**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of 41 residents (Resident R1). Review of the facility policy Elopement - Missing Resident dated 1/8/25, indicated the facility will provide to each resident adequate monitoring and interventions to maintain safety. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/30/25, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and a seizure disorder. Review of Section E: Behavior indicated Resident R1 had displayed wandering behaviors. Review of an Elopement Evaluation completed on 6/18/25, indicated Resident R1 was at risk for elopement. Review of the physician's order dated 6/18/25, indicated Resident R1 was ordered a security bracelet that alerts when an identified resident approaches a monitored door. Review of Resident R1's plan of care for Risk for Elopement initiated 6/18/25, indicated Resident R1 is at risk for elopement due to Alzheimer's disease and a history of wandering. Review of a progress note dated 7/7/25, at 8:43 a.m. indicated Resident R1 was testing door handles and keypads. When lobby door is open, she will start to run for the door. Review of a progress note dated 7/10/25, at 12:59 p.m. indicated Resident R1 was trying to open dining room windows this morning. Any time there is an open door and she notices, she will sprint towards it. Review of a progress note dated 7/15/25, at 11:18 p.m. indicated, At 7:13 p.m. resident was found on the 2nd floor walking up the middle hall from the stairwell. Nursing supervisor notified by security that the resident had gotten out of the locked unit. Upon investigation it was found that the maglocks (electrified magnetic locking mechanism) on the stairwell doors were not engaged due to planned power outage. Resident returned to locked unit without difficulty. Resident had no injury of any kind, did not fall or hurt herself in any way. No s/s (signs or symptoms) of emotional distress upon return to unit. Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. No emotional distress noted. MD (Doctor of Medicine) and NOK (next of kin) notified. During an interview on 7/17/25, at approximately 1:00 p.m. the Assistant Director of Nursing confirmed the facility failed to provide adequate supervision to prevent elopement for one of 41 residents (Resident R1).

Based on facility document review and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units (2A, 3A, 3B, 4A, and 4B).Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock (electrified magnetic locking mechanism) door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. No emotional distress noted. MD (Doctor of Medicine) and NOK (next of kin) notified. Review of an employee statement dated 7/15/25, written by Security Employee E1, indicated, While reviewing CCTV I noticed a resident enter the stairwell 1 entry on 4A. She was identified as [Resident R1]. I witnessed her walk down the stairwell and exit on 2A middle hall. She walked to the nurses station. I then called [Employee E2] and she and [Employee E3] responded to 2A and addressed it. She was returned to her unit right away. Subsequently upon further investigation the maglocks failed during the planned power outage. Review of an employee statement dated 7/15/25, written by Security Director Employee E4 indicated, At 1930 hrs (7:30 p.m.) on the above date (7/15/25) during a scheduled facility wide power shutdown, I received a call from Security Employee E1 reporting that a resident identified as [Resident R1] had entered stairwell #1 from unit 4A proceeding down to unit 2A. Security Employee E1 stated that the house supervisor was immediately notified of the incident. The resident was assessed by staff and returned to the unit. Under my direction, Security Employee E1 was instructed to check all maglocks on all stairwells, as an extra precaution all mechanical alarm boxes were to be tested and engaged. I advised Security Employee E1 that I was responding to the facility with a 20-30 min ETA (estimated time of arrival). Upon my arrival at 8pm Security Employee E1 informed me that all nursing unit maglocks were down. Nursing had placed a staff member at each door as an extra precaution. Upon investigation found that the battery backups for these doors had failed. Further investigation showed that the power supplies for these doors were not on generator power. ESM (Environmental Service Manager) Employee E5 was notified of the issue. Upon Employee E5's direction the facility electrician [Maintenance Employee E6] rewired the power supplied to a generator electric panel, restoring power to the affected doors at 2130 hrs (9:30 p.m.). the A side maglocks were fully functional. I made a sweep of the A side of the facilty and confirmed that all A side maglocks were again operating as designed. At 2230 (10:30 p.m.) power was restored to all B side maglocks. I again made a sweep of the B side to confirm all doors were working as designed. Upon review of the guard log book these doors were last tested at 1530 hrs (3:30 p.m.) and fully functional. I departed the facility at 2230 hrs (10:30 p.m.). All doors were fully functional. Review of a statement written by Environmental Service Manager Employee E5 stated that:7/15/25, (approximate times):8:00 a.m.: with Electric Maintenance Vendor V1 and V2 onsite, the local power provider terminated outside power and the facility converted to generator power. 4:00 - 4:30 p.m.: Electric Maintenance Vendor V2 advised that the Main Transfer Switch was faulty. At that time Facility Executive Employee E7, Director of Facilities Employee E8, and the County Electrician Employee E9 were contacted about the failed switch and the need to replace it immediately. 5:00 p.m. - Electric Vendor V2 was able to find a replacement switch, located approximately 90 miles away. The part was picked up and delivered at 8:00 p.m. Installation was begun at that time. 8:00 p.m. - Security Employee E1 notified that the maglock doors had failed and a resident got out of 4A. Battery backups were found to be low on power, and replace with new batteries. The decision was made change the maglocks from battery backup to generator power. 10:30 p.m. - All power to the maglock doors on the resident units was converted to generator emergency power. 7/16/25, (approximate times):12:00 a.m. - Electric Maintenance Vendor V2 completed the installation of the replacement part. The local power provider was called to restore service. The local power provider would not send anyone to restore power, due to confusion regarding the work order, with a work order from a sister facility. 2:00 a.m. - Power was restored by the local power provider. 7/17/25:Confirmed that all resident and non-resident area maglocks have backup generator power supply. During an interview on 7/17/25, at approximately 10:40 a.m. ESM Employee E5 confirmed that the facility had been unprepared for the maglock batteries to become too low on power during an extended power outage, and had not planned to have replacements used prior to the batteries completely failing. During an interview on 7/15/25, at approximately 1:00 p.m. the Assistant Director of Nursing confirmed the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3). Findings include: Review of the facility policy Abuse- Resident last reviewed on 1/5/24, indicated that the facility treat every resident with respect and dignity. The failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm is identified as neglect. All complaints/allegations of resident abuse/neglect shall be promptly reported to the administration and investigated. Alleged violations whether or not confirmed, must be reported. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness and dementia. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/18/24, indicated the diagnoses remained current. Section GG 0170 Mobility indicated functional abilities of the resident identified resident R3 required dependent care with rolling left to right which is indicated the helper does all the effort or two staff are required. Review of Resident R3's physican orders dated 10/31/23, prior to the incident and still current, indicated Resident R3 required bed mobility of assist of two. Review of Resident R3 plan of care, prior to incident and current, indicated resident R3 had behaviors of resistant with care. Review of an incident report dated 8/28/24, indicated that Resident R3 developed a 1.5 c.m. x 2.0 c.m. x 0.1 c.m. head laceration with a bruise requiring steri strips (tape that is used in place of sutures) to close when NA Employee E8 attempted to readjust a sheet around his waist to keep him from picking at his brief with no additional assistance when turning Resident R3 who cannot hold himself or stop himself from rolling, NA Employee E8 hit Resident R3s head off of the overbed table causing the laceration. During an interview on 9/25/24, at 8:15 a.m., NA Employee E5 stated that Resident R3 is rigid and required two staff since he becomes combative with care. NA Employee E5 stated that he frequently is assigned to Resident R3. During an interview on 9/25/24, at 8:40 with NA Employee E6 and E7 indicated that resident care is identified on the care sheets (a sheet shown to the surveyor and is on each nursing unit as a quick reference for each residents care needs for the nurse aides to utilize) but they also get report between shifts in case there are any changes. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3). 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1)(3) Management. 28 Pa Code: 211.10 (d) Resident care policies. 28 Pa Code: 211.12 (d)(3) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R20). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective 10/1/2019, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. A review of the clinical record indicated that Resident R20 was admitted to the facility on [DATE], with diagnoses which included dementia (group of symptoms that affects memory, thinking and interferes with daily life), and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of a physician order dated 7/6/23, indicated Resident R20 was admitted to hospice care (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care). Review of Resident R20 ' s MDS assessments revealed a MDS significant change was not completed to include Hospice services until 8/3/23. During an interview on 9/28/23, at 10:00 a.m. Registered Nurse Assessment Coordinator Employee E5 confirmed that the clinical record did not include documentation that Resident R20 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 211.5(f) Clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R53, R64, R71, and R76). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Medication Administration: Disposable, Pre-filled Insulin Pen reviewed 1/12/23, indicated the nurse monitors resident for adverse reactions, including hypoglycemia, and reports adverse effects to practitioner promptly and documents in EMR (electronic medical record). Review of the facility policy Emergency Care Guidelines: Hypoglycemia Protocol reviewed 1/12/23, indicated for Blood Glucose Monitor (BGM) reading less than 70 and symptomatic or less than 60 regardless of symptoms to recheck BGM in 15 minutes, treat according to protocol, and notify physician. For BGM less than 50, recheck BGM in 15 minutes and notify the physician. Review of the facility policy Notification of Change in Resident Condition and Treatment Changes reviewed 1/12/23, indicated the facility fully informs the resident, or notify the resident ' s representative, when there is a change in condition or treatment. The nurse assesses the resident ' s condition, notifies physician of changes, and documents findings and notifications in the nurse ' s notes. The nurse notifies the resident and responsible party, where applicable, of changes in physician order and documents notification in nurse ' s notes. Review of the clinical record indicated Resident R53 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R53 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/13/23, indicated the diagnoses remain current. Review of physician orders dated 10/6/22, indicated to inject Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale with meals and at bedtime and to notify the doctor if blood glucose was less than 70. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/25/23, at 8:14 a.m. the CBG was noted to be 69. On 8/9/23, at 7:56 a.m. the CBG was noted to be 62. Review of Resident R53's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/18/23, indicated to monitor for hypoglycemia symptoms, administer insulin per order, monitor BGMs and use sliding scale provided for coverage. Review of a clinical record indicated Resident R64 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and dementia (group of symptoms that affects memory, thinking, and interferes with daily life). Review of Resident R64 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 2/12/20, indicated to inject Novolog insulin per sliding scale three times a day, notify the doctor if blood glucose is less than 70. Review of Resident R64's eMAR revealed that the resident's CBG's were as follows: On 8/16/23, at 11:35 a.m. CBG was noted to be 62. On 8/8/23, at 11:25 a.m. CBG was noted to be 60. On 8/7/23, at 12:02 p.m. CBG was noted to be 67. On 8/3/23, at 11: 16 a.m. CBG was noted to be 58. On 8/1/23, at 11:27 a.m. CBG was noted to be 66. On 7/13/23, at 11:29 a.m. CBG was noted to be 51. On 7/8/23, at 6:12 p.m. CBG was noted to be 65. On 7/3/23, at 11:18 a.m. CBG was noted to be 65. On 4/21/23, at 12:20 p.m. CBG was noted to be 54. On 4/9/23, at 12:34 p.m. CBG was noted to be 66. On 3/26/23, at 4:58 p.m. CBG was noted to be 53. On 3/7/23, at 4:24 p.m. CBG was noted to be 49. On 2/26/23, at 5:27 p.m. CBG was noted to be 64. On 2/25/23, at 5:16 p.m. CBG was noted to be 57. On 2/13/23, at 4:12 p.m. CBG was noted to be 53. On 2/12/23, at 5:07 p.m. CBG was noted to be 54. A review of Resident R64's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R64 ' s care plan dated 8/21/22, indicated to administer insulin per doctors order, observe for side effects and effectiveness. Observe for sign and symptoms of hyper- or hypoglycemia. Obtain blood sugars as ordered. Review of the clinical record indicated Resident R71 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, and dementia. Review of Resident R71 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 5/22/23, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 4 units with meals, and to inject Lantus (glargine insulin - long-acting insulin that starts to work several hours after injection) 30 units once daily in the morning. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/17/23, at 7:43 a.m. the CBG was noted to be 65. On 5/1/23, at 10:55 a.m. the CBG was noted to be 68. Review of Resident R71's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 5/11/23, indicated administer insulin injections per orders. Observe for signs and symptoms of hyper- or hypoglycemia. Review of the clinical record indicated Resident R76 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, and anxiety. Review of Resident R76 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 7/28/23, indicated the diagnoses remain current. Review of physician orders dated 1/25/23, indicated to inject NovoLog insulin per sliding scale before meals and at bedtime. If BGM is less than 70, or greater then 400, call the doctor. Further review of physician orders dated 5/23/23, indicated to inject Lispro insulin per sliding scale before meals and at bedtime. If BGM is less than 70, or greater than 400, call the doctor. A physician order dated 7/21/23, continued the Lispro insulin per sliding scale and notification parameters of less than 70 or greater than 400. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/22/23, at 1:15 p.m. CBG was noted to be 469. On 6/20/23, at 11:58 a.m. CBG was noted to be 40. On 5/10/23, at 11:55 a.m. CBG was noted to be 460. Review of Resident R76's eMAR and clinical progress notes indicated the resident was not assessed for hyper- or hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/11/23, indicated to administer insulin injections per ordered. Observe resident for signs and symptoms of hyper- or hypoglycemia, notify doctor with results that are out of range as ordered. During an interview on 9/26/23, at 1:20 p.m. Registered Nurse (RN) Employee E1 stated for residents on insulin, the doctor is notified depending on resident orders and test results, usually less than 70 and greater than 400 unless otherwise ordered. There is an on-call service available after 5:00 p.m., if a doctor is notified of results it is documented in the progress notes of the resident ' s clinical record. During an interview on 9/26/23, at 1:40 p.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood glucose levels under 60, they would start the hypoglycemic protocol, and if greater than 400 they would assess the resident, call the doctor, and document in the progress notes. During an interview on 9/26/23, at 1:45 p.m. LPN Employee E3 stated they would follow the hypoglycemic protocol for blood glucose less than 60, and greater than 400 they would call the doctor and document in the progress notes. During an interview on 9/26/23, at 1:55 p.m. RN Employee E4 stated she would call the doctor or the on-call service for blood glucose over 400 and document in the progress notes of the clinical record. During an interview on 9/27/23, at 2:40 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R53, R64, R71, and R76. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident Rights. 28 Pa. Code 211.10 (c)(d) Resident Care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, employee personnel records, grievance and abuse investigation documents, reports submitted to the State field office, resident interview and staff interview it was determined that the facility failed to make certain that all allegations of verbal abuse are reported to the State Agency as required for one of five residents (Resident R96). Findings include: The facility Abuse: protection from abuse policy dated [DATE], indicated that the facility every resident with consideration, respect and full recognition of his/her dignity and individuality. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance. Alleged violations, whether or not confirmed, must be reported to the Administrator, PA Department of Health, the Area Agency on Aging, Compliance Officer, and to the Executive Director. Review of Resident R96's admission record indicated she was originally admitted on [DATE], with diagnoses that included Dementia (group of conditions characterized by impairment of at least two brain functions such as memory and loss of judgement). Review of Resident R96's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated [DATE], indicated that the diagnoses were current. Review of Grievances documentation dated [DATE], indicated that a visiting family member for a Resident in the 4B nursing wing submitted an allegation of verbal abuse. The allegation indicated that staff NA Employee E10 was yelling in the hallway about Resident R96Stop bothering us, she died a month ago and we tell you every day that they're dead! Review of interview form from investigation dated [DATE], indicated that the staff Nurse Aide(NA) Employee E10 said How many times do I have to tell you she is dead, dead, dead! I am not going to listen to this all night, go back to your room, in a loud tone. During an interview on [DATE], at 10:57 a.m. the Director of Nursing confirmed that the facility failed to make certain that an allegation of verbal abuse regarding Resident R96 was reported to the State Agency as required. During an interview on [DATE], at 11:06 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that an allegation of verbal abuse regarding Resident R96 was reported to the State Agency as required. 28 Pa. Code:201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.