Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for one of 13 residents reviewed (Resident 35). Findings include: Review of Resident 35's clinical record revealed a physician's order dated January 5, 2022, for FentaNYL (narcotic pain reliever) Patch 72 Hour 12 micrograms/hour - Apply 1 patch transdermally (to the skin) every 72 hours for pain and remove per schedule and an order dated August 4, 2021, to check the placement of the patch every shift. Review of Resident 35's progress notes revealed a nurse's note dated February 21, 2022, which stated, Upon checking the pain patch, was noted that most staff had stated that it was on the RUB [(right upper back)] but was on the LUB [(left upper back)] and had not been changed since 2/16. It was omitted on 2/19. Therefore, a new patch was applied to the RUB and the old patch from 2/16 was removed from the LUB. Review of Resident 35's February 2022 Medication Administration Record (MAR) revealed the FentaNYL patch from February 16, 2022 was documented as being removed on February 19, 2022 with a new patch placed the same date. Further review of Resident 35's February 2022 MAR revealed staff documented checking the placement of the patch on every shift from February 19, 2022 to February 21, 2022. Interview with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m. confirmed staff failed to follow physician's orders in changing Resident 35's FentaNYL patch and checking for placement of the patch each shift. 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure two of 13 residents reviewed received adequate supervision resulting in an elopement and a fall during a transfer using a lift (Residents 33 and 35). Findings include: Review of facility policy Elopement/Wandering Risk Assessment reviewed June 13, 2022, revealed that When responding to an alarm, if it cannot be determined what triggered the alarm, immediately verify that every resident is safe and accounted for by conducting a visual head and name reconciliation Review of Resident 33 progress notes dated June 1, 2021, at 11:46 p.m. revealed Approx. 7 p.m. this Nurse investigated a door alarm coming from Admin (administration) area; alarm computer was checked but did not indicate a code alert (alert notifying staff that a resident wandered outside of their designated area by a wearable tracker); this Nurse followed the sound to the door near Administration offices; no one was observed outside or inside. A surgical mask was found on the floor near the steps by the BR (bathroom) door in the same area. Review of Resident 33's progress notes dated June 1, 2021, at 11:46 p.m. revealed Approx. 7:20 p.m., this Nurse arrived @ (at) Res (resident) room to admin (administer) meds (medications) & (and) discovered Res was not in her room nor in her BR (bathroom). Call light was not on. Immediately, Activities Area was checked & all rooms/BR's on unit were checked for Res. When Res not found on unit, Security was notified. Review of Facility's investigation documentation for Resident 33's elopement dated June 1, 2021, revealed that staff did not conduct a visual head and name reconciliation when a door alarm was triggered by unknown means. Interview with the facility's Nursing Home Administrator and the Assistant Director of Nursing on June 10, 2022, failed to provide any documentation showing that staff conducted a visual head and name reconciliation as per facility policy Elopement/Wandering Risk Assessment. The facility failed to provide Resident 33 with adequate supervision, which resulted in Resident 33 eloping from the facility for 20 minutes before the facility recognized resident was missing. Review of facility policy Lifting/Transferring/Repositioning Resident Safely, last revised December 2018 revealed: Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance. Review of Resident 35's annual Minimum Data Set (MDS - periodic assessment of resident's needs) dated February 18, 2022 revealed the resident required an extensive assistance with two staff persons for transfers and had impairment to both upper and lower extremities. Review of Resident 35's care plan revealed the resident was at risk for falls due to unsteady gait and poor balance, with an intervention added October 23, 2018 to Please allow me to have assistance with 2 staff persons using Hoyer lift during transfers, toileting and [activities of daily living.] Review of Resident 35's progress notes revealed a nurse's note dated April 7, 2022, which stated, On 4/6/22 at [7:30 p.m.]. The nurse was called into the residents room by staff. The resident was assisted to the floor by [nurse aide.] The resident was on the VERA LIFT. While on the lift the resident let go of the handles and began to fall. The [nurse aide] then assisted the resident to the floor. The resident was free from injury. The note further indicated the root cause of Resident 35's fall was: The resident was being transfer using a lift with only one person. All lifts required 2 staff members. The facility's failure to have two staff persons present while assisting Resident 35 during a transfer in the lift which resulted in a fall was discussed with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies