabetic residents.
3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that they resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system.
4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Agency staff will be required to sign off on the training prior to their first shift worked in the facility.
5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting.
The implementation of the action plan was verified on October 18, 2023 at 10:12 p.m. Interviews were conducted with nursing staff on October 18, 2023 and October 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration.
The Immediate Jeopardy was lifted on October 19, 2023, at 4:57 p.m.
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 211.12 (d) (5) Nursing Services